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The treatment acceptability of a behavioral parent training program and its components Calvert, Susan Cross 1986

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THE TREATMENT ACCEPTABILITY OF A BEHAVIORAL PARENT TRAINING PROGRAM AND ITS COMPONENTS by S U S A N / C R Q S S CALVERT B.Sc, The University of Lethbridge, 1982 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES Department of Psychology We accept this thesis as conforming to the required standard THE UNIVERSITY' OF BRITISH COLUMBIA April, 1986 (8j Susan Cross Calvert In presenting t h i s thesis i n p a r t i a l f u l f i l l m e n t of the requirements for an advanced degree at The U n i v e r s i t y of B r i t i s h Columbia, I agree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e for reference and study. I further agree that permission for extensive copying of t h i s thesis for s c h o l a r l y purposes may be granted by the Head of my Department or by h i s or her representatives. I t i s understood that copying or p u b l i c a t i o n of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of Psychology The U n i v e r s i t y of B r i t i s h Columbia 2135 West MaH Vancouver, B r i t i s h Columbia Canada V6T 1W5 Date: A p r i l , 1986 Abstract Treatment acceptability research has typically examined the acceptability of single isolated procedures rather than a comprehensive program of integrated procedures designed to deal with a problematic behavior. One such program developed to treat child noncompliance and other conduct-disordered behaviors is the Forehand-McMahon parent training program (1981). This program has been extensively evaluated and its effectiveness, generalizability, and social validity have been documented in numerous investigations (see McMahon & Forehand, 1984, for a review). In this study, the treatment acceptability of the Forehand-McMahon parent training program (1981) was evaluated in terms of its five individual parenting skills (attends, rewards, ignoring, commands, time out), three methods of introducing each new skill to the child (presenting a rationale, presenting a rationale and modeling its use, or no rationale or modeling), and the program as an entity. Ninety nonreferred mothers of 3- to 8-year old children were presented with written descriptions of the Forehand-McMahon parent training program as it would be applied to a typical clinic-referred family. Subjects were randomly assigned to one of three groups by way of the written descriptions they received. These descriptions varied only in the method of introducing each new skill to the child. Subjects evaluated each of the individual parenting skills, the teaching method, and the overall program by way of the Treatment Evaluation Inventory (Kazdin, 1980a; 1980b) and the usefulness/difficulty measures of the Parent's Consumer Satisfaction Questionnaire (Forehand & McMahon, 1981). Subjects rated all aspects of the program very positively on overall ratings of acceptability suggesting that they perceived the program and its skills to be appropriate for the problem described, fair, sensible, and humane. Rewards, commands, and attends (strategies to increase deficit behavior) were rated as more acceptable than time out and ignoring (which attempt to reduce behavioral l i excesses). In terms of the methods of introducing each new skill to the child, presenting a rationale was rated as more acceptable than either presenting no rationale or presenting a rationale and modeling its use. Ratings of treatment acceptability were positively correlated with ratings of usefulness and negatively correlated with ratings of difficulty. The ordering of techniques on usefulness and difficulty dimensions directly paralleled ratings of acceptability with only one exception. Comparisons of these findings with previous studies of treatment acceptability and consumer satisfaction are made and discussed in light of the social validity of this parent training program. i i i Table of Contents Abstract i i Table of Contents i v L i s t of Tables v i L i s t of Figures v i i Acknowledgement v i i i I. INTRODUCTION 1 II . REVIEW OF THE TREATMENT ACCEPTABILITY LITERATURE 6 A. Kazdin's Research 6 B. Witt's Research 9 C. Other Treatment A c c e p t a b i l i t y Studies 11 D. Summary of the Treatment A c c e p t a b i l i t y Research ... 