parent training to increase compliance in a young multihandicapped child

PARENT TRAINING TO INCREASE COklPLIANCE IN A YOUNG MULTIHANDICAPPED CHILD

VINCENT B. VAN HASSELT

Department of Psychtatr). CY Human Beh,rvior. Unibrrstty of California Irhine Xledical Center

LORI A. SISSON Department of Psychtatry. UniLerstty of Pittsburgh School of Lledicine

and

SUSAN R. AACH Western Pennsylvania School for Blind Chtldren

Summary - A trainIns program was implemented to modify a mother‘s behavior management skills to improve compliance in her l-year-old child who suffered from xverc dewlopmental and physical disabilities. A multiple baseline analysis indicated that hehaworal intervention was effective in training the mother to make definitive comm,tnds, prwulc appropriate posittve attention. and persist with commands during socLtl interactions with her child. In addttion. substantial improvement in the child’s compliance \+ith mother‘s comm‘tnds followed introduction of parent training. Further. positive collateral effects included the child‘s increased time on-task and decreased oppositional hcha~tor. All zains were maintained at a h-month follow-up probe.

Applications of parent training strategies to the modification of maladaptive responses in developmentally and physically disabled children have proliferated in recent years (Breiner and Beck, 1954; Moore and Bailey, 1973). Reasons for the upsurge of clinical and investigative interest in training parents of these populations include findings with other groups that parent training improves child- parent interactions (Lysaght and Burchard, 1975), facilitates skill acquisition and generalization (Forehand rr ul., 1979), and reduces maladaptive responses (Johnson et al.. 1975). Also, the high incidence of behavior problems (e.g. self-injury, stereotypic acts, disruptive- ness, noncompliance), particularly in those children with multiple handicapping conditions (e.g. blind-mentally retarded, deaf-blind, cerebral palsied-deaf), has been implicated in the heightened activity of these children (Altman and Mira, 19S2; Rincover and Koegel, 1975; Van Hasselt, 1987). Further,

there are indications that parents of disabled

children experience high levels of stress, caused by such factors as increased and pro- longed child care duties, high medical ex- penses. and diminished social activity

(Murphy. 1952). This situation is exacerbated by the aforementioned behavioral disturbances exhibited by many severely disabled children (Friedrich and Friedrich. 19Sl). Consequently, a number of investigators contend that these children are at risk for social isolation, neglect, and even physical abuse (e.g. Ammerman rf ul., in press; Glaser and Bentovim. 1979). Par- ent training has been recommended to reduce stress and enhance behavior management skills in order to decrease the likelihood of these adverse events (Ammerman ef al., in press).

The purpose of the present study was threefold. First, a training program was implemented to modify parent bahaviors related to compliance and cooperative social play exhibited by a young child who was visually

Requests for reprints should be sent to Vincent B. Van Hasselt, Department of Psychiatry & Human Behavior, University of California Irvine Medical Center. 101 City Drive. South. Orange. CA 92668. U.S.A

275

776 VINCENT B. VAX HASSELT. LORI .A. SISSOX and SGSAK R .A.J,CH

impairsd and experienced delays across several

developmental areas. The majority of previous efforts have involved programming for chil-

dren without such severe physical and developmental disorders (Moreland er al., 1982). A second purpose of this investigation was to evaluate empirically changes in parent behavior that occurred as a function of the

intervention. Surprisingly. most parent training reports do not include documentation of changes in parents’ responses. but focus in- stead on child behavior only (see rrvievvs by Breiner and Beck. 19S-t: Moreland cr (11.. IYS2). Finally, several non-targeted child behaviors were monitored to ascertain possible collateral effects of parent training.

METHOD

Sl1b;ccr.s

The child, Jim, was a -!-year-old white male who attended a day preschool program at the Western Pennsylvania School for Blind Chil- dren (WPSBC)? He had a medical diagnosis of septo-optic dysplasia with associated disorders of blindness, diabetes insipidus. general hypo- tonia. and moderate-to-severe mental retarda- tion. Evaluation with the Vision-Up Assess- ment Profile showed significant delays across all developmental areas. with scores on gross/ fine motor, cognitive, social, self-help. and language scales indicating performance in the l-2 year range. He also displayed a number of maladaptive responses including stereotypic acts (head weaving, hand tlapping) and noncompliant behaviors (crying, screaming) at school and at home. He received medication for diabetes management at the time of the study. His mother was a 26-year-old married woman, with a high school education. She was unemployed at the time of the study. His father, although present in the household. did not participate in training. He was sporadically employed as an unskilled laborer.

