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A comparative study of parents and graduate students trained to conduct play therapy with mentally retarded children

Bowling, Donald Walter, Ph.D.

The Ohio State University, 1988

UMI 300 N. Zeeb Rd. Ann Arbor, Ml 48106

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UMI

A COMPARATIVE STUDY OF PARENTS AND GRADUATE STUDENTS

TRAINED TO CONDUCT PLAY THERAPY WITH

MENTALLY RETARDED CHILDREN

DISSERTATION

Presented in Partial Fulfillment of the Requirements

for the Degree Doctor of Philosophy in the

Graduate School of The Ohio State

University

Donald Walter Bowling, B.S., M.A.

*****

The Ohio State University

1988

Dissertation Committee: Approved by

Henry Leland, Ph.D.

DONALD WALTER BOWLING

11 ACKNOWLEDGEMENTS

I wish to express sincere appreciation to Dr. Henry

Leland/ for his constructive ideas and guidance throughout the research. Special thanks to Dr. David Hammer, for his suggestions and comments. Gratitude is expressed to Dr.

Johannes Rojahn, for his participation on my reading committee. The author is grateful to Dr. Jeri Briener for her technical assistances. Acknowledgement must also be given to Annick Parker, Angela Ray, Stephanie Wuebbens, Jo

Remotigue, Audrey Bloom, and Susan McCarthy for their valuable assistances. Kitty Talley did the typing and proofreading. Finally, to my family and friends, I offer sincere thanks for your support and encouragement.

Ill VITA

March 28r 1952 ...... Born - Hamilton, Ohio

1976 B.S., Eastern Kentucky University, Richmond, Kentucky

1977 ...... M.A., Eastern Kentucky University, Richmond, Kentucky

1977-1978 ...... Counselor, Talbert House, Cincinnati, Ohio

1978-1984 ...... Psychology Assistant, Orient Developmental Center, Orient, Ohio

1984 ...... Psychology Assistant, Montgomery Developmental Center, Huber Heights, Ohio

1984-1986 ...... Psychology Assistant, Central Ohio Psychiatric Hospital, Columbus, Ohio

1986-Present ...... Psychology Associate, Georgia Retardation Center, Atlanta, Georgia

FIELD OF STUDY

Major Field; Psychology

IV TABLE OP CONTENTS

ACKNOWLEDGEMENTS ...... iii

VITA ...... iv

LIST OF TABLES ...... vii

LIST OF FIGURES...... viii

CHAPTER PAGE

I. INTRODUCTION ...... 1

Statement of Problem ...... 6 Present Study ...... 11 Statement of Experimental Questions .... 11 Definitions...... 12

II. REVIEW OF THE L I T E R A T U R E ...... 14

Historical Overview of P l a y ...... 14 Play Psychotherapy Approaches ...... 16 Parental Involvement in Play Psychotherapy ...... 21 Play Psychotherapy with Mentally Retarded Children ...... 27 Parents as Therapeutic Change Agents with Mentally Retarded Children ...... 42

III METHODOLOGY...... 49

Sample Selection ...... 49 S a m p l e ...... 50 Dependent Variables ...... 52 P r o c e d u r e s ...... 54 IV. R E S U L T S ...... 60

Analysis of Adaptive Behavior ...... 60 Analysis of Adult-Child Interactions . . . 64 Analysis of Parental Satisfaction with T r e a t m e n t ...... 69

V. DISCUSSION...... 73

Adaptive Behavior ...... 73 Adult-Child Interactions ...... 75 Parental Satisfaction with Treatment .... 77 Review of Individual Play Therapy Goals . . 78 Limitations and Implications ...... 83 S u m m a r y ...... 88

Bibliography ...... 90

APPENDICES

A. SAMPLE SELECTION ABS RATINGS ...... 100

B. CONSENT LETTER ...... 102

C. PARENT'S MARITAL STATUS ...... 105

D. MOTHER'S A G E ...... 107

E. FATHER'S A G E ...... 109

F. MOTHER'S EDUCATIONAL LEVEL ...... Ill

G. FATHER'S EDUCATIONAL LEVEL ...... 113

H. CODING MANUAL FOR SCORING ADULT-CHILD INTERACTION ...... 115

I. PLAY THERAPY HANDOUT ...... 149

J. PARENT CONSUMER SATISFACTION QUESTIONAIRE . . . 155

K. PRETREATMENT AND POSTTREATMENT ABS RATINGS . . . 158

VI LIST OF TABLES

TABLE PAGE

1. Demographic data for subject s a m p l e ...... 51

2. Prescored tape and interrater reliability . . . 59

3. Means and standard deviations for ABS by treatment g r o u p ...... 62

4. ANOVA for adaptive behavior scale domains . . . 63

5. Mean scores and standard deviations for adult-child interactions ...... 66

6. ANOVA for adult-child interactions ...... 67

7. One-way analysis variance for parental satisfaction ...... 71

8. Individual play therapy goals and progress . . . 80

Vll LIST OF FIGURES

FIGURES PAGE

1. Time x's group interaction for adult questions...... 68

Vlll CHAPTER I

INTRODUCTION

When man evolved to walk erect, he no longer required

the use of his hands for locomotion. Man's hands were free

to perform such tasks as hunting and gathering, and provide

protection for self and others. In order to retain the

information gained through the manipulation of the environment, man's cognitive abilities increased; in turn, this allowed man to further increase his manipulation of the environment (Magoun, Darling, and Frost, 1960).

Considering that the ontogeny recapitulates the phylogeny, development for children follows the same phylogenetic course. The hand-to-brain development for the child occurs during play (Leland and Smith, 1965).

Play is a developmentally occurring behavior that is an essential part of the child's physical, cognitive, and social-emotional development. The importance of play for the child's growth and development is generally acknowledged (Leland, 1982; Bruner, Jolly, and Sylva, 1976;

Millar, 1968; Vygotsky, 1967; Piaget, 1962). Play is thought to be the child's most consistent form of expression and communication, providing children with the

1 2

opportunity to test emotions while learning new skills.

Children must be allowed the time to imitate, explore, find

themselves, and test their ideas.

The experiences the child derives through play are the

foundation to language acquisition. These experiences

during play also enable the child to assimilate the world,

build confidence, and practice interpersonal relationships

(Caplan and Caplan, 1973).

Through interpersonal relationships, the individual

gains the experiences necessary for the acquisition of

coping strategies (Leland, 1978). For children, play is

the medium to develop coping strategies. According to

Piaget (1962), children attempt to cope with new

experiences by imitating and mimicking the words and

actions of adults. The child also learns to behave in a

manner similar to that of his/her parents.

Parents can have an important influence on their

children when engaged in play (Strom, 1977). The parents'

participation in their children's play has been examined by

various schools within psychology, such as, social

learning, behaviorist, cognitive, and psychoanalytic.

According to Lewis (1979), a majority of play studies have focused on a child's relationship to objects, and have

overlooked the child's earlier relationship with the mother. He believes this relationship is an essential prerequisite, and maintains that play is the result of a 3

social act that occurs between the mother and child. When

interacting with the infant, the mother tends to ask a

number of questions, emphasizing her facial and vocal

expressions. Any arousal from the infant is then regarded

as a response to her questions.

Lewis stresses two points concerning the relationship

between the mother and child. The first involves the

concept, "attachment-security." When a secure and attached

relationship has developed, the child's play, exploration, and manipulative behaviors are facilitated. Secondly, the child's relationship to objects is directed by the mother.

For example, when the mother and child interact, the child attends to her carefully. This enables the mother to direct the child's attention to objects other than herself.

Garvey (1977) indicated that most aspects of play occur spontaneously, provided the young child receives some experiences based on a model Garvey referred to as

"nonliteral treatment." For example, while the mother changes her child's diaper, she engages in a game of peek-a-boo. Diapering is no longer considered just a caretaking responsibility, but, in essence, could be viewed as the foundation of play.

Dunn and Wooding (1977) stated that the traditional view of children learning as they play, places little emphasis on adult direction. The authors observed 24 children, 18 to 24 months of age, while the mothers either 4

engaged in housework, or were relaxing. It was found that when the mother's and child's attention centered on the object of play, the length of play increased significantly, c as compared to those incidences in which the mother paid no j attention. Based on this, Dunn and Wooding concluded that the mother-child relationship was an important medium to the social learning gained through play.

Nuttall, Stollak, Fitzgerald, and Meese (1985) examined mothers' perception of their children during free-play and structured-play sessions. The subjects were

52 mothers (X age = 27.1 yrs) and their 15-month-old infants. It was found the mothers' perceptions of the child's behavior influenced the mothers' behavior as well as mother-child interaction.

Rosenblatt (1977) suggested that adults are significant in the development of play because they not only present objects in a communicative structure, but give the objects social meaning. Rosenblatt considered play a cognitive activity through which the child gained knowledge of his/her world and. his/her relationship to it. However, the child lacks the insight into play with objects, and it is through his/her interactions with adults that he/she develops a repertoire of play skills.

In a study that involved 12 mother-infant dyads and 12 father-infant dyads (infants were 7, 10, and 13 months old), Crawley and Sherrod (1984) examined the developmental 5

changes that occurred in the content of mother-infant and

father-infant play. It wasa found that fathers tended to

engage in more rough play than mothers. The results also

indicated that parents of older infants engaged in role

games and pretend play more frequently than parents of

younger infants. It was concluded that both fathers and

mothers progress through development changes in play.

According to Strom (1977), parent-child play provides

the chances to learn ways to resolve conflicts, develop

expressive language skills, and share values. The

interaction also allows the parent and child to be

imaginative and creative.

Erikson (1963) indicated that, through play, the child

attempts to resolve his/her problems and conflicts. The

child continues until situations or difficulties are

encountered with which he/she is unable to cope. For some

children, the inability to cope manifests itself in the

form of emotional and/or behavioral problems. When this

occurs, psychotherapeutic intervention is needed.

Considering that play is the child's medium for self-

expression, communication, and expression of emotions

(Nickerson, 1973), it has therapeutic value (Schaefer,

1985) as an intervention with children.

The psychoanalytic and client-centered psychotherapy

approaches have used play as a therapeutic intervention with children. As Strom (1977) indicated, parents can have 6

an important influence on their children during play;

therefore, the therapeutic value of parents conducting play

should not be overlooked. According to Guerney (1983),

when parents conduct play therapy, the child's behavior

improves, as well as the parent-child relationship.

In a study representative of Guerney's Filial Therapy

(Sywulak, 1977), children received play therapy from both

parents. After four months of treatment, the children's

behavior improved. The parents' acceptance of the children

also improved. A follow-up study by Sensue (1981)

indicated the children maintained the gains made in play

therapy. The parents who conducted play therapy continued

to be highly accepting of their children.

Erikson (1963) stressed the importance of parent

participation in play with their children. When the parent

shares in make-believe, the child is reassured that his/her

play is valid and meaningful. Parents tend to communicate

more effectively in play with their children.

Statement of Problem

Play is viewed just as important in the development of mentally retarded children, as it is for normal children;

however, the retarded child experiences problems with playing spontaneously (Horne and Philleo, 1942). In addition, Mogford (1977) indicated that the mentally retarded child's ability to explore, interact with, and 7

master the environment, is impaired. Johnson and Eshler

(1985) found that retarded and nonretarded children engage

in similar amounts of symbolic play; however, the quality

of symbolic play was lower for retarded children.

Regardless of the differences, the assumption

(Mogford, 1976) is that social and intellectual competence

for the mentally retarded and normal child are acquired

through communication and interaction with parents. As with the normal child, the emphasis for the retarded child must be on interaction and play with parents.

In a ntudy that involved 67 families with moderate and

severely retarded children, age 2-12 years, McEvoy and

McConkey (1983) explored the children's play activities at home. The findings showed the children's play to be

lacking in direction and variety; however, mothers considered play to be important and enjoyable. Other researchers (Eheart, 1982; Hanzlik, and Marguerite, 1986;

Wasserman, Shilansky, and Hahn, 1986) have found that during free-play mothers of retarded children initiated and directed play more than mothers of nonretarded children.

Wasserman et al. (1986) also indicated that mothers of retarded children were less responsive during play. McEvoy and McConkey (1983) concluded that parents should be provided with the opportunity to learn how to facilitate their child's development through play. 8

Recent research has examined training parents to

participate in play with their retarded children. In a

study conducted by Yawkey (1982), 32 low-income families with at least one, three to five-year-old

developmentally-delayed child, participated in a parent-child home intervention program. The families were

randomly assigned so that 16 were in the parent play group and 16 received no treatment. The results showed that imaginative play for children in the parent play group significantly improved at home and in school. The parents of these children indicated significantly more positive opinions regarding the usefulness of play than parents in the no-treatment group.

McConkey, McEvoy, and Gallagher (1982) investigated the use of an instructional video course with parents of mentally handicapped children to enhance play. The participants were 34 families with moderate to severely retarded children, 2-15 years old. The course included six programs on the play of the mentally handicapped, practical activities for parents to use at home, a handbook, instructions on toy-making, and general information in play. The results indicated that parents found the course useful. At a three-month follow-up, the parents reported improvements in their children's pretend and conceptual play, and in fine-motor activities. The parents also reported that interactions with their children were more 9

enjoyable.

In another study, Moran and Whitman (1986) trained

parents in behavioral procedures to teach their delayed

children to play with developmentally appropriate toys.

The subjects were five mother-child dyads. The age range

for the mothers was 19 to 34 years. The children were 11

months to 2.5 years old. The results showed that mothers

could be trained to improve their rate of rewarding their

children's behavior. The children's rate of appropriate

toy behavior, as well as mother-child turn-taking,

increased.

Edmonson, Leland, de Jung, and Leach (1967) found that

retarded individuals experienced problems utilizing the

cues and stimuli in the environment which interfere with

the development of appropriate coping skills. When the retarded child's inability to effectively respond to environmental cues leads to the display of personal and/or socially maladaptive behavior, he/she becomes visible within the community. Whenever this occurs, a psychotherapeutic intervention is indicated (Leland and

Smith, 1974).

Research has shown that play therapy is an effective approach to use with mentally retarded children (Mehlman,

1953; Mundy, 1957; Leland, Walker, and Toboada, 1959;

Sherwood, 1981); however, none of these studies utilized parents to conduct play therapy. Leland and Smith (1972) 10

indicated that, between play therapy sessions, the child

may revert to his/her socially inappropriate behaviors,

negating the positive experiences gained. The authors

suggested that the possibility of this occurring could be

reduced by involving the parents, who would then work at

home with the child. Li (1981) believed that including

parents could increase the child's chances for success in play therapy, as well as enhance parent-child communication. It was Wehman's (1977) opinion that parents have an added advantage since the child's behavior was more likely to be spontaneous in the home. Despite these proposed reasons to involve parents in play psychotherapy, the focus of most research (Baker and Brightman, 1984;

Breiner and Forehand, 1982; Van Hasselt, Sisson, and Aach,

1987) has been on training parents of mentally retarded children in behavioral procedures to teach self-help skills and/or control behavior problems. According to Ginsberg

(1984), behavioral approaches have demonstrated success in changing the mentally retarded child's behavior; however, these approaches have overlooked developing the child's self-image. It was his opinion that development of the child's self-image could be accomplished through play therapy. With the trend toward retarded children remaining in the home and research (McConkey et al., 1982; Moran and

Whitman, 1986; and Yawkey, 1982) demonstrating that parents can be taught to participate in play, parents need to be 11 viewed as a treatment resource for play therapy.

Present Study

The present study is designed to determine if children with mental retardation who display socially maladaptive behavior will benefit from play therapy, from either a trained therapist or from a "trained parent." The purpose was to investigate the changes in children's adaptive behavior and adult-child interactions that may result when parents, as compared to graduate students, conduct play therapy. These two treatment groups will be contrasted with one that receives limited treatment.

Statement of Experimental Questions

The following experimental questions will be investigated in the present study:

1. a) Will play therapy conducted by a trained parent be

as effective as play therapy conducted by a trained

graduate student therapist in producing significant

changes in the children's adaptive behavior?

b) Will play conducted by a trained graduate student

therapist or a trained parent be as effective as

limited play therapy conducted by a trained

graduate student therapist in producing significant

change in the children's adaptive behavior? 12

2. a) Will play therapy conducted by a trained parent be

as effective as play therapy conducted by a trained

graduate student therapist in producing significant

changes in adult-child interactions?

b) Will play therapy conducted by a trained parent or

a trained graduate student therapist be as

effective as limited play therapy conducted by a

trained graduate student therapist in producing

significant changes in adult-child interactions?

3. Will parental satisfaction with treatment for the

parent-cherapist and graduate-therapist groups be

significantly greater than parental satisfaction with

treatment for the limited-play therapy group?

Definitions

Mental retardation; Significantly subaverage intellectual functioning existing concurrently with defects in adaptive behavior, and manifested during the developmental period (Grossman, 1983).

Adaptive behavior; Refers to effectiveness or degree with which an individual meets the standards of personal independence and social responsibility expected of one's age and cultural group (Grossman, 1983).

Socially maladaptive behavior; The inability to respond in a socially acceptable manner which is expected for one's age and cultural group. According to the 13

Adaptive Behavior Scale (Nihira, Foster, Shellhaas, and

Leland, 1975), scores on the Part II domains of Violent and

Destructive Behavior, Anitisocial Behavior, Rebellious

Behavior, Untrustworthy Behavior, and/or Psychological

Disturbances that are above the 80th percentile.

Play therapy; A type of psychotherapy for children utilizing play materials and fantasy construction

(Grossman, 1983). CHAPTER II

REVIEW OF THE LITERATURE

The present chapter will focus on five areas. First,

an historical overview of the importance of play in

childhood development; second, a review of

psychotherapeutic play approaches that have been used in

the treatment of children who exhibit maladaptive behavior;

third, an examination of the psychotherapeutic techniques

that have utilized parents in the therapeutic process;

fourth, a discussion and review of research of psychotherapeutic play approaches that have been used with the mentally retarded/developmentally disabled children with maladaptive behavior; and fifth, the status of utilizing parents of mentally retarded children as change agents in the therapeutic process.