16 I I I . PARENT TRAINING PROGRAM 17 IV. USE OF RATIONALES AND MODELING IN PARENT TRAINING PROGRAMS 20 V. RESEARCH PURPOSES AND HYPOTHESES 23 VI. OVERVIEW OF THE INVESTIGATION 25 VII. METHOD 26 A. Subjects 26 B. Design 27 C. Dependent Measures 28 D. Procedure 29 E. Scoring 30 i v VIII. RESULTS 32 A. Measures of A c c e p t a b i l i t y 32 B. U s e f u l n e s s / D i f f i c u l t y Measure 37 C. Relationship Between U s e f u l n e s s / D i f f i c u l t y Ratings and Ratings of A c c e p t a b i l i t y 43 IX. DISCUSSION 45 REFERENCES 55 APPENDICES A 61 B 63 C 73 D 75 E 77 F 101 G 103 H 105 I 107 J 109 v L i s t of Tables Table 1 — Mean TEI Ratings 33 2 — Mean Ratings of Perceived Usefulness 38 3 — Mean Ratings of Perceived D i f f i c u l t y 39 4 — I n t e r c o r r e l a t i o n s Between TEI and U s e f u l n e s s / D i f f i c u l t y Ratings 44 v i L i s t o f F i g u r e s F i g u r e 1 — M e a n T E I s c o r e f o r e a c h m e d i a t i o n a l g r o u p c o l l a p s e d a c r o s s t e c h n i q u e s 3 5 F i g u r e 2 — M e a n r a t i n g s o f d i f f i c u l t y f o r e a c h m e d i a t i o n a l g r o u p c o l l a p s e d a c r o s s t e c h n i q u e s 4 1 t v i i Acknowledgement I wish to express my appreciation to my research supervisor, Dr. Robert McMahon, and my research committee members, Dr. Keith Dobson and Dr. Barry Munro, for t h e i r guidance during the course of t h i s study. I am e s p e c i a l l y thankful to Gordon f or h i s tolerance, support, and encouragement over the past years. v i i i 1 Introduction In recent years, there has been discussion of the need to broaden criteria for evaluating psychological treatments other than traditional outcome measures such as measures of behavior and attitude change (Barlow, 1981; Bornstein & Rychtarik, 1983; Garfield, 1983; Jacobson, Follette, & Revenstorf, 1984; Kazdin, 1977; Kazdin & Wilson, 1978; Strupp & Hadley, 1977; Wolf, 1978). Obviously, the focus on outcome measures of client change has had priority and will continue to have priority since the primary goal of clinical research is to develop effective treatment techniques. However, other criteria have been proposed to supplement outcome measures and include considerations of cost, efficiency, therapist expertise, duration of treatment, proportion of clients who improve, and side effects (e.g., Kazdin, 1980c). Wolf (1978) has proposed that applied interventions be socially validated. Social validity refers to assessments of the social acceptability of intervention programs and would require validation of three types: (1) The social significance of the goals. Are the specific behavioral goals really what society wants? (2) The social appropriateness of the procedures. Do the ends justify the means? (3) The social importance of the effects. Are consumers satisfied with the results? AH the results, including unpredicted ones? (p. 207) Since Wolf's delineation of social validity, researchers in the field have focussed on three areas: the assessment of the clinical importance of behavior change, consumer satisfaction, and treatment acceptability. Two methods of determining the clinical importance of behavior change have been outlined by Kazdin (1977). Social comparison refers to comparing the client's behavior to that of the behavior of his or her nondeviant peers both before and after treatment. For treatment to be socially valid, the behavior of the client after treatment 2 should be indistinguishable from his or her peers. The subjective evaluation method refers to having individuals who likely have contact with the individual (for example, parents, spouse, teacher) assess the client's behavior to determine whether the changes made during treatment are viewed as qualitatively important (Kazdin, 1977). Consumer satisfaction refers to satisfaction with treatment outcome measured after treatment completion and may also include "satisfaction with the therapist, with various treatment procedures or skills, and with the teaching format employed in the treatment program" (McMahon & Forehand, 1983, p. 210). Satisfaction with treatment or consumer satisfaction has been a feature of evaluation research in community mental health for many years (Lebow, 1982; McMahon & Forehand, 1983). As a type of social validation among behavior therapists and researchers, consumer satisfaction has been a method of expanding outcome measures to include client feedback. According to McMahon and Forehand (1983), the most extensive use of consumer satisfaction measures in the behavioral treatment of children has been in the area of parent training. As defined by Kazdin (1980a), treatment acceptability refers to "judgements about the treatment procedures by non-professionals, laypersons, clients, and other potential consumers of treatment." (p. 259) Included in judgements of acceptability are considerations of appropriateness of treatment for the problem; whether treatment is just, sensible, and nonintrusive; and whether treatment concurs with popular notions of what treatment should be. In sum, treatment acceptability refers to the overall evaluation of the treatment procedures (Kazdin, 1980a). The case for evaluating treatment acceptability is justified on several grounds. Examining treatment acceptability provides an opportunity to understand the process of psychotherapy from the client's perspective since the opinion of the 3 client on the suitability, usefuless, and so on of the therapy is sought. Also, for certain clinical problems, there are several effective techniques available (Kazdin, 1980b). For example, the techniques of differential reinforcement, time out, response cost, and positive practice have all been found to be effective in reducing various disruptive child behaviors (Gelfand & Hartmann, 1984). Though these techniques have been shown to be effective, they may be differentially acceptable to the client (McMahon, Cross Calvert, Davies, & Flessati, 1986). Treatment procedures often raise ethical and legal issues since some procedures may infringe upon client rights, regardless of their effects on behavior (Kazdin, 1980b). This is especially pertinent in the treatment of children, the mentally retarded, the institutionalized mentally ill, or anyone incapable or unable to give informed consent. Research in treatment acceptability addresses concerns regarding methods used to obtain client change (Kazdin, 1980b). Treatment procedures viewed by society as more acceptable are more likely to be sought out and adhered to once treatment has begun (Kazdin, 1980b). It is likely that acceptable treatment procedures will result in fewer dropouts, greater client compliance, and greater overall satisfaction with treatment. Measures of treatment acceptability may predict who will drop out of therapy. By identifying variables that influence clients' reactions to treatment, effective treatments that have low acceptability might be altered so as to become more acceptable (Kazdin, 1980b). Additionally, there are likely certain subpopulations that would find some interventions more acceptable than would other subpopulations. For example, parents of children with severe behavior problems might rate intrusive treatment interventions as more acceptable than would parents of children with mild behavior problems. It would be important then to identify these subpopulations so that treatment procedures can be matched to particular client groups. 4 Finally, policy makers and the public have become concerned with the credibility, usefulness, and accountability of various interventions employed in mental health services. In evaluating treatment acceptability, the public can be reassured by other consumers that interventions are acceptable and appropriate (Parloff, 1983). Researchers have sometimes confused consumer satisfaction with treatment acceptability. For example, Hobbs, Walle, and Caldwell (1984) described a study in which mothers of noncompliant children evaluated one of three parent training conditions after having been trained in that particular technique. Similarly, Walle, Hobbs, and Caldwell (1984) had mothers of noncompliant children evaluate the acceptability of time out and attention after administering these techniques in various sequences and combinations (time out followed by attention, attention followed by time out, or attention and time out administered concurrently). Both studies discussed their results in terms of acceptability of treatment when it clearly falls under the rubric of consumer satisfaction. By definition, treatment acceptability refers to measures of acceptability completed by potential consumers of treatment procedures before they begin treatment. Alternatively, consumer satisfaction refers to satisfaction with treatment outcome after treatment completion. Therefore, consumer satisfaction measures are confounded by experience with the treatment whereas treatment acceptability measures are not. Consumer satisfaction measures completed after treatment termination give no indication of how the same program may have been evaluated prior to treatment; that is, by treatment acceptability measures. Furthermore, consumer satisfaction measures are typically completed only by subjects who complete treatment and not those who drop out or choose not to enter this type of treatment. 