Jim and his mother were referred for behavioral intervention by his teacher because of his severe tantrum behaviors vvhich interfered with acquisition of academic skills and led to social isolation and rejection by peers and adults. They were considered to be good candidates for a parent training approach due to the mother’s expressed concern about her child’s behavior. her interest in becoming involved in the treatment effort. and reports of increasing tension in the family. apparently resulting from ineffectiv,e management of Jim’s behaviors.

Serrirlg

The setting for this study was a large room (7 m by 7 m) furnished vvith chairs for mother and son and age-appropriate to>s as required bq’ assessment and training procedures (see below). In addition, a camera and microphone for videotaping were mounted on one wall. with recording, monitoring and controlling equipment located in an adjacent room.

To evaluate level of parent management skill and effects of parent training on child performance. mother-child interactions were assessed over the course of the study. Social play situations were chosen as assessment conditions due to Jim’s failure to explore and play with toys and initiate or sustain contact vvith others. Two conditions vvere defined: Toys present (TP) and Toys Absent (TA). In TP, the follouing toys were available: Big Wheels. ball, truck, and xylophone. At the start of TP, the mother and child received instructions to “play together with the toys”. In TA, no toys were available; mother and child were told to “play together for a little while”. While manipulation of the toys typically was the focus during TP, behaviors in TA included singing songs, playing Pat-a-Cake, and exploring the room. Assessment sessions were 10 minutes in

‘The Western Pennsylvania School for Blind Children is a nonprofit. approved private school providing servict’s to Irgally blind and blind multihandicapprd children ages 2-21 from I+‘sstsrn Pennsylvania.

PAREYT TR.-\INING 277

length and consisted of 5 minutes of TP and 5 minutes of TA conditions. Order of conditions was randomized across sessions. Baseline assessments were scheduled at the convenience of mother and child. once per day, twice per kveek. Following initiation of intervention. assessment was carried out immediately after each training session.

Mother-child interactions in TP and TA assessment conditions \vere videotaped and retrospectively rated by trained experimental assistants using l&second continuous interval recording procedures. ~ieasures of mother’s behaviors included the following: (a) Percent- age definitive commands: the ratio of mother’s definitive commands to definiti5.e commands plus ambiguous commands. Definitive commands were definitive statements to the child which labeled the behavior in Lvhich the child was to engage (e.g. -‘Let’s play the sylo- phone”) and often were accompanied by physical prompts. Ambiguous commands uere tentative or unclear statements which permit- ted the child tho option of not performing the activity the mother labeled (e.g. “Do you want to go for a walk?“). (b) Percentage positive attention: the ratio of mother’s positive attention to child compliance (see below). Positive attention included overt displays of positive physical or verbal attention to\vard the child. Only positive attention which occurred within 20 seconds following child compliance (i.e. presented as a consequence) was scored in this category. (c) Percentage persists: the ratio of mother’s persists to child’s failure to comply (see compliance, below). Persists were identi- cal to definitive commands except that they occurred when the child failed to comply and they repeated the content of the original command.

The following measures of the child’s behaviors also were calculated: (a) Percentage compliance: the ratio of child’s compliance to mother’s commands, whether definitive or ambiguous. Compliance was defined as performance of the behavior specified by mother’s command within 20 seconds of that command,

or submission to physical guidance, without engaging in oppositional behavior (see below).

(b) Percentage on-task: percentage of intervals in which child was on-task. On-task was scored when the child manipulated toys or partici- pated in social interaction (touching, talking. listening). independently or with manual guidance, without oppositional behavior for the entire l&second interval. (c) Percentage oppositional behavior: percentage of intervals in ivhich child eshibited oppositional behavior. that included crying. screaming. aggression. or throwing objects. (d) Percentage stereotypic behavior: percentage of intervals in which child exhibited stereotypic behavior. This included repetitive. non-functional movements such as rocking. head weaving, hand flapping. and tapping objects.