Historical Overview of Play

Play, from an historical perspective, can be traced back to Plato and Aristotle, who considered play the means for children to practice skills necessary for adulthood behavior (Jackson and Angelino, 1974). According to

Jackson and Angelino (1974), the poet Schiller suggested a

14 15

theory of play which was later revised by Spencer. It was

Spencer's position that play behavior was due to a surplus

of energy which resulted from the young child's not having

to focus on self-preservation. Groos's (1908) view of play

was influenced by Darwin's theory that survival was

contingent upon the organism's adaptation to the

environment. In Groos's opinion, play allowed the child to

develop skills essential for survival in adult life.

Piaget's theory of play (1962) was concerned with its

relationship to the child's intellectual development.

Piaget viewed play as spontaneous, pleasurable, involving

no conflicts, and an end in itself. For the young child,

new motor skills could be practiced until mastered; that

is, these skills could be assimulated to the child's

existing knowledge. With symbolic play, the child's

activities occurred for their own sake, not for adjustments

to reality.

Play created what Vygotsky (1967) referred to as "a

zone of potential development." It was his opinion that the child's play activities facilitated the acquisition of higher steps in the developmental process. A child would try to demonstrate behavior at a cognitive level not yet achieved. For example, a child goes through the motions of writing a name for the first time. According to Vygotsky, a child's developmental potential at a particular moment could be assessed by observing the distance between the 16

child's usual activities and the level achieved during

play.

Vygotsky (1967) was also interested in the rules that

govern play, the symbolic representation of play, and the

child's creation of imaginary play situations to help to

cope better with difficulties. These difficulties were usually associated with adults, or adult situations.

Play in psychoanalytic theories represents the child's attempt to seek immediate pleasure by fantasying what was wanted and how to fulfill wishes (Jackson and Angelino,

1974). Play was also viewed as a cathartic experience that served as an emotional release for the child's conflicts, fears, and anxieties associated with real life.

Historically, play has been viewed as important in the child's developmental process. In summary, play is considered a fundamental element in the child's cognitive, as well as social-emotional development.

Play Psychotherapy Approaches

Considering that play is viewed not only as an essential part of the child's development, but also a means to communicate and express emotions, it has been utilized in the treatment of children who display socially unacceptable behaviors. Schaefer (1976, 1985) and Schaefer and O'Connor (1983) reviewed the use of play in psychotherapy. Three of the approaches discussed were 17

psychoanalytic therapy, structured therapy, and

client-centered psychotherapy.

The foundation to the psychoanalytic approach

involving play was based upon the writings of Freud

(1938). According to Freud, the way in which a child makes use of objects during play can be indicative of their feelings. He observed children as obtaining information regarding the dynamics and growth of adult personality.

Anna Freud (1968) used play to establish rapport with emotionally disturbed children she was treating during the preanalytic stage of therapy. It was her impression that this was vital in preparing the child for therapy because one would gain insight into ones problems. This, also, enabled the therapist to become more familiar with the child's reactions and attitudes towards the things and people in the environment. In the actual therapy process,

Anna Freud used case history, dream interpretation, free association, and drawings.

Klein (1975) believed that the child's play behavior was similar to that of the adult's free association. That is, play was a consistent means of communication for the young child, as was expressive language for the adult.

Therefore, in working with children, Klein considered play to be the ideal substitute for free association. She interpreted the child's play, with respect to its' symbolic representation, as it related to emotions and anxieties 18

brought into therapy. Both toys and dramatization were

utilized with the children as a means to explore their

fantasies.

The structured play-psychotherapy approach developed out of the psychoanalytic play-therapy approach. Similar to the role of the psychoanalyst, the structured therapist assumes the responsibility for the direction of the client's therapeutic experience (Schaefer, 1976, 1985;

Schaefer and O'Connor, 1983).

It was within the context of this therapeutic framework that Levy (1939) developed his release therapy approach. He based his therapy on the rationale that one always needs relief from traumatic events. The child's play situations, according to Levy, result from the child's traumas. These included situations such as peer attack, sibling rivalry, punishment, and separation from parents.

Through play, the child is afforded the opportunity to master such experiences, and to safely leave them behind.

Hambridge (1955) believed that the child's stress could be identified through information obtained from parents and actual observations of the child's play. From these, the therapist recreates in play therapy similar situations which lead to the child's stress. This provides the child with a release for the anxiety maintained by those events. 19

Axline's (1947) play psychotherapy approach for

emotionally disturbed children was developed from the

client-centered psychotherapy approach that Rogers (1951)

utilized with adults. Unlike the directive role assumed by

the therapist in psychoanalytic therapy, the therapist in

the client-centered approach is nondirective. That is, the

individual client is credited with having the ability to

solve ones own difficulties, while developing more effective coping strategies.

For each individual, there is a constant endeavor to satisfy basic needs and achieve self-realization. When these opportunities are hindered, whether it be from the internal forces or the external environment, the individual's efforts continue (Axline, 1947). However, the alternative methods utilized by the individual to obtain satisfaction may be considered to be maladaptive. As these efforts become more inwardly directed, the greater the deviation there is from reality. Therefore, Axline (1976) perceived the goal of the client-centered approach to be one of providing the individual client with a relationship that afforded him the opportunity to maximize ones own potential in re-establishing an acceptable means to meet needs, while assuming a more functional role in society.

In nondirective play psychotherapy, Axline (1947) considered the goal to be similar to that of client-centered psychotherapy. The child was provided a 20

safe, secure environment to express fears, hostilities,

frustrations, and insecurities. This would then allow the

child, through play, to develop a more positive self-image,

while becoming more constructive in the approach to

satisfying basic needs. As in client-centered

psychotherapy with adults, the therapist's role in play

psychotherapy was reflective, not directive. Since the

child's expressive language skills were limited, the

therapist's awareness of the feelings expressed through the

child's play behavior was especially important. It was

essential for the therapist to reflect these feelings in a manner that assured both acceptance and understanding to

the child, regardless of the behavior. It was this

approach on the part of the therapist which facilitated the

child's understanding, as well as the acquiring of the

skills necessary to control maladaptive behavior.

The philosophy of Otto Rank (Schaefer, 1985) was the foundation to Moustakas's (1953) relationship therapy approach. It was Rank's position that to comprehend and constructively use the client's reactions to the therapeutic milieu was the origin of therapy.

Moustakas regarded therapy as a unique opportunity for growth, since it not only involved the child, but also the active participation of the therapist. The therapist would emphasize where the child was at that particular moment in time, while conveying a sense of acceptance and respect for 21

the child. It was Moustakas's belief that children needed

to view themselves as having the potential resources for

improvement, and that they were not dependent upon the

therapist. This could be achieved through play which was

not structured, and where the child was allowed to lead the

way. The therapist would merely listen to the child, not

interpret feelings or direct the child's activities.

Through this process, the child was enabled to make

decisions that would lead to the development of a more positive self-image.

In summary, play is considered to be the child's most

consonant form of communication. The psychotherapy approaches presented above have utilized play as a therapeutic means for children to express their thoughts and emotions.

Parental Involvement in Play Psychotherapy

In an attempt to facilitate the therapeutic process with children, a number of approaches have recommended the use of parents in some capacity.

Anna Freud (1968) did not directly involve parents in psychotherapy. Her emphasis was on counseling parents as to what changes to expect in their children, and to assist the parents in handling these changes. It was her opinion that children should not be seen in psychotherapy, unless the parents were in psychoanalysis, or had been previously. 22

Solmon (1938) believed parents could provide valuable

information to the therapist with respect to the activities

that take place in the home. Working with both the parents

and child in the therapeutic process was recommended by

Solmon (1948). It was his opinion that the young child's

problem could often be resolved through a change in the

parent’s attitude.

Hambridge (1955) considered parental involvement

essential in the child's treatment. Parents were told to

expect an increase in their child's aggressive behavior as

a result of treatment, but were not to change the structure within the home.

Contrary to Anna Freud, Axline (1947) indicated that parents, particularly those of handicapped children, should be directly involved in play psychotherapy because these parents experience problems accepting the child, especially when the child is mentally retarded. Axline believed that parental involvement in play psychotherapy would enable them to cope with their own guilt and inadequacies, and the playroom allows the child the opportunity to express feelings in a safe, secure setting, while in the presence of their parents.

Moustakas (1959) proposed that parents should conduct play psychotherapy with their children in the home. In

1966, Moustakas suggested that when the therapist works with the parents, the child's chances for success in play 23

psychotherapy increased. Parental participation enhances

the child's ability to solve problems, reduce tension,

express emotions, and develop a positive self-image. This

therapeutic relationship also allows the child to become

more aware of himself/herself, to perceive himself/herself

as loved, and to realize his/her importance within the

family.

Through the play psychotherapy experience, Moustakas

(1966) reported that parents believed changes had resulted

in both how they perceived their children, as well as

improvement in the relationship itself. For the child,

Moustakas indicated there was also a change in the child's

perception, viewing the parents now as caring and

accepting.

Wall (1979), using the Axline-Moustakas play

psychotherapy approaches, examined whether parents or

therapists are more effective change agents. Thirty-three

parents, along with their children, were randomly assigned

to one of three groups. The groups were; play

psychotherapy provided by therapist trainees; play

psychotherapy conducted by parents, with directions

provided by therapist trainee through a bug-in-the-ear; and

free play with no therapist present. Play psychotherapy was for eight weeks, forty minutes per week.

The results indicated that there was no significant

difference in the child's emotional adjustment, whether 24

play psychotherapy was conducted by the parent, or

therapist trainee. It was suggested that the short length

of treatment may have affected the results. Treatment did not produce any significant changes in the interpersonal relationship of parent and child. However, for the parents who participated in guided play psychotherapy, there was a significant improvement in their ability to communicate empathically with their children after treatment. Walls concluded that with more structure provided initially to parents, guided play psychotherapy could offer a unique way in the psychotherapy treatment of children.

Guerney (1964) believed that parents could comprehend their child's problems and assist in facilitating the child's problem-solving abilities. He recommended the use of a technique referred to as Filial Therapy, which involved the training of parents to conduct play psychotherapy with their children. The training consisted of play psychotherapy demonstrations and participation in role playing. When the training was completed, the play psychotherapy was conducted at home. The parents would then continue to meet with the therapist, weekly, to discuss progress and difficulties encountered.

By utilizing parents as therapist, Guerney (1964) believed the child's misconception of how the parents felt or behaved, could be resolved. Through this play psychotherapy approach, the child develops a more effective 25 means to express thoughts, feelings, and needs to his/her parents. Guerney was not specific in his reasons, but did not recommend this approach for use with mentally retarded children.

Stover and Guerney (1967) demonstrated that mothers who had received training in Filial Therapy could conduct play psychotherapy. The mothers were found to be empathie, attentive, and responsive to their children. While the mothers assumed an active role in play, the children were allowed to set the direction in play.

Guerney (1976) examined the effects the mothers' participation had on their children's behavior. The results indicated a significant decline in the children's pre- to postplay psychotherapy behavioral problems. In addition, the children, during psychotherapy treatment, exhibited greater independence and less aggressive behavior.

Glass (1987) conducted a study to examine the effects

Filial Therapy had on parental acceptance of child, self-esteem, parent-child relationship, and family environment. There were 15 parents and their children

(N=9) that participated in Filial Therapy. Twelve parents, along with their children (N=ll), received no treatment.

The parents in the Filial Therapy group received 10, 2-hour weekly training sessions. The results indicated that the parents in the Filial Therapy group increased their 26

unconditional love for their children. The perceptions of

expressed conflict in the family also improved.

Louise Guerney (1983) suggested the parent should be

the preferred choice to conduct play psychotherapy. Prom

the supervision provided by a professional, the parent can

be equally effective in play psychotherapy. Play

psychotherapy with the professional leads to changes in the

child's behavior; whereas, with the parent, the

relationship with the child improves, along with the use of what was learned in their daily interactions.

When the parent participates in play psychotherapy, there is no intimidating therapist-child relationship which may result in the child's removal from therapy just as progress is being made. The parent, through experience in play psychotherapy, has learned to be a positive rather than negative influence in their child's life (Bernard

Guerney, 1964).

A number of approaches, along with research, were presented which recommended parental involvement in play psychotherapy. However, parents are usually considered to be a source of the child's difficulties, so therapists typically object to the parents' active participation in problem-solving with their children during psychotherapy

(Guerney, 1983). 27

Play Psychotherapy with Mentally Retarded Children

Axline (1948) used nondirective play psychotherapy with a five-year-old boy, who was considered to be mentally

defective based upon a medical diagnosis and Binet IQ scores of 65 and 68. Initially, in the play situations, the boy was described as lethargic and disinterested in play. However, as the sessions progressed, he was reported to be alert and responsive. The boy, also, was provided with a group-play experience. The boy appeared to improve, both physically and psychologically, based upon his play- therapy participation. A one-year follow-up indicated that he continued his adjustment within the home and adapted well in school. At that time, his IQ score on the Binet was reported to be 105; thus, probably indicating that he was more emotionally disturbed than mentally retarded to begin with.

In another study, Axline (1949) used nondirective play psychotherapy with 15 children, ages six and seven, who were identified as behavior problems. Each child was seen individually for eight to twenty play-therapy sessions.

Ten of the children had IQ scores ranging from 66 to 74 when play therapy began. In one group, there was no change in post play-therapy IQ scores. For the other group, an increase in post play-therapy IQ scores occurred (an average of 21 points). The remaining five children, whose pre play-therapy IQ scores ranged from 105 to 114, showed 28

no change in post play-therapy IQ scores. Most of the

children appeared to benefit from the play-therapy

experiences, though not to the same extent.

Axline (1949) demonstrated that play therapy can

result in IQ score gains for some children whose initial IQ

scores were low (Cowen and Trippe, 1963). However, the children were not diagnosed as mentally retarded from the outset; as with the child reported on by Axline (1948), these children were also probably more emotionally disturbed.

Maisner (1950) discussed the use of play psychotherapy with 15 children between the ages of 8 and 13. As a part of their habilitation program, the children had been referred for maladaptive behavior based on teacher reports or results from the Rorschach test. The children had been institutionalized at Wayne County Training School from one month to three years, and their IQ scores ranged from 41 to

86. Each child was seen for a minimum of six individual play-therapy sessions. Most of the children received additional individual and group play therapy or counseling. Maisner reported every child made some improvements. The play-therapy program was considered to be successful based on test results, school progress and teachers' reports. Regarding the selection of the 15 children, Maisner gave no indication of how this was accomplished. That is, were these children selected 29

randomly from a maladaptive population, or because of their potential for success in play therapy, determined from

teacher reports? In addition, there were other components

of the children's habilitation program; so without a no-treatment group, the success Maisner reported cannot be based only on play-therapy participation.

A group psychotherapy approach that included some play materials was reported on by Abel (1953). This approach was used with three boys, ages 11, 13 and 14, who had been diagnosed as mildly mentally retarded and destructive.

Group psychotherapy was held two hours a week, for three months. Through role playing and expressive communication, the boys achieved approval and personal satisfaction from the group activities. Abel indicated a generalization of these improvements to the school setting; however, the effectiveness of group psychotherapy was based on observations of the boys. Actual pre- and posttreatment measurements of the boys' behavior would have provided much more useful information regarding the effectiveness of the group psychotherapy approach discussed by Abel.

Mehlman (1953) utilized a nondirective, group play psychotherapy approach with 32 institutionalized, mentally retarded children. The average age of these children was

10 years, and their IQ scores ranged from 50 to 78. Six weeks prior to, and after therapy, each child was assessed using the Stanford-Binet-Form L, Grace Arthur Point Scale 30

of Performance, Rorschach Psychodiaqnostic, California Test

of Personality? and the Haggerty-Olson-Wickman (HOW)

Behavior Rating Scale). The children were assigned to one

of three groups based on their overall adjustment rank

obtained from ratings on the Rorschach. There were eleven

children who received group play psychotherapy, which was

divided into two play groups of six and five children.

Both groups were seen for 29 sessions over a 16-week

period. The other two groups were used for control. One

group received no actual therapy, while the other was shown

movies. This group was included to insure that any

observed changes in the group psychotherapy condition were

a function of actual therapy, rather than from the effects

produced by changes in their institutional routine. The

results of the HOW Behavior Rating Scale indicated that the

play psychotherapy group demonstrated some improvements, as

compared to the group that received no therapy.

Mehlman's use of a tool to assess adaptive behavior and a control group, represented a well designed study.

Some of the children, however, were not mentally retarded.

In addition, there was no indication that the children experienced emotional difficulties or needed therapy.

Mundy (1957) discussed the use of nondirective play psychotherapy, modified by an analytical therapist who emphasized transferences, with fifteen institutionalized children, ages 5 to 12 years old, who had been diagnosed as 31

imbeciles. All the children were reported to exhibit some

behavior problems. It was not indicated how the children

were selected for this study. Each of the fifteen children

received nondirective play psychotherapy for a period of

nine months to one year. There was a control group of ten

children, matched for age, who were provided with only the

regular services made available in the institution. After

treatment, the play-psychotherapy group demonstrated an

increase in social behavior, as well as an increase of 9 IQ

points on the Stanford-Binet Intelligence Scale (Form L).

According to the staff, the social behavior of all children

in play therapy improved. Mundy also reported improvements

in the children's verbal skills. This was an indication of

the beneficial effects play therapy could have upon the

expressive language skills of the mentally retarded

children. A one-year follow-up indicated that, of the

children who received individual play psychotherapy, four

maintained their gains, and six demonstrated further gains

in IQ scores. These same six children had been moved to an

environment termed better. The same follow-up revealed

that eight of the control-group children remained unchanged.