5 In the following section, current research on the treatment acceptability of interventions for child behavior problems will be reviewed. The review is divided into three segments. The first segment will describe the pioneering work by Alan E. Kazdin. The investigation of factors relating to teachers' judgements of acceptability of classroom interventions by Joseph C. Witt and his associates is then described. The third segment will describe various other research investigations of treatment acceptability. 6 Review of the Treatment Acceptability Literature Kazdin's Research Research concerned with treatment acceptability was inaugurated by Alan Kazdin in a series of studies investigating the acceptability of various interventions for child behavior problems (Kazdin, 1980a, 1980b, 1981, 1984; Kazdin, French, & Sherick, 1981). Kazdin has developed a standard methodology in which subjects are presented with an audiotaped case description of a child's problem and several (usually four) treatment procedures designed to alleviate the problem. A replicated Latin square design is employed to control for potential order and sequence effects of the interventions. Subjects are asked to evaluate each procedure by completing the Treatment Evaluation Inventory (TEI; Kazdin, 1980a) and by rating fifteen sets of bipolar adjectives representing the Evaluative, Potency, and Activity dimensions of the Semantic Differential (Osgood, Suci, & Tannenbaum, 1957). Each subject is presented with a description of one of two children whose behavior warranted treatment. Age, gender, intelligence, and usually setting (Kazdin, 1980a, 1981, 1984; Kazdin et al., 1980) are varied to ensure that treatment evaluations are not restricted to these aspects of the description. In Kazdin's earlier studies (1980a, 1980b), both cases described highly disruptive and noncompliant behavior, likely classified as conduct disorder, while the later studies (Kazdin, 1981, 1984; Kazdin et al., 1981) described both conduct disorder and attention deficit disorder types of behavior. The TEI consists of fifteen items in a Likert-like format which assesses whether the treatment is acceptable for the child's problem behavior; the willingness to carry out this procedure; the suitability of the procedure for the child; how likeable, fair, and humane the procedure is; and so on. Kazdin initially generated a pool of 45 items thought to be related to acceptability. Through a 7 series of pilot investigations, the inventory was reduced to fifteen items and factor analyzed to yield a solution in which all items produced high loadings on a single principal component before rotation (range from .67 to .94). After varimax rotation, factor loadings ranged from .61 to .95 on the first factor (Kazdin, 1980a). The TEI has been shown to differentiate among various interventions in terms of their relative acceptability (Kazdin, 1980a, 1980b, 1981; Kazdin et al., 1981). Items on the Semantic Differential represent three dimensions: Evaluative (good-bad, kind-cruel), Potency (strong-weak, heavy-light), and Activity (active-passive, fast-slow). Kazdin has employed the Semantic Differential for two reasons. The Evaluative dimension represents an overall general evaluation of treatment while providing a methodologically distinct assessment device from the TEI. Second, the dimensions of Potency and Activity reflect different characteristics of treatment that may provide further information related to evaluations of treatment acceptability. In assessing the varying acceptability of child treatment approaches, Kazdin has consistently found that subjects (undergraduate students, inpatient psychiatric children and their parents, hospital staff) have been able to distinguish between alternative treatments on the basis of acceptability (Kazdin, 1980a, 1980b, 1981, 1984; Kazdin et al., 1981). In these studies, positive reinforcement has been rated as the most acceptable treatment. For example, Kazdin (1981) found that undergraduate students rated positive reinforcement most acceptable, followed by positive practice, time out, and medication. Another study found that positive reinforcement was rated as more acceptable than various forms of time out (Kazdin, 1980b). In addition to documenting the relative acceptability of various treatment interventions, Kazdin