Generally, one rater recorded the behaviors of mother and child. A second rater independently recorded behaviors for 201b of sessions across baseline and treatment phases. Raters were naive to the purpose of the investigation. Interrater agreement was calculated on a session-by-session. behavior-by-behavior basis by dividing total number of targst behaviors recorded in agreement by that number plus those recorded in disagreement, then multiply- ing by 100. Agreement was reached only when both observers marked the behavior as occur- ring the same number of times within the same observation interval. Mean agreement percentages for mother and child behaviors ranged from 83% to 97% (X = 88%).

The overall objective of parent training was

to improve mother-child interactions and to increase child compliance by refining the types of commands mother issued and the types of consequences mother provided for both appropriate and inappropriate child behavior. Three parent skill areas were targeted: (a) definitive commands, (b) positive attention. and (c) persists. Parent training was conducted over 26 15 minute sessions held twice weekly during a j-month period. Also, consistent ivith multiple baseline strategies (see Barlow and Hersen, 19&l), training was directed sequentially and

273 VISCENT B. \‘.AN H,\SSELT. LORl A. SISSOY and SUS.AS R :\.-\CIi

cumulatively to the targeted parent behaviors. Specifically. during the first phase of treatment. attention was directed toward increasing definitive commands. In the second phase, the primary focus was a positive attention. with attention directed to maintaining changes in the first behavior. In the third phase, primary attention was directed toward persists.

Intervention consisted of the application of multiple behavioral techniques which were applied to each category of mother behavior. These were: presentation of rationale, direct instructions, role-playing, modeling. behavior rehearsal, and performance feedback. For example, the objective of training in definitive commands was to teach mother to make fewer ambiguous and more definitive commands in her interactions with her child. This was accomplished by didactic presentation, discussion and identification of types of commands (using videotaped examples for reference). role-play of definitive commands with prompt- ing and therapist modeling, behavior rehearsal in direct interactions with the child. and correction or praise from therapist when ambiguous or definitive commands, respectively, were given. The primary purpose of training in positive attention was to teach mother to differentially reinforce (using praise and hugs) her child when he complied with a command and not when oppositional behavior occurred. Persists training involved teaching mother to insist that her commands be carried out by the child by restating her command and using manual guidance when necessary.

RESULTS

Results of the multiple baseline analysis for training of parent responses in TP and TA conditions are provided in Fig. 1. The introduction of treatment for definitive commands, positive attention, and persists resulted in improvement over baseline levels for all behaviors. For example, baseline mean percentages of definitive commands, positive attention, and persists were 44.5%. 19.8%,

and 21% respectively. in the TP condition. Following treatment, the mean percentages for these categories increased to 99.-l?, . SO.S’%. and 76.1%. X similar incrtzase was found for these responses in the TA condition, although levels were more variable across sessions. In addition, treatment effects were maintained at a 6-month follovv-up probe. Although small increases in all three parent behaviors were observed subsequent to introduction of treatment for definitive commands, effects on individual behaviors were most pronounced when treatment was applied directly to each of them. This demonstrates the sequential and cumulative effects of treatment and suggests that significant positive changes in parent performance were due primarily to the thera- peutic intervention and not to the influence of extraneous variables.

Figures 2-5 present the effects of parent training on child behaviors. As Fig. 2 indicates. improvement in compliance with commands was evident with implementation of parent training. Under TP conditions. compliance increased from a mean of lS.5% in baseline to

__ a mean ot ~3.6% during parent training on definitive commands. Parent training on positive attention appeared to increase compliance moderately (2 = 52%) over these levels while training on persists had no additional effects (,k’ = SO%). Under TA conditions, the effects of parent training on compliance were again most pronounced with introduction of the first parent training component. Although a response decrement was observed in compliance during positive attention instruction, compliance increased to generally high levels over the final component of parent training (persists).