Group play psychotherapy was conducted with eight severely retarded, preschool children, who were referred for pediatric services (Woodward, Siegel and Eustis,

1958). All of the children had some schizoid 32

characteristics, except for one. The parents also were

found to have some personality problems. The children's

initial participation in group play therapy was limited.

They appeared overly concerned about themselves, and

fearful. After two years of therapy, the children were

more actively involved in play, less fearful, and less

cautious. The children who responded the most to the group

play experience were found to have fewer psychotic

features. The children may have been more emotionally

disturbed than mentally retarded.

Individual play therapy was used by Subotnick and

Callahan (1959) with eight institutionalized, mentally retarded boys. The boys, 8 to 12 years old, had some emotional difficulties. Tests of measured intelligence revealed that the boys' IQ scores ranged from 53 to 88.

During the eight weeks prior to therapy, the boys served as their own control group. This was followed by eight weeks of individual play therapy, twice a week, for 45 minutes a session. There were no significant changes found based on the individual post play-therapy measurements. Based on the range of IQ scores, some of the children were not mentally retarded.

Leland, Walker and Toboada (1959) used an unstructured materials-unstructured group, play-psychotherapy approach with eight institutionalized, mildly and moderately retarded boys, ages 4 to 10 years old. This approach was 33

later discussed in detail by Leland and Smith (1965). The

boys were referred to therapy for difficulties related to

their social maturity and emotional maturity. Four of the

boys exhibited aggressive and destructive behaviors. The

other four displayed withdrawal behaviors. For over six

weeks/ the boys received group play psychotherapy.

Analysis of therapy consisted of pre- and posttherapy

assessments. Included in this were staff observations and

therapist notes. A follow-up observation was also

completed seven months after therapy was concluded.

According to the Vineland Social Maturity Scale, there were

no statistically significant changes in the boys' social maturity. However, there were some improvements observed

in the social maturity of the withdrawn boys, as compared

to the aggressive boys. The institutional staff did report

that, as a result of group play therapy, six of the eight boys were not viewed as difficult to manage behaviorly.

The aggressive behavior of two boys was observed to have increased. At the seven-month follow-up, two boys were to be discharged, two continued to show improvement, and two others remained unchanged since posttherapy observations.

This study represented one of the first attempts to assess the effects that play therapy could have upon the mentally retarded child's adaptive behavior using a standardized instrument. 34

Individual and group play psychotherapy were used by

Albini and Dinitz (1965) with mentally retarded,

institutionalized boys. To compare the effects of this

treatment, there were 37 boys who demonstrated aggressive

behavior, and 36 boys not considered to have behavior

problems. The boys were matched according to age (7 to 15

years old), IQ scores (40 to 78), and time spent in the

institution. There were a total of 48 half-hour play-

therapy sessions. There were no significant changes in the

boys' behavior as a result of their participation in play

therapy. According to a behavior checklist completed by

the teachers, there was some improvement in the boys'

classroom behavior. The results may be questionable since the children in the control group displayed no behavior problems in contrast to the children who received play therapy. In addition, some of the children were not mentally retarded.

In an effort to further utilize play as a psychotherapy approach with mentally retarded children who displayed either socially unacceptable behavior or have emotional difficulties, Leland and Smith (1965) developed a theoretical construct, along with a play-psychotherapy approach, designed to be used with mentally retarded children, regardless of their level of measured intelligence or adaptive behavior, whether it be mild, moderate, severe, or profound. The approach emphasized 35

working with the child at their present functioning level.

Through the interpersonal relationship established with the

child, the play psychotherapist, in this approach,

facilitates behavioral changes that lead to the child's

reduced visibility in the community. To achieve this, the play psychotherapist utilized "cognitive stimulation" and principles of learning.

Assisting the child to acquire cognitive, as well as behavioral control, and to then apply these skills in daily

life, is stressed by this approach. The therapeutic process consists of unblocking the child's cognitive functions. To achieve this, the techniques of reward, punishment, and cognitive stimulation are used. When the play psychotherapist in this approach rewards the child's behavior, the behavior, itself, is allowed to continue, and the play, itself, becomes rewarding. However, when the behavior displayed is not consistent with what the play psychotherapist wants, the therapist intrudes and blocks the behavior from occurring (punishment). This is accomplished by the play psychotherapist's questions and talking to the child about his/her behavior (cognitive stimulation). The idea behind this concept is to force the child to think about his/her behavior. This facilitates the child's cognitive awareness of his/her own behavior and a striving to maintain control of that behavior. Through modeling and imitating, the play psychotherapist 36

demonstrates what the child needs to do in order to gain

rewards from the therapist, that is, to be allowed to

continue with acceptable behavior. The cognitive blocking

for the mentally retarded/developmentally disabled, emotionally disturbed child is considered to result from organic, sociological, or psychological interference.

Based on this consideration, it becomes essential for the play psychotherapist of this approach, not to place cognitive demands on the child which are beyond his/her present developmental level, or inconsistent with the child's perceived need to reduce tension.

The structures of both play materials and the therapeutic process in this approach are manipulated and controlled. One approach alone was not considered to be adequate to meet the therapeutic needs of all children.

Since each child exhibits various coping difficulties,

Leland and Smith (1965, 1972) presented four psychotherapy approaches with varying degrees of structure. These were unstructured materials-unstructured therapeutic approach

(Ü-Ü), unstructured materials-structured therapeutic approach (Ü-S), and structured materials-structured therapeutic approach (S-S). The child's developmental functioning level and maladaptive behavior determined which of these play-therapy approaches were to be utilized

(Leland and Smith, 1965, 1972; Leland, 1983). 37

Newcomer and Morrison (1974) investigated the effect

individual and group play psychotherapy would have on the developmental level of 12 institutionalized, mildly and moderately retarded children. There was no indication of how the children were selected. The children, ages 5 to 11 years old, were randomly assigned so that four received individual play therapy, four were involved in group play therapy, and four received no therapy. Based on direct observations, each child was evaluated pre- and posttherapy with the Denver Developmental Screening Test (DDST). For six weeks, the children participated in ten hours of directive play therapy. This was followed by ten hours of nondirective play, also for six weeks. The treatment concluded with another ten hours of directive play therapy, for a six-week period. Based on the DDST, the intellectual-social functioning of the children improved as a result of their participation in play therapy. The mean scores on the DDST increased continuously over thirty play sessions for the children in both individual and group play therapy. The scores remained basically unchanged for the children who received no therapy. There was no significant difference in the scores obtained by the children in individual or group play therapy. The changes reported in the behavior of these institutionalized children may have resulted from the attention received, not their participation in play therapy; therefore, a follow-up to 38

examine whether or not the behavioral changes were

maintained would have been useful. It could not be

determined which approach, directive or nondirective play

therapy, was the most effective.

In another study, Morrison and Newcomer (1976)

compared directive and nondirective therapy with 14

institutionalized, mildly and moderately retarded

children. The children, selected by institutional staff, were not involved in any other treatment. The children were randomly assigned to receive directive play therapy

(N=5, mean age 9.5 years), nondirective play therapy (N=5, mean age 9.8 years), and no treatment (N=4, mean age 10 years). The Denver Developmental Screening Test (DDST) was completed pre- and posttreatment. The children received eleven, 45-minute play-therapy sessions for three weeks, from one of twelve nursing students. The nursing students were provided with some instructions in play therapy and one hour of supervision per week. Therapy was conducted in one of six playrooms, utilizing the structured or unstructured therapeutic approaches of Leland and Smith

(1965). According to the DDST fine-motor and personal-social scales, the children participating in play therapy demonstrated some improvements, as compared to the no-treatment group. There was no significant differences indicated between the two treatment groups. Different results may have been obtained had Morrison and Newcomer 39

utilized fewer therapists, and the eleven therapy sessions

been extended over a longer period of time.

A study conducted by Sherwood (1981) focused on the

effectiveness of free play versus play therapy, using

same-age and younger-age adaptive peers, to develop the

adaptive behavior and social interaction skills of

maladaptive, moderately retarded, school-aged children,

residing in the community. The children were selected

based on their Part II, Adaptive Behavior Scale (ABS),

(Nihira, Foster, Shellhaas and Leland, 1975) scores, at the

80th percentile or greater. Specifically, the domains of

Violent-Destructive Behavior, Antisocial Behavior,

Rebellious Behavior, Untrustworthy Behavior, and

Psychological Disturbances were used. The adaptive peers

had to display fewer domains of maladaptive behavior than

the socially maladaptive children they were to interact with, in play. The fourteen boys and ten girls selected were placed in twelve dyads, which included a socially adaptive, same-age or younger-age peer, and a socially maladaptive child. The twelve dyads were then randomly assigned to the conditions of either free play, or play therapy. For the six dyads participating in play therapy, an unstructured materials-structured therapeutic approach was utilized (Leland and Smith, 1965). Eight female graduate students, trained in Leland and Smith's (1965) play-therapy approach, were used as therapists in both 40

conditions. In the free-play setting, the therapists did

not interact with the children.

A pre and post play-therapy (ABS) and social

questionnaire (Furman and Masters, 1978) was adapted by

Sherwood for this study. The results of the ABS indicated

that the Violent-Destructive Behavior of the same-age group

(free play and play therapy) and younger-age group (free

play) increased. This behavior decreased for those

children in the younger-age, play-therapy group. There was

an increase in the personal independence (independent

functioning and domestic activity domains of the ABS) for

the same-age, free-play and play-therapy children. There

was a decline in this same area for the younger-age, free-

play and play-therapy children. As for cognitive skills,

domains of economic activity, language development, and

numbers and time, all the children showed improvement.

Play therapy facilitated the personal motivation of the

maladaptive, as well as adaptive children. For the

children in free play, there was a decrease in the area.

The social motivation for the adaptive peers was

significantly greater than that of the maladaptive

children.

According to the social questionnaire, the maladaptive children gave significantly more or less punishment, but what they received from classroom peers remained unchanged. For the children participating in play therapy. 41

as opposed to those children in free play, their rate of

reinforcement was greater. There was no significant

difference in the punishment for children in either

condition. Reinforcement was given and received

significantly more with peer and adult therapists in play

therapy than in the free-play setting. In general, the

study (Sherwood, 1981) was well designed, demonstrating

that including younger, mentally retarded children in play

therapy could positively affect the behavior of older

retarded children, and play, itself, facilitated the

cognitive abilities of all children participating.

However, it would have been useful to contrast the two

treatment groups with one that received no treatment; and

for the number of dyads, eight therapists may have been too

many.

In a case study, Moreno (1985) combined music therapy

and nondirective play therapy for use with a moderately

retarded, 17-year-old boy. The boy was hyperactive and

destructive toward classroom materials. Initially, the boy was resistant to therapy. By the third session, he

displayed some interest in the musical instruments. During

the fourth session, the boy was playing wooden sticks, but continued to play when the therapist began to play the piano. By the sixth session, the boy was receptive to learning music. As a result, Moreno reported the boy's classroom destructive behavior occurred less frequently. 42

The boy also isolated himself less and attended more to

classroom tasks.

Based on the research reviewed and the therapeutic

approach discussed, play psychotherapy has been demonstrated to be an effective approach to utilize with mentally retarded/developmentally disabled children who display maladaptive behavior and/or have emotional problems. Li (1981) indicated that, as a therapeutic approach with retarded children, play has been largely overlooked. An extensive review of the literature supports that position.

Parents as Therapeutic Change Agents with Mentally Retarded Children

Parental involvement in the play therapy process with mentally retarded children was suggested by Axline (1947),

Leland and Smith (1972), and Wehman (1977). However, despite further support for parental participation in play therapy (Li, 1981), a comprehensive review of the literature has revealed little research. In a 1972 study,

Seitz and Terdal examined parent-child interactions through a combined modeling and nondirective play-therapy approach. A four-year-old, mentally retarded boy, along with his mother, participated in the study. The boy had been referred to a university affiliated program for mentally retarded. The mother reported her son was 43

overactive, noncompliant, and displayed frequent temper

tantrums. The boy received individual play therapy, four

times a week, for two months. The therapeutic goals were

to improve attention span, self-image, and the use of

structured play, while providing a safe environment for the

expression of aggression. Each play-therapy session was

observed by the mother, along with another therapist who

answered her questions. The mother had been instructed to observe the interactions that occurred between the therapist and her son. When the mother was finally brought into the play-therapy situation, her behavior closely resembled that of the observed therapist. The mother received positive feedback after each session for demonstrating the desired behavior. The therapeutic gains made in the child's behavior with the therapist were maintained once the mother entered into play therapy. In addition, the results indicated a positive change in the mother's perception of her son, and the procedures learned were also used in the home, which enhanced the effect of play therapy. The significant implication of this study was the potential benefit that could be derived from parental involvement in play therapy with mentally retarded children.

A procedure similar to that of Seitz and Terdal (1972) was utilized by Seitz and Hoekenga (1974) to investigate parent-child interactions. The participants, four parents. 44

along with their mentally retarded children, were involved

in the program for one hour a day, three days a week, for

eight weeks. The therapists were graduate students who had

been specifically trained to comment on the child's

activities, reflect and expand upon the child's

verbalization, and participate in the activities chosen by

the child. For the first six sessions, parents observed

the therapists engaged in play with their children, while

another student provided a description of what was taking

place. Contingent upon their own feelings and responses

from the children, the parents began to replace the therapists during the third week. The parents were completely involved the last two weeks of the program. The verbal interactions that occurred between the . parent and child were used to examine progress. When the program concluded, all the children had increased the mean length of verbal utterances. According to Seitz and Hoekenga, parents' reduced verbalization could have contributed to this, since the children were provided with a greater opportunity to participate in the verbal exchange. In addition, changes in parental commands and questions were noted. When used to express an interest in the child's ongoing play behavior, there was a positive increase in parental responses. As a result, the children increased their positive responding. It appeared that both the parent and child were forced to cognitively process the 45

ongoing activities prior to responding to each other.

Estreicher (1983) adapted the approach of Leland and

Smith (1965) to conduct family therapy with four families.

Each of the families had a child diagnosed as mentally

retarded, with social-emotional difficulties. The mean

chronological age of the children was five years, seven months. Estreicher found that parents and siblings

increased verbal communication and eye contact with the

child, and included the child in family activities. The mothers appeared to use fewer statements to control behavior, and those by the fathers were considered more appropriate. The siblings indicated an interest in the activities of their brother or sister and were not critical of the retarded child's behavior. In general, the family's interactions with their retarded child improved. Although the study was designed more to investigate family therapy, the implication remains unchanged, that parental involvement can positively impact the therapeutic process.

Training the parents of mentally retarded/develop mentally disabled children in behavioral techinques to manage noncompliance or other inappropriate behaviors, has been the focus of several behavioral investigators

(Hawkins, Peterson, Schweid, and Bijou, 1966; Mash, Lazere,

Terdal, and Garner, 1973; Mash and Terdal, 1973; Tavormina,

1975; Eyberg and Matarazzo, 1980; and Van Hasselt, Sisson, and Aach, 1987). Other behavioral researchers (Baker and 46

Brightman, 1984; Baker and McCurry, 1984; Brightman, Baker,

Clark, and Ambrose, 1982; Clark, Baker, and Heifetz, 1982;

and Prieto-Bayard and Baker, 1986) have emphasized training

parents in behavioral procedures to teach self-help skills, as well as manage behavior problems.

Language intervention programs with developmentally delayed children is another area where parents have been utilized. MacDonald, Blott, Gordon, Spiegel, and Hartmann

(1974); McConkey, Jeffree, and Hewson (1979); and McConkey and O'Connor (1982), have all demonstrated that parents could facilitate improvements in their child's language skills.

A study by Breiner and Forehand (1982) which involved parent training is representative of the behavioral research in this area. The study focused on training parents in behavioral techniques to change the noncompliant behavior of their language and developmentally delayed children. The subjects, ten mother-child pairs, were randomly assigned to a parent training group, or discussion control group. The mean age of the children in the parent group was 57.8 months and 59.8 months for the discussion group. Each group met separately, for 90 minutes a week, for a total of six weeks. The parent group was trained in the use of positive interactions, appropriate use of commands, and a time-out procedure. The control group discussed disciplinary problems. 47

Based on the results, the mothers in the parent

training group demonstrated a significant increase in

attending to and rewarding their children's appropriate

behavior. There, also, was an increase in contingent

attention and the use of clearer commands. No significant

changes in these areas were reported for the discussion

control group. The attitudes of the mothers in the parent

group, in contrast to those of the discussion group, positively changed. Although there were no significant changes in the children's behavior, the parent training group mothers reported improvements and, based on their training, felt confident in handling future behavior problems. These opinions were not found in the discussion group. Breiner and Forehand attributed the lack of positive change to the children's behavior as a result of the vague, interrupted commands given by the mothers, not the refusal of the child to comply. It was also suggested that a larger sampling may lead to significant results.

The absence of change in the children's behavior (Breiner and Forehand, 1982) may not be related to the type of commands issued, but, rather, inherent in the behavioral approach, itself. For the most part, the approach has relied upon the use of our external locus of control; that is, the child is not forced, encouraged, or provided the opportunity to assume cognitive control. This would then account for the confidence expressed by the parents in 48

dealing with future problems.

Regardless of the approach, it was evident from the research presented in this section that parents can assume a therapeutic role in changing the behavior or language skills of their retarded or developmentally delayed children.

In summary, the present chapter has reviewed a number of approaches found to be applicable with mentally retarded children who have emotional difficulties, and/or exhibit socially unacceptable behaviors. While the therapeutic value of play and the advantage of utilizing parents with these children is recognized, further research is needed

(Li, 1981). The present study was designed to investigate the changes in children's adaptive behavior and adult/child interactions that may result when parents, as compared to graduate students, conduct play therapy. These two treatment groups will be contrasted with one that receives limited treatment. CHAPTER III

METHODOLOGY

The present study was designed so that mentally retarded, school-aged children who display socially maladaptive behavior, will receive play therapy from their trained parent, a trained graduate student in psychology, or receive limited treatment.