has assessed various parameters related to treatment 8 acceptability. He found that treatments were rated more acceptable when they were applied to more severe clinical problems (Kazdin, 1980a) and that acceptability of a procedure can be altered by changing the manner in which it is presented to the clients and implemented (Kazdin, 1980b). For example, variations of time out that do not completely remove the child from the situation were rated as more acceptable than was an isolation form of time out. Kazdin (1981) also demonstrated that the efficacy of a treatment was not related to acceptability, but undesirable side effects of treatment did decrease acceptability ratings. These parametric studies are limited in their generalizability due to their exclusive reliance on undergraduate students as raters of acceptability. In two additional studies, Kazdin has had potential consumers complete the acceptability measures (Kazdin, 1984; Kazdin et al., 1981). In the 1981 study, inpatient psychiatric children, their parents, and hospital staff on the unit differentiated among alternative treatments on the basis of their acceptability. Reinforcement of incompatible behavior was rated as most acceptable followed by positive practice, medication, and time-out from reinforcement. Although the three groups of subjects rated the treatments in the same order, the children tended to rate the treatments as less acceptable than did their parents, with staff ratings falling between the two groups. The second study (Kazdin, 1984) had inpatient psychiatric children and their parents rate three intervention alternatives: time-out from reinforcement, locked seclusion, and medication. Kazdin found that parents rated time-out from reinforcement as most acceptable while the children rated medication as most acceptable. Treatments that produced strong effects were rated as more acceptable by both groups than treatments that produced weak effects, in contrast to Kazdin's 1981 study with an analogue population. 9 Witt's Research An extension of Kazdin's work has been initiated by Witt and his colleagues into the acceptability of behavioral interventions in the public school setting (Elliott, Witt, Galvin, & Peterson, 1984; Martens, Witt, Elliott, & Darveaux, 1985; Witt, Elliott, & Martens, 1984; Witt & Martens, 1983; Witt, Martens, & Elliott, 1984; Witt, Moe, Gutkin, & Andrews, 1984; Witt & Robbins, 1985). In contrast to Kazdin's methodology, Witt's general design consists of having subjects read one of several possible case descriptions depicting a problem behavior, and then evaluating the acceptability of one intervention designed to modify the behavior. Since Witt uses a between-subjects design, multiple cases are created to operationalize all combinations of the independent variables. In all of the studies, Witt has varied the level of behavior problem severity. These levels were selected from earlier pilot work (Witt, Martens, & Elliott, 1984). For example, the lowest level of severity used was daydreaming while destruction of others' property ranked as the highest level of severity. In addition to varying level of behavior problem severity, Witt has investigated other parameters of intervention techniques and the interactions among the variables. Examples of paramaters investigated are teacher time involvement, positive versus reductive interventions, intervention complexity, and teacher experience. Treatment acceptability has been measured by the Intervention Rating Profile (IRP), a 20-item Likert-like scale developed to assess teachers' perceptions of the acceptability of classroom interventions (Witt & Martens, 1983). The IRP and its shorter form, the IRP-15 possess relatively good psychometric properties (Witt & Elliott, 1985). A principal components factor analysis with varimax rotation yielded one primary factor accounting for 41% of the variance (labeled as a general acceptability dimension) and four secondary factors described as the amount of risk 1 0 to the child; the amount of teacher time required for the intervention; the degree to which the intervention has negative effects on other children; and the amount of teacher skill required to implement the intervention. Using Cronbach's alpha, reliability was found to be .91. Using the IRP-15, items loaded on a single factor ranging from .82 to .95 which seems to reflect a general acceptability dimension. Reliability of the IRP-15 using Cronbach's alpha was found to be .98 (Martens et al., 1985). In a series of