While parent training was specifically de- signed to give mother techniques to increase child compliance, positive effects of parent training were observed on child’s oppositional and on-task responses as well. Figure 3 shows steady and cumulative decreases in child oppositional behavior. As Fig. 4 indicates, increases were found for on-task behavior over the course of treatment. These gains were main-

PARENT TRAISING

Fig. I. Efftxts of parent truning on mother behavior\: (a) psrccntagc of t~t:ll cornman& whtch wcrc’ dsf~n~t~vc (top panel): (b) pcrccntagc of child compliant rcsponccs rccciving positive attention (middle pancl); and (c) pcrccntagc of instanct’s in which child failed to comply and mother perktcd \\ith command (bottom p.~ncl). Misbing data points rcprrsent no opportunitirs to cxhihit the behaviors due IO child cmittinp no compliant rcsponbcs or IOWL complmnt

responses to commands (middle and hottom panels, ruspcctivcly).

tained near post-treatment levels at the 6- month follow-up probe. No changes were noted in level of stereotypic behavior across baseline or treatment conditions (see Fig. 5).

DISCUSSION

The purpose of this study uas to improve behavior management skills in a mother of a young multihandicapped child. Results indicated that a multiple component parent training strategy improved her ability to make definitive commands, provide appropriate

positive attention, and persist with commands. Further, higher levels of child compliance were observed concurrent with the introduction of parent intervention. Examination of collateral effects revealed that the child exhibited decreased oppositional behavior and greater percentage time on-task with parent’s skill acquisition. However, no change was evident in the child’s stereotypic responses. Parent and child behavioral gains were maintained at a Gmonth follow-up assessment.

Anecdotal reports from mother indicated that these positive behavior changes were

250 VINCENT B V.-lx HASSELT. LORI A. SISSON and SUS.AN R. .A.-\CH

60-

50-

40-

30

zo-

IO

0-

Fi g. 2. Effects of parent trainln g on pcrccntagc of mother cummands receiving child compllancr. ,\lking data points rcpresznt no opportunities to exhibit the behavior due to mother giving no commands.

evident at homes as well as in the laboratory setting. In addition, classroom staff noted greater child compliance, especially surround- ing self-care activities which previously had been problematic. These changes were attri- buted to improved mother--child interactions at home which enabled the child to acquire feeding, dressing, and grooming skills.

These findings generally are consistent with results of previous attempts to instruct parents to modify compliance in their handicapped children (Eyeberg and Matarazzo, 1980; Moore and Baily, 1973; Tavormina, 1975). The present study expands this literajure by target- ing behavior management skills in a parent of a child with multiple handicapping conditions. In addition, parent behaviors were monitored to demonstrate the controlling effects of treat-

ment, and to ascertain specific factors account- ing for observed changes in child behavior. In this case, it appears that parent training in definitive commands was the most important factor contributing to improved child compliance. Also, despite arguments for the need to evaluate nontargeted behaviors within the context of parent interventions (Moreland er al., 1982), this report is one of the few to accomplish this task with a de~~slopmentally and physically disabled child. Shaping parent commands and consequnces for compliance appears to be a cost-efficient strategy for changing a variety of child behaviors in a social play situation.

Several limitations of this investigation war- rant attention. First, the present intervention utilized a multi-element treatment package. It

2s 1

QE”NIT,VE

COHMaNQS DEFlMTlVi COMMANDS.

md P0SIrI.E ITTENTION, DEFlNlrl.E POSITIVE md

BASELINE COMMlNDS ATTENTION PERSISTS

lo- I I

I I I I

so- I I

I !

I

Fig. 3. Effects of parent trainin g ou pcrccntagc of intcrv;IIh in which child oppoxitwnul hehavlor occurred

uas initially felt that such a comprehensive strategy was necessary due to the severity of the child’s disability and behavior management problems. Further research is needed to deter- mine whether such a broad-spectrum approach is needed with multihandicapped children. Second, frequency of stereotypic acts did not decrease over the course of the program. Prior

research (e.g. Baumeister and Forehand 1973; Berkson and Davenport, 1962) has indicated that these behaviors are common in many blind individuals, particularly in those with multiple impairments. It is highly likely that direct intervention is required to ameliorate this response class, which may be chronic and pervasive in a large number of multihandicapped children.

REFERENCES

Altman K. and Mira M. (19SZ) Training parents of developmentally disabled children. In hlatbon J. L. and Andrasik F. (Eds). Trec~mw~r lssws rrr~d Innorwriorrs irl kfeniul Rercwda!ron. Plenum Press, NW York.

Ammerman R. T.. Van Hasselt V. B. and Hersen M. (In Press). Maltreatment of handicapped children: A critiul review. 1. Family Violence.