The study is intended to investigate the effectiveness of parents as compared to graduate students in facilitating improvements in the children's adaptive behavior and adult-child interactions. These two treatment groups were to be contrasted with one that received limited treatment.

Sample Selection

The sample was selected from four community training centers, which are operated by the Franklin County Program for the Mentally Retarded (PCPMR).

The Adaptive Behavior Scale (ABS)(Nihira, Foster,

Shellhaas and Leland, 1975), which was completed by the classroom teacher at the request of the author, was utilized to select the children who exhibited socially unacceptable behavior. The author then examined the

49 50

protocols of each child (N=80) to determine the number of

Part II maladaptive domains that were at the 80 th

percentile or greater. Five Part II domains were

specifically examined to evaluate extrapunitive behavior.

These domains were; Violent and Destructive Behavior;

Antisocial Behavior; Rebellious Behavior; Untrustworthy

Behavior; and Psychological Disturbances. The children at or above the 80th percentile on any of these domains were selected.

Sample

The sample initially selected for participation in the present study consisted of 30 mentally retarded children

(20 males, 10 females). However, prior to actual treatment, three parents withdrew their children from participation (19 males, 8 females). All children met the established criteria previously discussed. The ABS ratings obtained for each child (N=27), completed by the classroom teacher, can be found in Appendix A.

Based upon the information obtained on the consent letter (see Appendix B), the parents or guardians who indicated a willingness to participate directly in play therapy with their own children were assigned to the parent-therapist group (N=8). The remaining children were randomly assigned to either the graduate student-therapist group (N=9) or the limited-treatment group (N=10). Parents 51

received $20.00 for allowing their children to take part in

the present study; an additional $30.00 was paid to parents who participated in play therapy with their children. This was indicated in the consent letter sent to each parent or guardian (Appendix B).

The demographic data for the children participating in the study is reported in Table 1. The information

TABLE 1

DEMOGRAPHIC DATA FOR SUBJECT SAMPLE

PARENT GRADUATE LIMITED THERAPIST THERAPIST TREATMENT GROUP (N=8) GROUP )N=9) GROUP (N-10)

SEX 3-M 8-M 8-M 5-F 1-F 2-F

MEAN (C.A.)* 11.875 10.00 10.00

AGE RANGE* 9-15 6-14 7-15

RACE 6-CAUCASIAN 3-CAUCASIAN 6-CAUCASIAN 2-BLACK 6-BLACK 4-BLACK

* Reported In years

summarized pertains to the children's sex, mean chronological age (C.A.), and age range of each group, as well as their race.

Information regarding the natural parents' marital status, mother's age, father's age, mother's education, and father's education, is contained in Appendices C, D, E, F and G, respectively. 52 Dependent Variables

AAMD Adaptive Behavior Scale (ABS)

The Adaptive Behavior Scale (ABS) is a behavior rating

scale developed by Nihira, et al., (1975) to objectively measure adaptive behavior. It was designed to be utilized with mentally retarded/developmentally disabled, and/or emotionally disturbed persons who are at least age six and older. The ABS is an assessment tool that requires no specialized training for the individual respondent. The individual must have either observed the person, or have knowledge regarding their daily behavior.

The ABS consists of two parts. Part I of the ABS is concerned with the individual's adaptive behavior, and is comprised of ten domains. Nihira, et al., (1975) reported a mean interrater reliability of .86 for Part I of ABS.

The specific domains utilized for the present study were:

Independent Functioning; Economic Activity; Language

Development; Numbers and Time; Domestic Activity;

Self-Direction; Responsibility; and Socialization.

There are thirteen domains on Part II of the ABS, which are utilized to measure an individual's maladaptive behavior regarding personality and behavior disorders

(Nihira, et al., 1975). The interrater reliability for

Part II of the ABS was reported by Nihira, et al., (1975) to have a mean of .57. From the thirteen domains on Part

II of the ABS, five domains related to the extrapunitive 53

behavior (social maladaptive) were used for the present

study. These were as follows:

I. Violent and Destructive Behavior

II. Antisocial Behavior

III. Rebellious Behavior

IV. Untrustworthy Behavior

XIII. Psychological Disturbances

Adult-Child Interactions

A modified format of the behavioral coding system presented in Forehand and McMahon (1981) for use with delayed children (Breiner and Forehand, 1982) was used in the present study to score adult-child interactions during play psychotherapy. Since the coding system scored the use of time out and warnings, these were not applicable to therapeutic approach employed in the present study; therefore, both were deleted from the coding manual. The adult behaviors to be observed were: 1) attends and rewards; 2) directions; 3) questions; 4) contingent attention. The child behaviors observed were; 1) response or nonresponse to directions; 2) unacceptable behaviors.

The coding manual along with a sample scoring sheet can be found in Appendix H. 54

Procedures

Pretreatment

The ABS was administered to the parents of the 27

children four weeks prior to play therapy. To obtain this

information, the parents were randomly assigned to either a graduate student not participating in play therapy, or the author.

The week treatment began, the parents in the parent- therapist group (7 females, 1 male) received one, four-hour training session regarding play therapy from the author.

The training focused on familiarizing the parents with the nature of play therapy, the play materials, and the role of the therapist in the Leland and Smith (1965) Unstructured

Materials-structured Therapy approach. The training consisted of videotaped demonstrations (Deutsch and Leland,

1976) and instruction from a handout developed by the author, based on the Leland and Smith (1965) chapter.

Unstructured Materials-structured Therapy approach. This is presented in Appendix I.

Treatment

The therapists for play therapy were the eight parents trained by the author, as well as two graduate students trained in the Leland and Smith (1965) play-therapy approaches. The graduate students had a minimum of one year of supervised experience. The 19 children comprising the graduate-student group (N=9) and the limited-treatment 55

group (N=10) were randomly assigned to the two graduate

students. Each child in the parent-therapist group and the

graduate student-therapist group were seen in play therapy

for 12, 30-minute sessions. These sessions were held twice

a week for six weeks. After each session, the author or

one of the graduate student therapists, was available to

answer questions and provide feedback to the parent

therapists.

Play therapy for each of the children was conducted in

a room set up with unstructured-play materials at the

Nisonger Center, The Ohio State University. The materials

utilized were sand, water, plastic bottles, buckets,

shovels, bubbles, Play-doh, musical instruments,

construction paper, crayons, balls, and wooden blocks.

The parent and graduate student therapists were

actively involved in each play-therapy session, utilizing the Leland and Smith (1965) Unstructured Materials- structured Therapy approach.

Limited-Treatment Group

The therapists for the limited-treatment group were the two graduate students who provided therapy for the treatment group. The children receiving limited treatment

(N=10) were randomly assigned to the two graduate students. The children met with their assigned graduate student therapist for two, 30-minute play sessions during the initial and final weeks of treatment. 56

The playroom and unstructured-play materials utilized

by the two treatment groups were also used with the

children in the limited-treatment group. As with the

treatment group, the graduate student therapists actively participated in play, and used the same Unstructured

Materials-structured Therapy approach (Leland and Smith,

1965).

Videotape Observations

The parent and graduate student therapists were informed that 10 minutes of two play-therapy sessions would be videotaped. Since children in the limited-treatment group were seen only twice, all children were videotaped during the initial and final sessions. A Panasonic videorecorder was used. One child in the limited-treatment group was unavailable for videotaping.

Individual Goals

Play therapy goals were established for each child, including those in the limited-treatment group, during the initial play-therapy session. For the parent-therapist group, the goals were determined by the author or graduate student therapists after a review of the initial videotape. The parent therapists were told of these goals prior to the second play-therapy session. Upon completion of the final videotaping, progress toward these goals was examined. Again, this process was completed by the author or graduate student therapists. 57

Posttreatment

Four weeks after the final play-therapy session, the

author and the same graduate student used to collect

pretreatment information, again administered the ABS to the parents.

The parents were also requested to complete a Consumer

Satisfaction Scale (Forehand and McMahon, 1981) to examine parental perceptions of the play therapy received. A copy can be found in Appendix J.

Videotape Ratings

Two graduate students, naive to the purpose of the present study, received approximately 50 hours of training in the behavioral coding system adapted from the one utilized by Breiner and Forehand (1982) to score adult-child interactions. The training method utilized was based on the format discussed in Forehand and McMahon

(1981). This consisted of role-play situations and videotaped observations.

Two videotapes of adult-child interactions were recorded, one specifically to train the observers and the other for reliability purposes. These tapes were recorded in the same playroom used in the present study, with the same play materials, and using the same unstructured materials-structured therapy approach. To further simulate the videotapes to be coded, the training and reliability tapes were each ten minutes in length. A tone, sounding in 58

30-second intervals, was included to signal a new recording

interval. The adults interacting with the children were

the two graduate students who served as therapists. The

children met the established criteria, but were not

participants in treatment.

Prior to the observers’ viewing the training tape, the

author along with another trainer simultaneously coded the

adult-child interactions. Whenever disagreement occurred

as to how to code the observed behavior, the rules outlined

in the coding manual (see Appendix H) were used as the

determining factor.

The observers’ training continued until 80% agreement was obtained with the ten-minute, prescored videotape.

Reliability was calculated for each behavior across the entire videotape in the following manner: total agreement for overall videotape, divided by total agreement plus disagreements for the overall videotape (Forehand and

McMahon, 1981). Reliability checks were conducted before and after the actual coding of the play therapy videotapes. The percentage of observer agreement with the prescored reliability tapes and interrater agreement are shown in Table 2.

The videotaped sessions for each child were randomly assigned to one of the two observers. Each ten-minute videotape was coded so that a tone would sound every 30 seconds to signal the start of a new recording interval. 59

The observers were each equipped with score sheets and a

coding manual.

TABLE 2

PRESCORED TAPE AND INTERRATER RELIABILITY

PRE POST OBSERVER 1 OBSERVER 2 OBSERVER 1 OBSERVER 1 OBSERVER 2 OBSERVER 1 AND AND AND AND AND AND TAPE TAPE OBSERVER 2 TAPE TAPE OBSERVER 2

ADULT BEHAVIORS

Attends 83 88 83 86 86 100 Rewards 88 82 88 100 100 100 Questions 92 83 83 78 67 86 Total Directions 85 90 89 100 100 95 A Direction 100 100 100 91 91 100 B Direction 82 86 83 88 88 100 Contingent Attention 100 100 100 100 100 100

CHILD BEHAVIORS

Response to Direction 100 100 100 91 91 100 No Response to Direction 100 100 100 100 100 100 Unacceptable Behavior 100 100 100 100 100 100 CHAPTER IV

RESULTS

The data was analyzed with respect to changes in the

children's scores on the Adaptive Behavior Scale (Nihira,

et al., 1975), adult-child interactions, and consumer

satisfaction with treatment. The type of treatment

received was the independent variable (parent-therapist

group, graduate-therapist group and limited-treatment

group). The results from the data analyses will be

presented in the following order: Analysis of Adaptive

Behavior; Analysis of Adult-Child Interactions; and

Analysis of Parental Satisfaction with Treatment.

Analysis of Adaptive Behavior

To investigate changes in the children's adaptive behavior, a mixed analysis of variance (one between and one within-group factor) was performed, utilizing the Adaptive

Behavior Scale (ABS) scores obtained from the pretreatment and posttreatment assessments. There were eight domains

(percentiles) from Part I of the ABS used in the present study; to reduce the number of measures, the domains were combined into four dependent variables (Leland, Shoaee and

60 61

Vayda, 1975). The four dependent measures were as follows:

Personal Independence included the domains of Independent

Functioning and Domestic Activity; the domains of Economic

Activity, Language Development, Numbers, and Time comprised

the Cognitive Triad; Personal Motivation consisted of

Self-Direction domain; and the domains of Responsibility and Socialization made up Social Motivation. The raw scores from the five domains on Part II of the ABS, representing socially maladaptive behavior, were analyzed.

These were Violent and Destructive Behavior, Antisocial

Behavior, Rebellious Behavior, Untrustworthy Behavior, and

Psychological Disturbances. The means and standard deviation for each of these nine domains are shown in

Table 3. A copy of the pretreatment and posttreatment ABS ratings can be found in Appendix K.

The F values obtained from the mixed analysis of variance are contained in Table 4. For the four measures on Part I of the ABS, there were no significant (p<.05) treatment effects, time effects, or interactions.

Table 4 shows that no significant treatment effects or interactions (p<.05) were found for the five domains on

Part II of the ABS. There was, however, an indication of a significant time effect for three of the domains. These were Antisocial Behavior (F [1,24] = 19.20, p<.001).

Rebellious Behavior (F [1,24] = 14.68, p<.001), and

Psychological Disturbances (F [1,23] = 9.30, p<.01). As TABLE 3

MEANS AND STANDARD DEVIATIONS FOR ABS BY TREATMENT GROUP

Parent Graduate Limited Therapist Therapist Treatment Group (N=8) Group (N°9) Group (N=10)

ABS STANDARD ABS STANDARD ABS STANDARD ABS MEANS DEVIATION MEANS DEVIATION MEANS DEVIATION

PART I (PERCENTILES)

Personal 51.12» 18.25 50.27 11.33 53.85 19.23 Independence 48.03b 20.17 50.83 14.14 57.20 18.32

Cognitive 51.51 19.59 51.24 18.21 59.56 12.28 Triad 53.02 19.67 53.54 19.54 60.96 12.87

Personal 46.12 30.13 51.22 17.34 51.00 22.97 Motivation 36.25 23.93 54.22 19.49 51.40 27.43

Social 58.43 15.75 64.88 11.19 58.70 17.84 Motivation 56.75 22.98 66.11 21.80 57.25 19.23

PART II (RAW SCORES)

Violent/Destructive 4.87 4.58 2.66 2.23 5.90 4.50 Behavior 3.87 3.75 3.00 4.27 3.50 3.83

Antisocial 6.25 3.01 4.66 4.15 6.10 4.43 Behavior 2.62 3.29 3.11 3.44 4.00 3.49

Rebellious 6.75 3.05 6.44 6.98 8.90 6.90 Behavior 4.12 2.79 3.33 5.19 4.70 3.97

Untrustworthy .62 1.18 .22 ; .66 .10 .31 Behavior .50 .75 .00 .00 .40 1.26

Psychological 5.87 2.79 7.33 3.46 8.00 4.89 Disturbances 5.12 3.94 4.44 3.50 4.00 3.82

» Pretreatment b Posttreatment 63

TABLE 4

ANOVA FOR ADAPTIVE BEHAVIOR SCALE DOMAINS

______SOURCE BETWEEN TREATMENT ABS GROUPS____ TIME TIME X's GROUP df MS df MS df MS PART I

Personal 2 189.53 .08 1 .99 .21 2 46.05 .09 Independence 24 502.78 24 87.16 24 87.16

Cognitive 2 395.48 .73 1 40.42 .98 2 1.10 .03 Triad 24 540.30 24 41.25 24 41.25

Personal 2 659.56 .65 1 62.37 .49 2 194.35 1.52 Motivation 24 1111.09 24 127.82 24 127.82

Social 2 355.87 .64 1 5.46 .04 2 11.64 .09 Motivation 24 555.18 24 129.71 24 129.72

PART 11

Violent/Destructi ve 2 18.27 .67 1 13.99 3.60**** 2 8.86 2.28 Behavior 24 27.25 24 3.88 24 3.88

Antisocial 2 6.41 .27 1 78.85 19.21** 2 4.82 1.18 Behavior 24 23.36 24 4.10 24 4.10

Rebellious 2 18.46 .42 1 146.87 14.68** 2 2.98 .30 Behavior 24 44.06 24 10.00 24 10.00

Untrustworthy 2 .89 ,.85 1 .01 .01 2 .37 1.21 Behavior 24 1.06 24 .30 24 .30

Psychological 2 2.21 .11 1 74.53 9.30*** 2 8.96 1.12 Disturbances 23* 20.86 23 8.01 23 8.01

* Data missing for one child in parent group on this variable ** p<.001 *** p<.01 **** p<.10 64

shown in Table 3, there was a significant decrease in the

pretreatment to posttreatment raw-score means for the three

treatment groups on each of these measures. While no

significant time effect (p<.05) occurred for two remaining

Part II domains, the Violent and Destructive Behavior domain (F [1,24] = 3.60, p<.10) approached the 95% confidence interval.

Analysis of Adult-Child Interactions

A mixed analysis of variance (one between and one within-group factor) was conducted in order to analyze changes in adult-child interactions. This analysis was based on the data recorded from the two, 10 minute videotaped play-therapy sessions by the two naive observers. As indicated in the methodology chapter, one child who received limited treatment was not videotaped; and the video equipment malfunctioned during the taping of another child in that same group, so that child's data was excluded from analysis. Seven dependent measures were examined with respect to the adult's behavior. These were attend, reward, questions, total directions, A directions,

B directions, and contingent attention. The three child behaviors analyzed were; response to directions; no response to directions; and unacceptable behavior. The means and standard deviations for these nine frequency measures are present in Table 5. 65

Table 6 shows the F values from the mixed analysis of variance. No significant (p<.05) treatment effects, time effects, or interactions were found with regard to the adult behaviors of attends, rewards, total directions, A directions, B directions, and contingent attention.

There were no significant treatment effects or time effects - involving adult questions, but there was a significant time x's group interaction (F [2,22] = 6.74, p<.01). Whereas the questions for the parent group increased from the initial to the final videotaped session

(X = 17.50; X = 31.87, respectively), the limited-treatment group questions decreased (X = 37.62; X = 23, respectively). The questions for the graduate-therapist group essentially remained unchanged, from the initial videotaped session (X = 17,66) to the final one (X =

16.77). This interaction is depicted in Figure 1. A simple main effect for the initial and final measure of questions indicated a significant group difference at the initial measurement (F [2,22] = 4.00, p<.05), but revealed no significant group differences at the final measurement.