studies, Witt and his associates have found that the acceptability of classroom interventions is mediated by many factors. For various behavior problems, interventions requiring high amounts of teacher time for planning and implementations were less acceptable than those requiring lesser amounts of time (Witt, Elliott, & Martens, 1984; Witt, Martens, & Elliott, 1984). However, lower levels of teacher time involvement were viewed as less acceptable for severe, as opposed to mild and moderate, behavior problems (Witt, Martens, & Elliott, 1984). Teacher acceptability ratings were found to vary significantly with the severity of the behavior problems (Martens et al., 1985; Witt, Elliott, & Martens, 1984; Witt, Moe, Gutkin, & Andrews, 1984). Interventions applied to more severe behavior problems have been rated as more acceptable than interventions applied to mild behavior problems (Martens et al., 1985; Witt & Robbins, 1985). Generally, positive or reinforcing interventions were judged as more acceptable than negative or reductive interventions (Elliott et al., 1984; Witt, Elliott, & Martens, 1984), thus extending Kazdin's findings to a different consumer population. Positive interventions were viewed as less risky than negative or reductive interventions (Witt, Elliott, & Martens, 1984). Highly experienced teachers generally rated interventions as less acceptable than teachers new to the profession (Witt & Robbins, 1985; Witt, Moe, Gutkin, & Andrews, 1984). Interventions implemented by 1 1 the teacher were rated as more acceptable than those implemented by someone else (Witt & Robbins, 1985). Interventions described in pragmatic language were evaluated as significantly more acceptable than interventions described in either behavioral or humanistic terms (Witt, Moe, Gutkin, & Andrews, 1984). Other Treatment Acceptability Studies Although Kazdin and Witt have been responsible for the proliferation of two distinct programs of research in treatment acceptability, other studies have appeared in the literature which address and extend this same research area while utilizing methodologies that depart from the standard formats employed by Kazdin and Witt. Frentz and Kelley (1986) describe a study in which 82 nonclinic mothers of 2-to 12-year old children read one of two vignettes describing an 8-year old noncompliant and aggressive boy that varied only in behavior problem severity (mild versus severe). Using the TEI (Kazdin, 1980a), subjects rated five different reductive treatment methods (differential attention, response cost, time out, time out with spanking, spanking alone) which were presented in a randomized order following the case description. Additionally, mothers completed the Eyberg Child Behavior Inventory (Eyberg & Robinson, 1983; Eyberg & Ross, 1978; Robinson, Eyberg, & Ross, 1980) for their child. The Eyberg Child Behavior Inventory is a 36-item behavior problem checklist that has been shown to be a reliable and valid measure of conduct problems in children aged 2 to 16 years. Frentz and Kelley (1986) found that response cost was rated significantly more acceptable than all other interventions. Time out was rated significantly more acceptable than differential attention, time out with spanking, and spanking alone, which were all rated in the unacceptable range of the TEI (i.e., 15-60). All treatments were perceived as more acceptable when applied to the severe behavior 12 problem description rather than the mild behavior problem description, with rank ordering of the interventions remaining the same. The authors hypothesized that parents who perceived their child as exhibiting behavior problems, as measured by the Eyberg Child Behavior Inventory and similar to scores obtained by clinic mothers, might differ in their acceptability ratings from parents who viewed their children as nonproblematic. This prediction was not supported. Regular classroom elementary teachers rated the acceptability of four classroom treatment interventions (medication, time-out from reinforcement, positive practice, and reinforcement of incompatible behavior) in a study conducted by McKee (1984). Teachers were assigned to treatment conditions based on their score on a measure of knowledge of social learning principles (high versus low) and randomly assigned within knowledge groups to one of two case descriptions. Both cases described an aggressive, nonconcompliant 9 year-old boy. The second case varied only by the inclusion of additional information suggesting that the child