Barlow D. H. and Hersen M. (198-i) Smglr Casr EC- perimenrul Designs: Srrutegies for Srdying Behavior Chnnpe (2nd Edn). Pergamon Press. iiew York.

Baumeister A. A. and Forehand R. (1973) Stereotyped acts. In N. R. Ellis (Ed.). ln~err~urionol Rrrierv 0~. Research in ,Mend Rerarclurion, Vol. 6. Academic Press. New York.

Berkson G. and Davenport R. K. (1967) Stereotyped movements of mental defectives: I. Initial survey. r\m. J. Men. Drf. 64, 8-B-552.

Breiner J. and Beck S. (1984) Parents as change agents in the management of their developmentally delayed children’s noncompliant behaviors: A critical review. Appi. Res. Mmr. Rerard. 5, 259-278.

Fig. 1. Effects of parent truintng on psrcrntage of intervals in which child on-task behavior was recorded

Eyeberg S. M. and Matarazzo R. G. (IYSU) Training parents as therapists: A compnrtson between individual parent-child interaction training and parent group didactic training. J. Cfirr. Psychol. 36, 4924YY.

Forehand R., Sturgis E. T.. McMahon R. J., Aguar D.. Green K.. Wells K. C. and Breiner J. (1979) Parent behavioral training to modify child noncompliance: Treatment generalization across time and from home to school. Behuv. Modif. 3, Z-26.

Friedrich W. N. and Friedrich W. L. (1981) Psychosocial aspects of parents of handicapped and nonhandicapped children. Am. J. Menr. Def. 85, jjl-553.

Glaser D. and Bentovim A. (1979) Abuse and risk to handicapped and chronically ill children. Child Abuse and Neylecr 3. 565-575.

Johnson M. R.. Whitman T. L. and Barloon-Noble R. (1975) A home-based program for a preschool behavior- ally disturbed child with parents as therapists. J. Behar. Ther. Exp. Psychiaf. 9. 6j_70.

Lysaght T. V. and Burchard J. D. (1975) The analysis and modification of a deviant parent-youth communication pattern. J. Behav. Ther. Exp. Psychiaf. 6. 330-312.

Moore 8. L. and Bailey J. S. (1973) Social punishment in the modification of a preschool child’s “autistic-like” behavior with a mother as therapist. J. Appf. Behrrv. Anal. 6, 497-507.

Moreland J. R.. Schwebel A. I.. Beck S. and Wells R. (1982) Parents as therapists: A review of the behavior therapy parent training literature - lY7S to 1981. Behav. Modif. 6. 250-276.

Murphy M. H. (19S2) The family with a handicapped child: A review of the literature. Devel. Behav. Ped. 3, 7242.

Rincover A. and Koegel R. L. (1’375) Setting generality and stimulus control in autistic children. J. Appl. Behav. Anal. 3, 235-2-S.

Tavormina J. B. (1975) Relative effectiveness of behavioral and reflective group counseling with parents of mentally retarded children. J. Consul. Clin. Psychol. 43. 22-31.

Van Hasselt V. B. (1957) Behavior therapy for visually handicapped persons. In Hersen M., Eisler R. M. & Miller P. M. (Eds), Progress in Behavior Modification. Vol. 21. Sage Publications: Beverly Hills.

0

COMYANOS,

ATTENTION. and POSlTiVC OEFINITIVE POSITIVE aed

SASELINE COMHANNOS ATTENTION PERSISTS FOLLOW-

UP

5 i S SIONS . TOYS PRESENl 0 TOYS 18SENT

Fig. 5. Effects uf parent training on percentage of intervals in which child stcrcotypic behavior

~~lc~r~oll,lrtlsrnlrrlrs - This study was wpportrd by il grant from The Buhl Foundation and Contract No. 3lH!-S2-036X

(Early Childhood Rcscurch Institute) from the U.S. Department of Education. However. the opinwm cxprad hcrcin do not ntxessarily rellect the position or policy of the U.S. Dcpartmcnt of Education ad no officd cnclorwment by the Dcpurtment should bc inferred. The authors wish to thank Lynn Donahus, ?.lark Kilwin. Judith A. Lownzstty, hlarj Louis. Louise E. Moore. and Collcrn McGinnis for their varird contributions to the htudy.

parent training to increase compliance in a young multihandicapped child

Documents