Regarding the children's behavior. Table 6 also indicates that no significant (p<.05) treatment effect, time effect, or interactions, were found for responses to directions. The children's not responding to adult directions occurred so infrequently, it did not merit a statistical test. Table 6 shows there was a significant 66

TABLE 5

MEAN SCORES AND STANDARD DEVIATIONS FOR ADULT-CHILD INTERACTIONS

Parent Graduate Limited Therapist Therapist Treatment Group (N=8) Group (N=9) Group (N=10)*

MEANS STANDARD MEANS STANDARD MEANS STANDARD SCORE DEVIATION SCORE DEVIATION SCORE DEVIATION

ADULT BEHAVIORS

Attends 26.37» 17.82 29.67 11.69 36.62 7.20 30.87b 18.65 37.00 14.00 26.62 11.89

Rewards 14.25 11.31 31.33 19.77 17.87 9.86 19.37 14.27 28.55 19.12 21.87 15.30

Questions 17.50 10.07 17.66 10.63 37.62 25.05 31.87 19.59 16.77 8.82 23.00 12.52

Total Directions 55.87 32.83 65.00 26.37 54.75 35.34 51.87 27.96 66.22 24.41 62.50 35.16

A Direction 15.12 8.14 14.55 4.12 16.00 6.16 16.25 11.00 13.55 4.09 18.50 6.23

8 Direction 41.25 25.56 49.22 23.95 38.75 32.19 35.75 19.30 50.88 22.22 44.00 29.76

Contingent Attention 4.87 3.09 8.66 3.08 6.00 3.66 7.12 5.64 6.44 2.24 8.75 5.54

CHILD BEHAVIORS

Response to 15.00 7.98 14.55 4.12 16.00 6.16 Direction 15.00 11.30 13.44 3.94 18.50 6.23

No Response to 0.00 0.00 0.00 0.00 0.00 0.00 Direction 0.00 0.00 0.00 0.00 0.00 0.00

Unacceptable .75 1.03 2.00 3.20 .75 1.16 Behavior .25 .70 2.77 3.41 .12 .35

* One child was not videotaped, and the camera malfunctioned when recording another child, so thst data was excluded.

» Initial taping b Final taping 67

TABLE 6

ANOVA FOR ADULT-CHILD INTERACTIONS

______SOURCE

BETWEEN TREATMENT WITHIN GROUPS TIME TIME X's GROUP 1»;— df HS df MS df MS ADULT BEHAVIORS

Attends 2 99.29 .47 1 4.65 .02 2 356.66 1.85 22* 201.43 22 192.95 22 192.95

Rewards 2 812.67 2.33 1 55.78 .41 2 78.85 .57 22 348.87 22 137.28 22 137.28

Questions 2 735.01 2.11 1 1.80 .01 2 841.84 6.74** 22 348.59 22 124.88 22 124.88

Total Directions 2 595.00 .38 1 34.23 .11 2 138.68 ,45 22 1546.38 22 305.84 22 305.84

A Direction 2 43.31 .78 1 9.54 .23 2 13.28 .33 22 55.61 22 40.79 22 40.79

B Direction 2 622.74 .56 1 2.78 .01 2 120.19 .57 22 1116.46 22 210.22 22 210.22

Contingent Attention 2 11.90 .66 1 10.68 .74 2 32.36 2.25 22 18.15 22 14.38 22 14.38

CHILD BEHAVIORS

Response to 2 46.26 .88 1 2.67 .062 2 14.28 .32 Direction 22 52.68 22 44.52 22 44.52

Unacceptable 2 21.25 3.99*** 1 .17 .05 2 2.60 .72 Behavior 22 5.33 22 3.62 22 3.62

* Data missing for two children in the limited-treatment group ** p<.01 *** p(.05 68

Parent Therapist - P Graduate Therapist - 6 Limited Treatment Group - L

30 I 25 20 I

INITIAL FINAL VIDEOTAPING VIDEOTAPING

FIGURE I

TIME X's GROUP INTERACTION FOR ADULT QUESTIONS 69

difference between the treatment groups' unacceptable

behavior (F [2.22] = 3.99, p<.05). The mean values for

unacceptable behavior was higher for the graduate-therapist group (X Initial = 2.00; X Final = 2.77) than for the parent-therapist group (X = .75; X = .25, respectively) and the limited-treatment group (X = .75; X = .12, respectively).

Analysis of Parental Satisfaction with Treatment

Parental satisfaction with treatment was assessed by the Consumer Satisfaction Scale adapted for use in the present study. A copy can be found in Appendix J. A one-way analysis of variance was performed to analyze group differences with respect to parental satisfaction with treatment. Overall parental satisfaction with treatment was found to be significantly different between the three groups (F [2,23] = 9.17, p<.01). Tukey's post hoc test

(p<.05) indicated that parents of both the parent-therapist and graduate-therapist groups rated their satisfaction with treatment significantly higher than the parents of the children that received limited treatment. These two groups, however, were not significantly different from each other. The individual item analyses contained in Table 7 shows a significant difference between the three treatment groups. As with overall satisfaction, a Tukey's post hoc test (p<.05) revealed that parents of the parent-therapist 70 and graduate-therapist groups were not significantly different, but rated their satisfaction higher than the limited-treatment group parents. This occurred on all items, with the exception of items three, six, and nine. 71

TABLE 7

ONE-WAY ANALYSIS VARIANCE FOR PARENTAL SATISFACTION

MEAN SCORE --- LIMITED CONSUMER SATISFACTION PARENT GRADUATE TREAT OUESTIONAIRE______F VALUE & SIGNIFICANCE GROUP GROUP GROUP

INDIVIDUAL ITEM - ANALYSES

1. The major problem(s) which F(2,23)=9.17,p<.01 5.87 5.55 4.22 originally prompted me to allow my child to take part in the study are at this point: (1) considerably worse to (7) greatly improved.

2. The problems of my child F(2,23)=10.27,p<.001 5.62 5.33 4.11 which have been treated using play are at this point: (1) considerably worse to (7) greatly improved.

3. The problems of child which F(2,23)=.80 N.S. 4.25 4.55 4.11 have not been treated are: (1) considerably worse to (7) greatly improved.

4. Hy feelings at this point F{2,22)=5.32,p<.05 6.00 5.37 4.44 about my child's progress are that I am: (1) very . dissatisfied to (7) very satisfied.

5. To what degree has the F(2,23)=6.13,p<.01 5.25 5.33 4.11 treatment program helped with other general, personal or family problems not directly related to your child: (1) hindered much more to (7) helped very much.

6. At this point, my expectation F(2,23)-1.07,N.S. 5.12 5.11 4.44 for a satisfactory outcome of treatment is: (1) very pessimistic to (7) very optimistic. 72

Table 7 (continued)

----- MEAN SCORE ----- LIMITED CONSUMER SATISFACTION PARENT GRADUATE TREAT OUESTIONAIRE______F VALUE & SIGNIFICANCE GROUP GROUP GROUP

7. I feel the approach to F(2,23)=4.14,p<.05 6.00 5.66 4.77 . treating my child’s behavior problems by using this type of play therapy program is; (1) very inappropriate to (7) very appropriate.

8. Would you recommend the F(2,23)=12.27,p<.001 6.75 6.22 4.66 program to a friend or relative: (1) strongly recommend to (7) strongly not recommend.

9. How confident are you in F(2,23)=2.52,N.S. 6.12 6.33 5.22 managing current behavior problems in the home on your own: (1) very confident to (7) very unconfident.

10. My overall feeling about the F(2,23)=4.16,p<.05 6.12 5.55 4.66 treatment program for my child is: (1) very negative to (7) very positive. CHAPTER V

DISCUSSION

The present study was designed so that socially maladaptive, mentally retarded children received play therapy from either a trained parent, or a trained therapist. The purpose was to investigate the effectiveness of parents, as compared to graduate students, in facilitating improvements in the children's adaptive behavior and adult-child interactions. These two treatment groups were contrasted with one that received limited treatment. The present chapter will discuss the results in relation to the experimental questions presented in

Chapter I.

Adaptive Behavior

Experimental question number one involved the investigation of significant changes in adaptive behavior for socially maladaptive children who received play therapy from their trained parent, a trained graduate student, or had limited treatment. The mixed analysis of variance performed on the pretreatment and posttreatment Adaptive

Behavior Scale (Nihira, et al., 1975) revealed no

73 74

significant findings for the four Part I domains. There 3 were also no significant differences in the posttreatment

means for any of the three treatment groups.

Regarding the personal independence (independent

functioning and domestic activity) domain, this result was

not unexpected, since the training for these skills

requires specifically designed programs which were not

provided in play therapy.

The present study was interested in how play therapy

would effect the children's adaptive behavior;

specifically, the cognitive triad, personal motivation, and

social motivation domains. As with the personal

independence domain, there were no significant results.

Some possible reasons for this will be addressed in a later

section.

Analysis revealed a significant finding for the Part

II domains of Antisocial Behavior, Rebellious Behavior, and

Psychological Disturbances. The mean scores for these domains decreased from the pretreatment to posttreatment measurements for the parent-therapist and graduate- therapist groups, as well as for the limited-treatment group. Although the children may have derived some therapeutic benefit from their play experiences, another explanation for the decrease in maladaptive behavior could be a statistical regression toward the mean. That is, since the pretreatment data was indicative of extreme 75

scores, the tendency would be for the posttreatftient scores

to move toward the average for the group. This could

account for the appearance that play therapy had a positive

effect for all treatment groups.

Adult-Child Interactions

Experimental question number two involved the investigation of significant changes in adult-child interactions for socially maladaptive children as a function of play therapy conducted by a trained parent or a trained graduate student, in contrast to a limited-treatment group.

Analysis of adult-child interactions revealed no statistically significant findings with respect to adult behaviors (attends, rewards, directions, and contingent attention) either between or within the parent-therapist group, graduate-therapist group, or limited-treatment group.

There were some statistical trends for the adult behaviors of rewards (F[2,22]=2.25,p<.13). Regarding rewards, the trend occurred for the between-group measures. The rate of rewards was higher for the graduate- therapist group as compared to the limited-treatment and parent-therapist group. This would appear to suggest the graduate therapist's years of experience may have contributed to their higher rate of rewarding the 76 children's behavior.

The trend for contingent attention (F[2,22]=2.25, p<.ll) occurred for time by group interaction. The contingent attention for the parent-therapist and limited-treatment groups increased from the initial videotaped session to the final videotaped session, while the contingent attention decreased for the graduate-therapist group. The change for the parent-therapist group may have occurred because of the training received, but needs to be examined with caution because the limited treatment group, using experienced graduate-therapist, also increased.

A significant interaction was found for adult questions. There was no significant difference between the three groups with respect to the final means; however, there was a statistical trend for between groups, main effect (F[2,22]=2.11,p<.15). This could be attributed to the initial differences in questioning on the part of the therapists.

Play therapists, utilizing the Leland and Smith (1965) play-therapy approach, have been taught to question the child's undesirable behavior, which then forces the child to think about his/her actions. As a part of their training, the parent-therapist group received such instructions. This could have been a contributing factor to the increase in questions. 77

A significant finding was revealed with respect to the children's unacceptable behavior. For the graduate- therapist group, the behavior occurred at a higher rate, pretreatment and posttreatment, as compared to the parent- therapist group and the limited-treatment group. It will be recalled there were no within-treatment group effects for any of the three groups. Considering that the therapists were viewed as nonthreatening, the children in the graduate-therapist group may have been more inclined to test the limits; this could have contributed to the higher rate of unacceptable behavior. Regardless of the therapeutic role attempted by the parent therapists, to their children they were viewed as parents first; therefore, the children were less willing to test the limits, since parents tend to be associated with a punitive role. As for the limited-treatment group, the opportunity to play alone, which only occurred twice, may have been more important than "acting out."

Parental Satisfaction with Treatment

Experimental question number three examined differences in parental satisfaction with respect to the treatment their children received. Analysis revealed no significant difference between the parent-therapist and graduate-therapist groups' satisfaction with treatment; however, these two groups rated their satisfaction with 78

treatment significantly higher than the limited-treatment

group. Parents from the two treatment groups reported

feeling their children's behavior had improved. They,

also, indicated that the play-therapy approach was an

appropriate way for treating their children's behavior

problems, and would recommend such a program to others.

Some of the comments from the parent therapists

indicated they found the interaction with their children

helpful. One parent remarked they enjoyed the opportunity

to use their own imagination. Two of the parent therapists

indicated treatment of this type was needed when their children were younger.

Review of Individual Play therapy Goals

There was no statistical analysis performed on the children's individual therapy goals; however, to present a picture of ongoing play therapy, a post hoc decision was made to include a review. Based upon a review of the individual goals and progress, the following is presented as a general overview of the goals and progress specific to each treatment group. The individualized goals, along with progress, are contained in Table 8.

The primary goals established for the parent-therapist group were to enhance following directions, attention to activities, eye contact, and interaction with parent-therapist. The areas that appeared to show the most 79

improvement were attention to activities and eye contact.

Slight improvement occurred for following directions and

interactions with parent-therapist. One child did improve

with expressing anger in a socially acceptable manner.

Other areas of noted improvement were gross motor activity,

sociodramatic play, turn-taking, and expressive language.

The goals for the graduate-therapist group focused on

enhancing the areas of attention to activities, following

directions, expressive language, turn-taking, tactile

stimulation, and self-control. The most noted improvements

occurred with following directions, expressive language,

and maladaptive behaviors. A few of the children

demonstrated improved eye contact, as well as attention to

activities and turn-taking. One child who had difficulties with separating from his mother for play therapy, showed

some improvement by the final session. Another child

showed some progress toward self-control. In conclusion, one child's maladaptive behavior remained the same throughout play therapy.

The goals for the limited-treatment group emphasized following directions, attention to activities, verbal interaction skills, and turn-taking. Turn-taking and following directions were the areas that showed some improvement. There was also slight improvement indicated for attention to activities and verbal interaction skills.

In addition, improvements occurred for eye contact, active 80

TABLE 8

INDIVIDUAL PLAY THERAPY GOALS AND PROGRESS

SUBJECT GOALS PROGRESS

PARENT-THERAPIST GROUP:

1 - To Improve following Improved in discussing activities with therapist, directions and involve but would not involve therapist in activity. parent in activities. Needs further improvement in expressing affection at appropriate times. Verbalization by therapist was good and attended to child's activities frequently.

2 - To improve cooperative Showed improvement in later sessions with respect functional play and to interacting with therapist; therapist gave good attention to activities. verbal reinforcement.

3 - To improve eye contact Eye contact with therapist improved, but therapist and ability to make made choices regarding activities; therapist gave choices related to good verbal reinforcement. activities.

4 - To improve attention to Good verbalization, good turn-taking, and improved activities some with attention to activities; needed to initiate more activities. Therapist used good verbal reinforcement, but needed to impose limits - not stopping on child's demand.

5 - To improve eye contact, Improved in later sessions with respect to following directions, following directions, especially with hands-on and attending to activity. Eye contact showed some improvement, activities. but no change with verbalization. Therapist's use of verbal reinforcement got better in later sessions, and made child finish activity before moving on.

6 - To improve attending to Eye contact and attention to activity improved by activities and socially last session; did good asking for new activity; acceptable manner to expression of anger improved by last session. express anger. Therapist did not listen to child's requests, did not Interact with child (parallel), and gave child no choice as to end product.

To improve eye contact Still preferred to play independently; did show and interaction with good sociodramatic play - could make things out of parent during play. sand and pretend. Therapist used good verbalizations, gave verbal reinforcement, and attended to child's activities. 81

Table 8 (continued)

SUBJECT GOALS PROGRESS

8 - To Improve eye contact Improved in gross motor activity and in area of and attention to attention span. Therapist usually chose activities. activities and needed to involve child more in this area.

GRAOUATE-TIŒRAPIST GROUP:

9 - To improve attention to Accepted therapist by making request of activities. therapist. Echolalia could not be faded out.

10 - To include therapist in Permitted therapist to take more active part in play activity. play; did increase verbalization and eye contact.

11 - To improve attention to Following directions and attention span improved. activities and appro Echolalia decreased as appropriate verbalizations priate verbalizations. to the therapist increased.

12 - To improve vocaliza Vocalizations increased when therapist intervened, tions, interactions with and following directions increased by last therapist and on-task session. behavior.

13 - To improve attention to He was very destructible throughout most play activities and the sessions. He displayed self-talk and self-abuse. following directions. He accepted therapist by the last session and used some sign language. There appeared to be some emotional difficulties.

14 - To improve play and Appeared to become more tolerant toward textured tolerance to materials items. Spent increasing amount of time in therapy of various textures. building appropriately with legos and blocks. He began to express self more effectively.

15 - To improve impulse Total behavior improved. Therapist required that control and the play occurs with one toy at a time: he was following directions. compliant with this playroom "rule." Compliance with structured activities also increased. Vocalizations occurred upon request of the therapist.

16 - To improve eye contact, Still required verbal prompting to look at attention to activities, therapist and object playing with. He spent less self-control, and turn- time exhibiting masturbation using both hands to taking skills. play with toys; did show some improvement in turn-taking. 82

Table 8 (continued)

SUBJECT GOALS PROGRESS

17 - To Improve attention to By last play therapy session, had Improved about activities and detach leaving mother. Eye contact had Increased, and he ment from mother. put toys away after activities, with no problem.

LIMITED-TREATKNT GROUP:

IB - To Interact with others Did participate In turn-taking during second during play. session.

19 - To Interact with others Continued behaviors In second session; did not during play and decrease physical Intrusion by therapist. echolallc speech.

20 - To Improve following Second session, named objects, pointed, laughed, directions. and followed directions.

21 - To Improve attention to Second session, preferred to look around room. activities.

22 - To Improve attention to Second session, followed directions better, but activities. Include continued preference to work alone; echolalia therapist In play, and still present. decrease echolallc speech.

23 - To Improve attention to Second session, responded with verbal and physical activities following prompting; tested limits. directions.

24 - To Improve verbal Inter Second session, no change In these areas, but did actions, turn-taking be make some good eye contact. havior, and the Initia tion of play activities.

25 - To Improve more appro Second session, talked with some verbal reminder, priate verbalizations good turn-taking skills; needs more advanced play and turn-taking with same materials. behavior.

26 - To Improve sociodramatic Second session was were positive, responded to play and verbal Inter therapist's questions; good sharing and turn actions. taking.

27 - To Improve Interactions Second session, active participation Improved, as with therapist. well as attention span. 83

participation, and naming of objects.

Overall, the children in the graduate-therapist group

appeared to show the most improvement. In conclusion, most

of the parent-therapist demonstrated good attending and

rewarding behaviors; however, a few parent-therapists did

not actively involve the child in decision making, or

interact with the child.

Limitations and Implications

The possibility that treatment from either a trained parent or a trained therapist, when compared to a limited- treatment group, would lead to a change in the children's adaptive areas was not statistically supported. Since the

Adaptive Behavior Scale appears to be an objective, sensi tive instrument to assess therapeutic change (Sherwood,

1981), other factors may have contributed to the lack of treatment effect. The small sample size, along with the lack of a control group, made it statistically difficult to demonstrate any type of treatment effects, if any did occur. Future studies need to consist of a larger sample and employ the use of a control group. In addition to the above factors, a regression toward the mean occurred on three of the four Part II, maladaptive behavior measures, for the three treatment groups. According to Andrews and

Harvey (1981), a regression toward the mean may mask therapeutic improvements in a pretreatment-posttreatment 84

outcome design.

Although the changes in the children's adaptive behavior was not statistically supported, Strupp (1986)

indicated that individuals are highly complex and that therapeutic outcome cannot be assessed with a single variable. Examination of the subjective goals appears to suggest that regardless of treatment group, some of the children made progress. There appears to have been more overall progress toward the goals for the graduate- therapist group; however, it should be noted that the graduate therapists reviewed the progress for all children in the study. To avoid potential therapist bias, future studies need to include independent evaluators to assess therapy progress. Strupp further added that therapeutic outcomes are not stationary points, that the quality and functioning of the individual's interpersonal relationships, before and after therapy, need to be examined. Other researchers (Breiner and Young, 1985

Brody and Forehand, 1986; Forehand, Brody, and Smith, 1986

Forehand, Lautenschlager, Faust, and Graziano, 1986

Friedrich, Wilturner, and Cohen, 1985; and Middlebrook and

Forehand, 1985) have found that the parents' emotional state, marital satisfaction, and social interactions effect their perceptions of the child's behavior. It is recommended that future studies using parents in play therapy examine these variables, as well as include a 85

follow-up evaluation to investigate for treatment effects

which may not occur until long after treatment ended.

In examining adult-child interactions, one

statistically significant between-groups main effect

regarding children's unacceptable behavior was found,

specifically, that the therapist group was significantly

higher than the parent-therapist and limited-treatment

groups. There was significant within group, time by group

interaction, such that questions for the parent-therapist group increased from the initial videotaped session to the final videotaped session, while the questions for the limited-treatment group decreased, and the questions for the the therapist group remained unchanged. As with the

Adaptive Behavior Scale measures, the small sample size perhaps limited the demonstration of further statistically significant findings, if any occurred, concerning adult-child interactions, regardless of treatment group. A major limitation was the initially difference between group rates of behavior for both the adult therapist and children. Since the two graduate student therapists were the same for the therapist group and limited-treatment group, this complicated the analysis for both statistical and interpretative purposes. To avoid these limitations in the future, studies need to insure that all groups are treated the same, either statistically, or procedurally. 86

One of the difficulties encountered with the present

study was finding parents who would not only allow their

children to participate, but would be willing to do so

themselves. Due to the limited number of parents

indicating a desire to participate in play therapy with

their children, the parent-therapist group was

self-selected.

Another limitation related to finding individuals

willing to participate was that none of the groups were

balanced for socioeconomic factors. Although only one

group of parents participated in play therapy, the parents'

social class, educational level, and income have been reported to be positively related to successful acquisition of skills taught in parent-training programs (Clark, Baker, and Heifetz, 1982). A number of other investigators (Baker and McCurry, 1984; Clark et al., 1982; Saddler, Seyden,

Howe, and Kiminsky, 1976; and Salzinger, Fellman, and

Portnoy, 1970) have found that the parents of mental retarded children, with low income and low educational levels, experience problems mastering the content of parent-training programs. Since these socioeconomic factors were not controlled for in the present study, future studies may need to analyze these variables as they pertain to the training of parent therapists.

In relationship to the problems experienced with controlling for parental socioeconomic factors, similar 87

difficulties were encountered with the children. That is,

none of the groups were balanced with respect to race, sex,

and age. There was a disproportionate percentage of

Caucasian children to black children in the parent-

therapist group (75%; 25%, respectively), as well as in the limited-treatment group (60%; 40%, respectively). The reverse occurred for the graduate-therapist group (67% black; 33% Caucasian). Regarding the sex of the children, only 30% were females, the lowest percentage of which were in the graduate-therapist and limited-treatment groups

(10%; 20%, respectively). There was a much higher percentage in the parent-therapist group (63%). As for age, the mean age of the parent-therapist group was nearly two years higher.

The self-selection of the parent therapists, the small sample size, along with the lack of a control group, may have effected the outcome of the study. In addition, the problems discussed about the parents' socioeconomical factors, and the difficulties of demographically matching the children, may have also effected the outcome.

Considering these variables, it is questionable whether or not the results from the present study would generalize to the mentally retarded population. 88

Summary

The present study was designed so that socially

maladaptive, mentally retarded children received play

therapy from either trained parents or trained therapists.

The purpose was to investigate the effectiveness of

parents, as compared to graduate students, in facilitating

improvements in the children's adaptive behavior and

adult-child interactions. These two treatment groups were

contrasted with one that received limited treatment.

Twenty-seven children participated in the research. Eight

of the children received play therapy from their trained

^parents. The remaining nineteen children were randomly

assigned to receive play therapy from two trained

therapists, or to a limited-treatment group. There were

twelve, 30-minute play-therapy sessions conducted. Prior

to actual play therapy, the parents received four hours of

training in the Leland and Smith (1965) unstructured-

materials structured-therapy approach. Pretreatment to

Posttreatment behavioral changes were measured using parent

ratings on the Adaptive Behavior Scale. Videotaped

observations from the initial and final play-therapy

sessions were used to assess changes in adult-child

interactions. At posttreatment, parents completed a

questionnaire to determine satisfaction with treatment.

The results indicated there were no significant

changes or differences with respect to the adaptive 89 behavior for the children who received treatment from their trained parents or a trained therapist. Similar findings were revealed for the limited-treatment group. A significant decrease in antisocial behavior, rebellious behavior, and psychological disturbances, occurred for all children, regardless of treatment group. Regarding adult-child interactions, no significant changes or differences were found. The results indicated a significant difference between the groups with respect to unacceptable behavior displayed during play therapy. The behavior was higher for children in the trained-therapist group as compared to the parent-therapist and limited-treatment groups. Parents from the two treatment y groups rated their satisfaction with treatment significantly higher than did the limited-treatment group parents.

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SAMPLE SELECTION ABS RATINGS

100 101

SAMPLE SELECTION ABS RATINGS

PART I PART II

1 ÿ J 1 _iS s 1 i 5 5 I N g 1 g S i l

1 F 13 pc 55I) 62 32 70 0 ic 0 2* 5* 2 K 10 p 20 32 29 25 9* 7 4 0 2 3 M 11 p 30 30 19 49 2 2 8* 0 0 4 F 12 p 70 58 73 77 4 0 8* 0 1 5 M 12 p 36 46 8 33 16* 17* 37* 0 15* 6 F 8 p 38 50 18 21 8* 8* 17* 0 5 7 F 11 p 65 38 24 80 1 0 2 0 6* 8 F 12 p 49 50 35 47 1 2 7* 0 0 9 M 6 G 34 57 51 24 14* 2 2 0 2

10 F 10 G 68 52 61 92 1 8* 6 0 1 11 M 13 G 44 27 44 39 14* 4 21* 0 6 12 M 9 G 36 41 45 50 7 0 2 0 10 * 13 M 9 G 52 58 53 50 13* 11* 9* 4 7* 14 M 13 G 26 20 5 27 16* 9 15* 0 11* 15 M 6 G 42 56 60 45 13* 11* 18* 0 27* 16 M 12 6 33 35 31 50 10* 15* 16* 0 18* 17 M 8 G 26 38 20 35 9* 0 25* 0 5 18 M 7 L 33 30 11 10 5* 0 1

19 M 10 L 44 59 61 62 5 9* 0 1 20 M 9 L 36 43 45 55 5 2 0 6* 21 M 13 L 40 31 21 41 8* 8* 13* 0 0 22 M 11 L 79 66 61 74 5 4 13* 1 3 23 M 8 L 49 44 45 54 20* 8* 17* 0 7* 24 M 7 L 59 60 79 98 2 2 0 0 7* 25 M 11 L 65 60 59 79 1 2 3 1 6* 26 F 12 L 67 83 61 68 0 0 7* 0 11* 27 F 7 L 33 53 21 10 7 4 9* 0 3

® P - Represents Parent Group 6 - Represents Graduate-Student Group L - Represents Limlted-Treatment Group b Part I Scores - Percentiles c Part II Scores - Raw Scores * Represents Part II domains >80% APPENDIX B

CONSENT LETTER

102 103 Dear Parent/Guardian:

My name is Donald W. Bowling. I am a graduate student at The Ohio State University working toward completion of my doctoral degree in psychology.

I have obtained permission from Dr. Lynn Krause, Assistant Superintendent of the Franklin County Board of MR/DD to have children in the school program participate in a study I am conducting. I am interested in how children interact with an adult in a play therapy situation. I would like to have your child participate in twelve 30-minute play therapy sessions. Some parents will be needed to directly participate in play therapy with their children.

Each child will receive play therapy from either a graduate student with at least one year of supervised experience or one of their parents. I will conduct at least one four-hour training sessions on. the materials and methods used in play therapy for those parents participating in play therapy.

Play therapy will be held at least two times a week, for six weeks, at the Nisonger Center on the Ohio State University campus. Two of the play sessions will be videotaped and these will be erased upon completion of the study. The results will be shared with the Franklin County Board of MR/DD and parents.

The parents of the children participating in play therapy will receive $30.00. Parents also participating in the play therapy will receive an additional $20.00. Half of the money will be paid after the 6th session. The other half will be paid upon the completion of the remaining 6 play sessions.

Some parents may not have the necessary means of transportation for traveling to Ohio State University. Assistance with transportation will be provided to anyone, if needed.

I will be available to discuss any questions you may have regarding the study. You may also contact me if you need to withdraw from the study prior to its completion.

Please check the statement(s) which apply to you and return within one week to your child's school. Thank you.

la) My child has my permission to participate in the study. 104

_lb) My child does not have my permission to participate in the study. _2 ) I want to participate in play therapy with my child. 3) I need assistance with transportation to Ohio State University to participate in the study.

PARENT/GUARDIAN DONALD W. BOWLING GRADUATE STUDENT

HENRY LELAND, Ph.D. FACULTY ADVISOR APPENDIX C

PARENT'S MARITAL STATUS

105 106

PARENT'S MARITAL STATUS

GROUP

GRADUATE LIMITED PARENT THERAPIST , TREATMENT TOTAL MARITAL STATUS N . PERCENT N PERCENT _N PERCENT Jt PERCENT SINGLE 0 0.0 4 44.4 0 0.0 3 11.5

SEPARATED 0 0.0 0 0.0 1 10.0 1 3.8

MARRIED 5 62.5 4 44.4 7 70.0 16 61.5

DIVORCED 3 37.5 1 11.1 2 20.0 6 23.1

TOTAL 8 100.0 9 100.0 10 100.0 26 100.0 APPENDIX D

MOTHER'S AGE

107 108

MOTHER'S AGE

GROUP

GRADUATE LIMITED PARENT THERAPIST TREATMENT TOTAL MOTHER'S AGE N PERCENT N PERCENT N PERCENT _N PERCENT

25-29 0 0.0 2 25.0 1 11.1 3 12.0

30-34 4 50.0 1 12.5 2 22.2 7 28.0

35-39 4 50.0 1 12.5 4 44.4 9 35.0

40-44 0 0.0 2 25.0 1 11.1 3 12.0

45-49 0 0.0 1 12.5 0 0.0 1 4.0

50 OR MORE 0 0.0 1 12.5 1 11.1 2 8.0

TOTAL 8 100.0 8 100.0 9 100.0 25 100.0

UNKNOWN 0 0.0 1 11.1 1 10.0 2 7.4 APPENDIX E

FATHER'S AGE

109 110

FATHER'S AGE

GROUP

GRADUATE LIMITED PARENT THERAPIST TREATMENT TOTAL FATHER'S AGE N PERCENT N PERCENT N PERCENT _N PERCENT

25-29 1 12.5 0 0.0 0 0.0 1 4.2

30-34 3 37.5 0 0.0 1 10.0 4 16.7

36-39 4 50.0 2 33.3 4 40.0 10 41.7

40-44 0 0.0 2 33.3 4 40.0 6 25.0

45-49 0 0.0 0 0.0 0 0.0 0 0.0

50 OR MORE 0 0.0 2 33.3 1 10.0 3 12.5

TOTAL 8 100.0 6 100.0 10 100.0 24 100.0

UNKNOWN 0 0.0 3 33.3 0 0.0 , 3 11.1 APPENDIX F

MOTHER'S EDUCATIONAL LEVEL

111 112

MOTHER'S EDUCATIONAL LEVEL

GROUP

GRADUATE LIMITED PARENT THERAPIST TREATMENT TOTAL EDUCATION N PERCENT N PERCENT N PERCENT _N PERCENT NONE 0 0.0 0 0.0 0 0.1 0 0.0

1 - 7 0 0.0 0 0.0 1 11.1 1 4.2

8th GRADE 0 0.0 1 12.5 0 0.0 1 4.2

SOME HS 0 0.0 3 37.5 0 0.0 3 12.5

HS DIPLOMA 4 57.1 1 12.5 3 33.3 8 33.3

SOME COLL 2 28.6 2 25.0 5 55.6 9 37.5

COLL DEGREE 1 14.3 1 12.5 0 0.0 2 8.3

GRAD TRNG 0 0.0 0 0.0 0 0.0 0 0.0

TOTAL 7 100.0 8 100.0 9 100.0 24 100.0

UNKNOWN 1 12.5 1 11.1 1 10.0 3 11.1 APPENDIX G

FATHER'S EDUCATIONAL LEVEL

113 114

FATHER'S EDUCATIONAL LEVEL

GROUP

GRADUATE LIMITED PARENT THERAPIST TREATMENT TOTAL EDUCATION N PERCENT N PERCENT N PERCENT _N PERCENT NONE 0 0.0 0 0.0 0 0.0 0 0.0

1 - 7 0 0.0 0 0.0 0 0.0 0 0.0

8th GRADE 0 0.0 1 20.0 0 0.0 1 4.5

SOME HS 1 14.3 0 0.0 1 10.0 2 9.1

HS DIPLOMA 3 42.9 3 60.0 6 60.0 12 54.5

SOME COLL 2 28.6 0 0.0 1 10.0 3 13.6

COLL DEGREE 1 14.3 1 20.0 1 10.0 3 13.6

GRAD TRNG 0 0.0 0 0.0 1 10.0 1 4.5

TOTAL 7 100.0 5 100.0 10 100.0 22 100.0

UNKNOWN 1 12.5 4 44.4 0 0.0 5 18.5 APPENDIX H

CODING MANUAL FOR SCORING ADULT-CHILD INTERACTION

115 116

THE SCORE SHEET

Example :

Each score sheet contains ten rectangular blocks, subdivided into three rows and ten columns, with a circle following each rectangle (see example above). Each rectangle represents 30 seconds of observation time. The three rows represent three categories of behavior: adult actions in row 1, child responses in row 2 and adult reactions in row 3. The behaviors recorded within a single column indicate a sequence of related behaviors, or an interaction. The columns also denote the order of occurrence for these interactions. They do not provide precise temporal information since the time span represented between columns may range from one to twenty-nine seconds. Note that up to ten interactions may be scored each 30 seconds (one per column); all subsequent interactions in the 30 second interval are not scored.

Most often, however, fewer than ten columns will be used since fewer than ten interactions will occur in 30 seconds. Also, in most cases, not all rows in each column 117

will be used. From one to three rows per column may be

used, contingent on the interaction which occurs. In

summary, each rectangle marks a 30 second interval, each

row indicates a different category of behavior, and each

column contains an interaction consisting of a sequence of

one to three behaviors.

The circle on the score sheet will be used to record

on additional category of child behavior on an interval

sampling basis. The category to be coded is acceptableness

of child behavior. Each circle will be scored for the same

30 second interval as the rectangle which precedes it.

Unacceptable child behavior will be recorded at the time

that behavior occurs during the 30 second interval.

However, unacceptable child behavior may be recorded only

once per circle regardless of subsequent occurrences during

the remainder of the interval. If child behavior is

acceptable for the entire 30 second interval, acceptable child behavior will be recorded in the circle. Therefore, the circle will essentially denote the presence or absence of at least one unacceptable behavior.

During the rating of each videotaped play session, a tone will cue observers at the end of each 30 second interval to shift to the next rectangle and circle. 118

II.

THE CATEGORIES; SYMBOLS AND RULES OF SCORING

The category Acceptableness of Child Behavior, which

is recorded in the circles, is defined below:

Category Symbol Behavior

1. Acceptableness of + 1. Unacceptable child Child Behavior behavior a. Cry-whine-yell- tantrum b. Aggression c. Rebellious behavior

2. Acceptable child behavior

Listed below are the three categories of behavior recorded in the three rows of the rectangles and the behaviors included in each category:

Category Symbol Behavior

1. Adult Cues D 1. direction (row 1) Q 2. question A 3. attend

R 4. reward

2. Child's Responses R 1. response (row 2) N 2. no response

3. Adult Consequences A 1. attend (row 3) R 2. reward 119

Examine the sample score sheet presented on the following page. Notice two points about the rectangles.

First, within any given rectangle, all of the columns are not scored. As noted previously, only rarely will ten or more scorable behavioral interactions occur during a 30 second interval. Second, all three categories (rows) in the rectangle need not be scored in any given interaction

(column). The following rules determine what categories of behavior are scored for any given interaction.

1. The occurrence of any of the four adults

(category 1) is recorded in row 1, unless all ten

columns in the rectangle have been used before

the 30 second interval is completed. Adults are

recorded in order, beginning in the far left

column. An adult is the cue that initiates the

start of an interaction.

2. A child's response (category 2) may be scored in

row 2 if and only if the recorded adult in row 1

was a direction (D). If a child's response does

not occur, the next recording will be an adult

placed in row 1 of the next column to the right.

3. The adult consequence (category 3) may be scored

in row 3 if, and only if, the recorded child's

response in row 2 was no response (N); the next 120

scoring will again be an adult in row 1 of the

next column.

To summarize: the rules for scoring an interaction, or

sequence of behaviors, specify that any recordable adult,

up to ten per rectangle, is always scored. A score for

category 2 (child's response) depends on the occurrence of

a specific type of adult (D) in category 1. A score for

category 3 (Adult) depends on the occurrence of a specific

child response (C) in category 2.

Notice that all circles have been scored as either

acceptable or unacceptable child behavior. All circles

must always be scored. The rule for scoring unacceptable

child behavior (+) is simply that at least one of the three

forms of unacceptable behavior listed occurred at some point during the interval. Unacceptable behavior is scored at the time it occurs. Appropriate child behavior may be scored only at the end of a 30 second interval. Acceptable behavior (left blank) is the absence of any unacceptable behavior during an entire interval. 121

SCORE SHEET

CHILD'S CODE_ PAGE_

TAPE NUMBER OBSERVERS INITIALS O

Row 1 Row 2 Row 3 Circle D-direction R-response R-reward + -unacceptable Q-question N-no response A-attend child A-attend behavior R-reward -acceptable child behav. 122

III.

DEFINITIONS OF BEHAVIOR AND EXAMPLES OF SCORING

Acceptableness of Child Behavior

An interval sampling procedure is used to record these behaviors in the circles. Interval sampling requires a binary decision by the coder; either the child's behavior

is acceptable for the entire 30 second interval, or the child emits one or more of the three forms of unacceptable behavior listed above. Immediately after one of the unacceptable behaviors is observed, record a plus mark (+) in the circle being coded. Disregard further unacceptable acts occurring within that interval. In the absence of unacceptable child behavior, leave the circle blank.

Unacceptable Child Behavior

a. Whine-Cry-Yell-Tantrum

The first three behaviors are self-explanatory.

They are to be scored as inappropriate, regardless of the eliciting situation. Tantrums are any combination of whining, yelling, crying, hitting and kicking.

b. Aggression

This includes behaviors in which the child damages or destroys an object or attempts or threatens to damage an object or injure a person. The potential for damage to objects or injury to persons is the critical factor in scoring, not the actual occurrence. It would not 123

be scored as aggressive if it were considered acceptable

within the context of that play situation. Examples of

aggression toward persons include biting, kicking,

slapping, hitting, or grabbing an object,

c. Rebellious Behavior

This includes verbal and nonverbal repetitive

requests for attention (at least three requests occurring

right after the other; e.g., pulling on an adult, "Can I play with record player, can I, huh?"), stated refusal to follow direction (not the act of no response; e.g., "I won't put the toys away," or "I won't play with the blocks," or continued play with objects after a direction, etc.), disrespectful statements (smart comments; e.g.,

"You're mean to me and I don't like you anymore"), profanity and commands to the adult which threaten unacceptable behavior (e.g., "I don't want to play with the damn blocks," or "you leave me alone or I will scream"), child wanders about playroom and child leaves or attempts to leave playroom before end of play session. Exception to latter may be need for child to use restroom.

Acceptable Behavior

Acceptable child behavior is defined as the absence of all unacceptable behaviors listed above. Note for the child's behavior to be recorded as acceptable, it must occur for the entire 30 second interval being observed. 124

Adult Cues (Category 1)

The four adult behaviors discussed above initiate the

recording or behavioral interactions (columns). These are

the foundation to all coding done in the rectangles. With

the exception of physical rewards, all behaviors are

verbal. Even though there may be several "forms" of a

behavior, all forms of that behavior are scored as if

identical. The four behaviors are mutually exclusive.

There may be difficult discriminations for each behavior

which are outlined under the heading, "Exclusions";

critical factors for making discriminations are outlined

under the heading "Cue for Recording."

Note; Only adult behaviors directed to or including

the child are scored. The only instance where this becomes

a factor is the adult use of "we."

Examples ;

A. Adult: "We need some more sand." (D)

B. Adult: "I need some more sand." (not scored)

C. Adult: "I think we need some more sand." (D)

Direction (D)

There are two types of direction: A and B. Each is

defined differently, but both are scored as directions (D)

in row 1.

A - Direction

Statements that tell the child what to do, suggest what to do, question, rule, or contingency to which a 125

motoric or verbal response is acceptable and feasible.

With question directions, a motoric response must be

available.

1. Direct Directions - These are stated

directly and specify the child behavior to be initiated or

stopped.

Examples :

A. Hand me one block.

B. Play with the blocks.

C. Look here. ^

D . Come here.

E. Find another one.

F. Color it yellow.

G. Roll the clay into a ball.

H. Stop throwing sand.

I. Stop kicking me.

J. Do not do that.

2. Indirect Directions - Suggestions to respond motorically or verbally that are not questions.

Examples :

A. Let's make a sand castle.

B. Let's play with the clay.

C. You should pick up the toys now.

3. Question Directions - Questions to which a motoric response is available in addition to the verbal response and which direct the child's behavior not 126

following it.

Examples :

A. Why don't you make it higher?

B. Can you tell me what color this is?

C. Could you draw me a picture?

D. Why don't we sit here?

E. Why don't you hand me a crayon?

Exclusion; Questions beginning with "Do you want..." are always scored as a question (Q) and never as a direction

(D).

Cue for Recording

In order to be scored as a direction (D), the question must direct the child; not occur following his behavior.

(The latter would be scored as a Q. )

Examples :

A. Child stacking blocks

Adult: "Aren't you going to stack them higher?"

(D because child is to continue the activity)

B. Adult: "Aren't you coloring?" (Q follows

activity)

C. Child sitting on floor

Adult: "Are you going to play in the sand?" (D)

D. Child playing in the sand

Adult: "Are you playing in the sand?" (Q)

4. Permission Statements and Rules - Permission statements ("You may...") or rules ("There will be...") 127

which specify a behavior to be initiated or stopped in the

present.

Examples ;

A. You may get something else to play with now.

B. There will be no putting objects in your mouth.

C. We are going to play with the bubbles now.

D. You can stack the blocks higher.

5. If...Then Statements - Refer to positive or neutral results. The "if..." part of the statement is the direction, while the "then" component is simple information which is not scored.

Examples ;

A. If you put on one more block, they will all fall.

B. If you bury your hands in the sand, I will find

them.

6. Chain Directions - Chain directions are, a) a series of logically or syntactically related directions that are, b) given in rapid succession without pause. In most situations, the cue for scoring two or more directions as a chain is that they are connected by a conjunction (see example A). Each direction in a chain is recorded as for all directions (D), but the chain is indicated by drawing a single line above all directions in the chain (e.g., D D).

A. Stand up, come here, and sit down. (D D D)

B. Stand up and come over here. (D D)

C. Pick up the blocks, put them away, and get the 128

clay. (D D D)

Exclusions

1. Directions referring to past or future

behavior.

Examples :

A. If you'd picked it up last night, you'd have it

done now.

B. You may go outside after Ms. Brown leaves.

2. Directions stating general rules or general

permission in which reference to a specific behavior is

omitted.

Examples :

A. You may do what you like.

B. Time is up.

C. Now it's my turn.

B - Direction

There are scorable directions under 1-6 above to which the child has no opportunity to respond. This happens when the direction is immediately followed (within five seconds) by adult verbiage which does not allow enough time for the child to respond. (Chain directions, number six above, are not included; note that if there is a pause between directions, it is not scored as a chain direction, but as a series of interrupted directions which are B directions, if the adult follows the directions himself, or if the adult restricts the child's ability precluding a response 129

opportunity. B directions may also be vague directions.)

7. Vague Directions - Vague directions which do

not specify the child behavior to be initiated or stopped.

Examples ;

A. Try.

B. Let's pretend.

C. Be careful.

D. Act like a big boy/girl, please.

Cue for Recording

1. Time reference - Directions must refer to on-going behavior to be scored. However, this rule does not depend strictly on verb tense. Temporal contiguity of the adult's verbalizations with the behavior it is referring to is of importance, not the verb tense; i.e., if the adult is referring to behavior expected to be completed momentarily (future tense) or to behavior first demonstrated, the event is close enough in time to be considered present. The "present" tense is best conceptualized by exclusion. Statements that refer to activities of the previous session, that morning, that evening, last Christmas, etc., are not considered in the

"present." However, most references to activities that are occurring, or can occur within the therapy session, would be considered in the "present" tense.

Examples :

A. We will play with clay now. (D) 130

B. You will have to pick up the toys next. (D)

C. Are you going to hand me the block? (D)

2. Initiation of behavior sequence - An

important factor in differentiating certain directions from

information is the child's behavior preceding the adult's

action. The key factor about the child's behavior is

whether the child requested information (i.e., made a

verbal request prior to the adult's statements) or did not

request information (the adult gave a direction following

nonverbal behavior by the child).

Examples ;

A. Child: moves toward an object, (nonverbal)

Adult: "We must finish playing with the block

first." (D)

B. Child: "Can I play with the record player?"

Adult: "No, not now." (Not scored; this is

information which the child requested.)

Questions (Q)

Any interrogative to which the only acceptable

response is verbal.

General questions

Examples :

A. What do you want to do?

B. What are you making?

C. Do you need more sand?

D. Do you want some help? 131

Tag questions

Examples ;

A. That's a block, isn't it? (A Q)

B. Put up the clay, will you? (D)

Note; A statement consisting of a direction plus a tag

question is scored as a question direction (D).

"Do you want..?" questions

Examples :

A. Do you want the crayons?

B. Do you want to build a sand castle?

Questions by inflection - Multiple-word statements with a rising inflection are scored as questions. Note that these same statements without the rising inflection may be scored as attends in other cases.

Examples :

Child: playing with blocks

A. Adult; "You are playing in the sand?" (Q)

B. Adult; "Flaying in the sand?" (Q)

C. Adult; "You're playing with the block." (A)

Exclusions ;

1. Questions to which nonverbal response is also acceptable - This does not include questions beginning with "Do you want to...?" which are always scored as questions.

Examples ;

See Direction; Form 3 (Question Directions) 132

2. Single words - Single words made into

questions strictly by inflection of the voice are

information only and, therefore, not scorable. This does

not include interrogatives such as, who, what, when, there,

how, or why.

Examples :

A. Oh?

B. OK?

C. Really?

D. See?

3. Questions reflecting the child's question -

As noted above under directions, the initiation of the

interaction is important here. If the child initially asks

a question (verbalization), the adult's reflection cannot

be a question. It is nonscorable, or information,

response. A reflection is terminated following the adult's

initial reflective statement; i.e., further "reflection" of

the same question is scored as the appropriate adult

category.

A. Child: "When can I play with the block?"

Adult: "When can you play with the blocks? Now,

I guess."

Attends (A)

Descriptive phrases that follow and refer to a) the

child's on-going behavior or objects directly related to his play, or b) spatial orientation or appearance, attends 133

are usually neutral statements.

Description of activity

Examples :

A. You are stacking the blocks high.

B. You are doing a good job coloring.

C. You are making a sand castle.

Descriptions of the child's spatial orientation or appearance

Examples :

A. "You are sitting on my lap."

B. "You are sitting on the yellow bean bag."

C. "You are wearing a blue skirt."

Exclusions :

1. Reflections or repetition of the child's statements - This is similar to the rules above for directions and questions concerning initiation of the interaction. If the child elicits the attend with a verbal statement or request for information as opposed to a nonverbal cue, an attend is not scored.

Examples:

A. Child: "I've got the blocks now."

Adult: "Oh, you've got it now." (not scored)

B. Child: Picking up the crayons

Adult: "Oh, you have got the crayons." (A)

C. Child: Stacks 10 blocks

"How many is that?" 134

Adult: "That's 10 blocks." (A)

2. Child's name without reference to his

behavior.

3. Description of past or future behavior - As discussed under directions above, the important factor is not verb tense, but the time the behavioral reference occurs.

Examples and scoring:

A. You played with the blocks last session, (not

scored)

B. Child: Stacking blocks

Adult: "You will have the blocks stacked real

high soon." (A)

4. Inferences and interpretations -

Descriptions of the child's internal "state of being"

(inferred) and interpretations about the child's activity.

Examples :

A. You are really upset.

B. You look tired.

C. You really like coloring.

5. Negative attends - Descriptions or statements of what the child did not do.

Examples :

A. You're not making a sand castle.

B. You didn't stack the blocks high enough. 135

6. Criticism or corrective statements -

Criticism of the child by any statement referring to the

child's prior, on-going, or future behavior that is

negative in evaluation, states disapproval, or denotes less

than average performance.

Examples :

A. That's not good at all.

B. You've been a bad boy/girl this session.

C. Wrong.

D. You're acting like a baby.

Cue for Recording

1. Types of attends - Two types of attending factor out in the coding: 1) "You do..." and "You are..." statements; and 2) "X is ...," or information giving attends. The "You..." type are easy to recognize.

Examples :

A. Child: Playing in the sand

Adult: "You're playing in the sand."(A, You do)

B. Child: Sitting in the bean bag chair

Adult: "You're sitting in the bean bag." (A, You

are)

C. Child: Stacking blocks

Adult: "That's a tall tower." (A, X is)

2. Attends must refer to the child's behavior -

It is not always apparent that a given information type remark follows and refers to child behavior. The best 136

available rule is that if an information statement ("X

is...") follows and refers to nonverbal child behavior,

then an attend (A) is scored.

Examples ;

A. Child; Playing with a block

Adult: "That's a block-*" (A)

Gray Area: It is not always apparent that a given

information type remark follows and refers to child

behavior. The best available cue is observable child

behavior.

Reward

Any comments that refer to the child or the child's prior, on-going, or future behavior that shows approval.

Temporal factors do not enter into the scoring of rewards.

Physical affection is also scored as reward.

The positive behavior specified (labeled reward)

Examples :

A. You color well.

B. That is a good job.

C. That looks great.

The positive behavior is not specified (unlabeled reward)

Examples :

A. Thank you.

B. Good.

C. Great. 137

Exclusions:

The following single words are considered information

and are not scored.

A. Yeah

B. OK

C. Uh-huh

D. Oh

E. Yes

F. You're welcome

Description of child's behavior indicating better than

average performance

Examples :

A. You did that so fast.

B. You're building it very high.

C. You put those away so fast.

Cues for Scoring: To decide if comments of this type should be scored as reward, cue on whether comment implies that the child's performance is better than average. For example, "You're building it very slowly" might be scored as an R or not scored (excluded as a criticism) depending upon the context.

Physical affection

Examples :

A. Hugs child

B. Hand claps

C. Pulls child onto lap 138

D. Ruffles child's hair

Note: Only each initiation of physical affection is

credited as reward; i.e., if the adult places and leaves

her arms around the child or the child remains sitting on

the adult's lap, he/she is scored for only one reward.

Also, note that this category is physical affection.

Grabbing the child by the arm and dragging him across the

room is not a reward. To be scored as a reward, physical

contact must be initiated by the adult.

Child Responses (Category 2)

When the adult gives a direction (D), the rater must

decide the type of child response to record in row 2.

There are three possible decisions regarding the type of

response: responds (R), no response (N), or no opportunity

to respond ( lea'^e row 2 blank ).

The rater must make an approximation of time in order

to determine the child's response. After the adult's direction (D), the rater is to begin counting slowly one to five. To help, the rater may tap his/her foot. The three different types of responses which the rater may select

(category 2) all depend on this approximation of five seconds beyond the direction interval.

Child Response (R)

In order to determine a response, there must be an observable cue reflecting the initiation of that response 139 within five seconds from the end of the adult direction

(D). (Note; For a chain direction, start counting after the last direction in the chain.) There are four types of responses :

1. Movement toward a specified goal object within

five seconds

2. Initiation of a specific task with five seconds

3. Verbalization after a request for a verbal

response within five seconds

4. Initiation of a specified motor or verbal

response for five seconds

Initiation of the inhibited response must also

occur within five seconds after the adult

direction.

Examples :

A. Adult: "Come over here, please." (D)

Child: Looks up and starts moving toward adult

within five seconds. (R)

B. Adult: "Tell me, what color is this crayon?" (D)

Child: Says color within five seconds. (R)

C. Adult: "Stop coloring." (D)

Child: Continues coloring for three seconds,

then stops for five seconds. (R)

D. Adult: "We must finish with the sand before

coloring." (D)

Child: Returns to sand and does not approach 140

crayons for five seconds. (R)

No Response (N)

In the presence of an observable cue, no response is

determined by;

1. The failure to initiate a response (R) within

five seconds after an adult direction (D)

2. The initiation of a prohibited activity within

five seconds following the termination of the

adult direction to inhibit that activity (D)

Examples :

A. Adult: "Let's play in the sand." (D)

Child: "Just a second," and then continues to

wander about the room. (N)

B. Adult: "Stop running." (D)

Child: Pauses briefly, and then runs again after

two seconds. (N)

C. Adult: "Let's make a sand castle." (D)

Child: Continues to play in sand; makes no

effort to respond to adult. (N)

No-opportunity-for-response (leave row 2 blank)

Vague directions - When the direction is so broad or vague that the necessary cue to define a response is not available.

Examples :

A. Child: Sitting at the table

Adult: "Let's pretend." (D) 141

Child: Picks up a block (not scorable)

For further explanation, see examples under "If/then

Statements" (Form 5), Exclusion 2, and under B Directions,

Form 7 (Vague directions).

Cue for Recording

There may be a gray area with respect to vague

directions. For example, if the adult says, "Hurry up,"

score a direction (D); but it can be difficult to decide if the child is actually "hurrying." In some cases, it is not as clear. If you score a response, you ought to be able to score a no response. If a response is unclear, leave category 2 blank.

Interrupted Directions - This occurs when the adult issues a scorable behavior (repeats the direction, issues a new direction, asks a question, attends, rewards), or makes a nonscorable response before five seconds have elapsed since the initial direction. Note that a verbalization cannot interrupt unless it occurs following the sentence in which the direction occurs.

Exclusions

Chain directions are not scored as interruptions.

Cue for Recording

1. Scoring a response to interrupted directions

- If the five-second interval following a direction is interrupted by any of the adult actions, the child's response (row 2) in the column under the first direction is 142 left blank and the adult action which interrupted the direction is entered in row 1 of the next column. If a nonscorable response interrupts, row 2 is again left blank and the next scorable adult action is entered in row 1 of the next column.

Examples ;

A. Child: Playing with blocks

Adult: "Come here, please."

Child: Still playing after two seconds

Adult: "C'mon (pause), I want you to get over

here."

Child: Looks; begins to approach adult

(Score: D D D) R

B. Child: Playing with blocks

Adult: "Time to put the blocks away."

Child: Picks up blocks; two seconds pass.

Adult: "Thank you. That's a good girl. Come

here."

Child: Staying near blocks; four seconds pass.

Adult: "You are nice to play with when you help

clean up."

(Score: D P D P) R P

2. Scoring a response to chain directions - If there is no pause between directions, they are scored as

(A) directions, form 6 (Chain directions), and a response 143

is scored on the basis of initiation of response to the first direction in the chain. In other words, in completing the child's response (row 2) following a chain direction, all the directions except the first one are ignored.

Example:

A. Child: Playing with blocks

Adult: "Pick those up and put them on the

shelf."

Child: Still picking up the blocks after two

seconds

Adult: "Also, wipe your nose, please."

Child: Still picking up blocks; two seconds pass

without wiping nose

Adult: "Let's play in the sand together. OK?"

Child: Pushes box of blocks toward shelf; five

seconds pass

Adult: Well,what do you want to do?"

Child: Blows nose and smiles

(Score: D D D D Q) R N

Adult Reactions (Category 3)

A behavior can be scored in row 3 on one condition: child response (R) has been scored in row 2. The following sequence should be used when the child's behavior has been recorded in row 2: 1) count and/or tap foot slowly from 144

one to five; 2) forget about the child; 3) watch the

adult. The key to scoring praise and attends in row 3 is

that they occur within the five-second interval.

Reward (R)

The adult issues reward (as defined above under Adult

Actions) within five seconds after the initiation of a

child response.

Examples :

A. Adult: "Hand me the shovel." (one second passes)

Child: Begins to hand shovel (two seconds pass)

Adult: "Thank you." (Score: D) R P

B. Adult: "Turn on cold water." (four seconds pass)

Child: Turns on cold water (six seconds pass)

Adult: "That's a good job." (Score: D R) R

Attends (A)

The adult issues an attend (as defined above under

Adult Actions) within five seconds after the initiation of

a response.

Examples :

A. Adult: "Let's play in the sand." (three seconds

pass)

Child: Goes to sand box and starts to play in

sand (three seconds pass)

Adult: "You are making a sand castle." 145

(Score: D) R A

Failure-to-reinforce-response

Failure to Respond - This occurs when the adult fails to respond in the five-second interval following the initiation of a response. Row 3 is left blank.

Interruption - This occurs when the adult issues a direction, question, or nonscorable response within five seconds of the onset of a response.

Examples :

A. Adult: "Let's color a picture." (two seconds

pass)

Child: Begins to color on paper (two seconds

pass)

Adult: "What are you doing?" (Score: D Q) R

General Scoring Rules

1. To score an adult verbalization as a direction

(D), question (Q), a verb is a necessary, but insufficient component.

Exclusion: One word questions (how, what, etc. )

Examples :

A. How about some more wheels? (not scored)

B. Just a minute, (not scored)

C. Just wait a minute. (D) 146

2. Adult statements which reflect child verbiage

(ordinarily scored as directions, questions, or attends)

are not scored. A reflection is considered to be

terminated following the adult's initial reflective

statement; i.e., further reflections of the child verbiage

are scored as the appropriate adult behavior. (See

examples in appropriate sections of the manual.)

3. Only reward (R) is not time-bound; in addition,

it is the only adult behavior that can be scored when it reflects child verbiage.

4. If the adult directs the child to engage in a behavior which he is already doing, then a response is scored as long as the child is engaged in the activity at the termination of the adult direction.

Examples :

A. Child; Filling a bucket with sand

Adult: "Keep filling the bucket." (D^

Child: Continues to fill bucket for two

seconds (R)

However, if the child is already engaged in an activity and the adult refers to that activity by saying, "Are you doing...(activity label)?"; score as a question, not a direction.

5. "Going" statements - The key to scoring is to focus on temporal cues (e.g., see Cues for Recording, 1.

Time Reference, in the direction section). If the behavior 147 is ongoing or expected to be completed momentarily, then the verbiage may be scored.

Examples :

A. Are you going to color it red? (D)

B. You’re going to put that on the table. (A or

D, depending upon whether the adult is

directing or following the child's

activity.)

C. Are you going to set the table tonight? (not

scored - in the future.)

6. "See" - Unfortunately, there is no general rule available for the many ways in which this word is employed. The following are guidelines for scoring; "See" can be:

A. Never scored

1) See?

2) Let's see.

3) See !

B. Scored as a B-Direction (B)

1) See the army man.

C. Scored as a direction (D)

1) See if you can find...

2) See if you can be quiet...

D. Scored as a question (Q)

1) Do you see it? 148

Note: "Look" is a clear-cut direction, and there should be no scoring difficulties.

7. When the adult obviously stumbles or stutters over a sentence or phrase, this is not considered scorable behavior.

Examples :

A. "Bill, try to - try to - try to pick them

up." (D)

B. "Tell me - tell me - tell me how many blocks

there are." (D)

C. "Tell me. Tell me right now!" (D D) APPENDIX I

PLAY THERAPY HANDOUT

149 150

PLAY THERAPY HANDOUT

I. APPROACH USED TO MODIFY THE CHILD'S BEHAVIORS'

A. To make the child think about what he is doing, to find substitute behaviors, to gain control over his behavior, and apply this to daily experiences, the methods of rewarding, intruding and modeling are used in the playroom.

1. Rewarding - when the therapist rewards what the child is doing, the child's activity is allowed to continue. This increases the chances that the child will do it more frequently.

a. For example, the child is asked what he is making with clay and responds, "a cookie"; the activity is allowed to continue.

2. Intruding - When the child's behavior is not consistent with what the therapist wants, the therapist intrudes (usually verbally), stopping the child's behavior. The child, in order to avoid this, will attempt to conform more to the demand of the therapist and receive the reward of the therapist, which allows the child to continue his activity.

a. Through his intrusions, the therapist functions as a model as to what he wants the child to do in this situation, or how he wants the child to behave. This helps the child go directly to the kind of behavior or play activity considered most acceptable. By functioning as a model, the therapist guides the child toward what must be done in order to gain a reward, and the child's understanding of this becomes a process of thinking.

b. When the therapist intrudes, the child develops an awareness that there are two people present who must interact. This becomes one of the first processes in therapy. 151

c. Over a period of time, it is presumed that the child, in order to get rid of the therapist's intrusion will;

1 ) begin trying certain activities

2 ) explain to the therapist what these activities are

3) find that he is permitted to continue the activities without intrusion and move ahead on his own.

For example: The child is wandering about the playroom and therapist asks the child what he is doing. If the child replies, "I don't know," the therapist continues to intrude. The child will find his exploratory activity is interrupted beyond his ability to continue. The therapist will continue providing the kind of clues that are needed for the child to work his way out of this situation.

d. It is important to remember not to make demands on the child that he may not understand.

II. DIRTY PLAYROOM SETTING

A. The playroom should not be decorated so that the child's play can be messy without fear of destroying anything of value.

B. Things made in the playrogm are for play there and cannot be taken home.

C. When play is over, the child helps to clean up.

III. PLAY MATERIALS

A. Materials used are sand, water, buckets, shovels, plastic bottles, fingerpaints, mirror, crayons, Play-doh, clay, construction paper and wooden blocks.

1. The way the child goes about making things is more important than what is actually made. 152

2. The child can use up the play materials, but is not permitted to misuse materials, such as throwing them at the therapist.

3. The child is not allowed to eat or swallow materials. The child needs to understand that these are not food and are used for play.

IV. PLAY PROCEDURES

A. Before each play session, the therapist plans the activities he wants the child to try.

1. The types of activities are not left solely up to the child.

B. Play materials are set up before the child comes into the playroom.

1. If Play-doh is to be used, it is on the table.

2. The therapist talks with the child about what, the child wants to make. What is actually made is not important.

3. When the child is finished making something, the therapist talks with the child about it.

a. If the child says he has made worms, then the talk may be whether his worms look like the real thing.

b. Talking about what the child feels is not as important as building his confidence so the child feels he has achieved something.

C. Encourage the child to talk about the types of activities he would like to do or the things he wants to make.

1. If the child talks about making things and the play materials are not at hand, talk with him about what things are needed.

a. This helps to plan activities for the next session. 153

b. If these materials cannot be obtained, talk about why they cannot be obtained with the child.

c. The idea is to help the child learn to plan ahead and understand that, even when things are not always available, it could be done another day.

D. The therapist is an active participant in the child's play.

1. When the child makes something, the therapist helps. When it is finished, they play with it.

a. For example, the child makes a snake from clay, so the therapist makes one, too. If the child wants the snakes to fight, it is allowed because it permits the child to express anger without physically attacking the therapist.

b. Another example is fingerpainting. The therapist demonstrates using paint with fingers and hand, but the child makes something. When the child finishes, they discuss what it is.

2. The therapist participates when the child's behavior is acceptable.

3. When the child's behavior is not acceptable, or he does not talk about what he is doing, the therapist intrudes on the activity and talks with the child about what he is doing.

4. It is important for the therapist to move at the child's pace. Just remember that play and the things made are for fun.

V. GOALS

A. Improve the child's self-concept.

1. This is achieved by building on the child's confidence and focusing on what is really happening.

2. It is important to help the child understand that there are things he cannot do, but emphasize the many things he can do. 154

B. Improve the child's self-control.

1. Helping the child to increase his understanding that the desires he is trying to satisfy can be done in an acceptable manner.

C. Improve the child's social interactions.

1. In play, the child learns the rules of society.

2. He learnp» .vhen rules are applied, how they are applied, and the difference between those that are never broken and those that can be broken on certain occasions.

a. In play, the child learns he can never hit his parents and/or therapist.

b. Throwing water playfully can be accepted, but when he becomes aggressive, it is stopped.

c. On special occasions, things made in play can be taken home. APPENDIX J

PARENT CONSUMER SATISFACTION QUESTIONAIRE

155 156

PARENT CONSUMER SATISFACTION QUESTIONAIRE

THE OVERALL PROGRAM

Please circle the response to each question which best expresses how you honestly feel.

I. The major probTem(s) which originally prompted me to allow my child to take part In the study are at this point

considerably worse slightly same slightly Improved greatly worse worse Improved Improved

2. The problems of my child which have been treated using play are at this point

considerably worse slightly same slightly Improved greatly worse worse Improved Improved

3. The problems of my child which have not been treated are considerably worse slightly same slightly Improved greatly worse worse Improved Improved

4. My feelings at this point about my child's progress are that I am

very dissatisfied slightly neutral slightly satisfied very dissatisfied dissatisfied satisfied satisfied

5. To what degree has the treatment program helped with other general, personal or family problems not directly related to your child hindered hindered hindered neither helped helped helped very much more slightly helped nor slightly much hindered

6. At this point, my expectation for a satisfactory outcome of the treatment Is

very pessimistic slightly neutral slightly optimistic very pessimistic pessimistic optimistic optimistic 157

7. I feel the approach to treating my child's behavior problems by using this type of play therapy program is ^

very inappropriate slightly neutral slightly appropriate very inappro- inappro- appro- appro priate priate priate priate

8. Would you recommend the program to a friend or relative?

strongly recommend slightly neutral slightly not Strongly recommend recommend not reconmend not recommend recommend

9. How confident are you in managing current behavior problems in the home on your own?

very confident somewhat neutral somewhat unconfident very confident confident unconfident unconfident

10. My overall feeling about the treatment program for my child is

very negative somewhat neutral slightly positive very negative negative positive positive APPENDIX K

PRETREATMENT AND POSTTREATMENT ABS RATINGS

158 a» uy w ro SUBJECT

SEX

C O r o C o co ro AGE IN YEARS

TREADENT GROUP

99“T5 o to CO to ■T» cn tn 0» 4k cn 4k 4k 4k o \ CO a \ O i ro ro to VI 00 CO eo VO en ro o ro O VI CO cn cn ro to cn VO a \ 00 VI VO 00 CO to VI PERSONAL cn en cn tn tn tn cn cn cn tn cn INDEPENDENCE o O" cn cn en cn w VO VO COGNITIVE ro 00 ro ro CO VI to ro V| o 00 VO 4k o> to O >-* >-» TRIAD oi Co CO CO tn tn CO VI to to VI VI to CO vj iO Vj a. o> m o cn 4k 4k VI VI CO ro w tn VI tn cn w ro VI VO PERSONAL H-* ro en ro ro tn 4k to VO VO VO ro to 00 ro ro VO VO 00 00 tn MOTIVATION 3

ÇJ a \ to *s! o eo tn 4k tn to O ro CO 00 VI a> VI 4» o% o VO ro VO en MOnVATTON cn cn I en en cn tn en tn tn tn cn en cn tn en cn

VIOLENT AND Ca> ro w ^ w cn o rvj CO en CO **o ro en *-» ro o to ro co o o DESTRUCTIVE BEHAVIOR en to O ’**»! o -Tk o o v en ***J CO o o r\3 I—* oo 0 » ro en eo »-* o% eo o to ANnS OCIAL * * # * * * BEHAVIOR s ro ^ o o g> o eo ^ en ■*-J eo o **u w 00 no o cn o oo oo o o REBELLIOUS * * » * * * * » * » BEHAVIOR

OO OO oo oo UNïRUSTVORfTHY oo oo »-*ro oo oo M CO o oo BEHAVIOR PSYCHOLOGICAL o» o o» H-» vD* ro * o 0 *0 * "O» ro ^ 0* 0 eo* * * ^ o v* ro o ro co co* oo * co to DISTURBANCES cn VO 160

Pretreatment and Posttreatment ABS Ratings (continued)

PART I PART II I !lg il i s 5 > a

14 M 13 G 40 29.3 38 60 1 1 3 0 7 31.5 26.6 47 34.5 0 0 0 0 0

15 M 6 G 68.5 81.5 62 82 2 1 4 0 4 71.5 79 89 92 0 0 0 0 3

16 M 12 G 51.5 34 42 65 1 4 4 0 6* 50 37 31 55 0 4 2 0 6*

17 M 8 G 58.5 43.3 20 48.5 0 5 5 0 11* 50 58.3 30 85.5 2 4 6 0 7*

18 M 7 l. 76.5 71.5 89 75 5 2 21* 0 10* 67 55.5 90 61 0 0 5* 0 5

19 M 10 I. 53 64 69 61 6 13* 10* 0 11* 56.5 52.3 50 52 2 4 2 0 4

20 M 9 L 36 52.3 62 66.5 8 0 0 0 0 40.5 52.7 66 60 3 0 0 0 0

21 M 15 L 17.5 31.7 11 25.5 12* 11* 7* 0 11* 17 34.3 17 23 8* 8 6 0 0

22 M 12 L 60 57 25 31.5 14* 8* 14* 0 15* 48 72.7 31 46.5 12* 6 10* 0 13*

23 M 9 L 43.5 69.3 62 55 7 5 16* 0 10* 78 71.7 62 83 2 0 3 0 1

24 M 7 L 68.5 52 52 65 3 2 1 0 9* 77.5 76.5 73 80 1 1 0 0 6*

25 M 2 L 42 66 50 83.5 2 11* 5 0 4 63.5 57.7 7 75 0 6 6 0 2 161

Pretreatment and Posttreatment ABS Ratings (continued)

PART I PART II

Së So, -, h if if ;s ss KË sg Kg ii " I f I s

26 78 59.3 31 63 10 * 64.5 67.7 39 57 5

27 63.5 72.5 59 61 0 4 12* 0 2 59.5 68.5 79 35 2 9* 12* 0 4

® P - Represents Parent Group G - Represents Graduate-Student Group L - Represents Limlted-Treatment Group

^ Pretreatment c Posttreatment

Part 1 Scores - Percentiles ® Part ÎI Scores - Raw Scores

* Represents Part II domains >80%