had been in special education classes and was now being mainstreamed. Teachers in the high and low knowledge groups read the assigned case description and then rated the acceptability of the four treatments in a replicated Latin-square design. Treatment acceptability was measured by the TEI (Kazdin, 1980a), selected adjectives from the Semantic Differential (Osgood et al, 1957), and a questionnaire which in part asked subjects to rank order the treatments in terms of the likelihood of being used by the subject. McKee (1984) found that high knowledge group teachers rated the four treatments as more acceptable than the low knowledge group teachers. The implication of such a finding is that one might increase the treatment acceptability of behavioral interventions by correspondingly increasing the rater's knowledge of behavioral principles. Reinforcement was rated as most acceptable, followed by 13 time out and positive practice, which did not differ from each other in terms of acceptability. Medication was rated as the least acceptable intervention. This sequence of differing acceptability is generally consistent with Kazdin's and Witt's findings. Acceptability ratings for the two cases were not found to be significantly different. In a study conducted by Dorsett and Hobbs (1985), twenty parents of nonreferred children between the ages of 3 and 12 viewed a videotape of a mother implementing four different behavior management techniques (exclusionary time out, nonexclusionary time out, social reinforcement, and token reinforcement with praise) for her daughter's oppositional behavior. Half of the subjects viewed implementations that were "easy"; that is, the child cooperated with the application of the procedure and no adverse side effects were shown. The remaining parents evaluated "difficult" implementations in which the child cooperated less and adverse side effects were included, such as crying and escape behaviors in the time-out condition, aruging about when the back-up reinforcer would be delivered in the token reinforcement condition, and the child requesting to be left alone in the social reinforcement condition. Subjects evaluated each of the four techniques by completing the TEI (Kazdin, 1980a). The results of this study lend further support for earlier findings of greater acceptability of reinforcement procedures relative to time-out procedures for child behavior problems. Social reinforcement was rated as most acceptable, followed by token reinforcement, nonexclusionary time out, and exclusionary time out. No significant statistical differences were found either between the two types of time out or the two types of reinforcement. Contrary to Kazdin's (1981) findings that undesirable side effects of treatment decreased acceptability ratings, Dorsett and Hobbs found no significant differences 14 i n T E I s c o r e s a s a f u n c t i o n o f e a s y v e r s u s d i f f i c u l t i m p l e m e n t a t i o n s . T h e a u t h o r s s u g g e s t s e v e r a l p o s s i b l e e x p l a n a t i o n s f o r t h i s d i s p a r i t y . F i r s t , t h e s i d e e f f e c t s p r e s e n t e d b y w a y o f v i d e o t a p e m a y h a v e b e e n p e r c e i v e d a s l e s s s e v e r e t h a n t h o s e d e s c r i b e d o n a u d i o t a p e b y K a z d i n ( 1 9 8 1 ) . S e c o n d , s u b j e c t s i n t h i s s t u d y w e r e l i k e l y g i v e n m o r e i n f o r m a t i o n o n t h e a d m i n i s t r a t i o n o f t h e s e t e c h n i q u e s a n d t h e a p p r o p r i a t e h a n d l i n g o f n e g a t i v e b e h a v i o r s d u e t o t h e m e t h o d o f p r e s e n t a t i o n t h a n t h e s u b j e c t s i n K a z d i n ' s s t u d y . T h e a u t h o r s s p e c u l a t e t h a t t r e a t m e n t s w i t h a d v e r s e s i d e e f f e c t s m a y b e e v a l u a t e d m o r e f a v o u r a b l y i f t h e m o d e l m a n a g e s t h e n e g a t i v e b e h a v i o r e f f e c t i v e l y . F i n a l l y , p a r e n t a l p e r c e p t i o n s o f a d v e r s e s i d e e f f e c t s a n d t h e i r s u b s e q u e n t r a t i n g s o f t r e a t m e n t a c c e p t a b i l i t y m a y d i f f e r s u b s t a n t i a l l y f r o m t h o s e o f u n d e r g r a d u a t e s t u d e n t s u s e d i n K a z d i n ' s ( 1 9 8 1 ) s t u d y . A s t u d y c o n d u c t e d b y N o r t o n , A u s t e n , A l l e n , a n d H i l t o n ( 1 9 8 3 ) c o m p a r e d r a t i n g s o f i n t e r v e n t i o n a c c e p t a b i l i t y a n d e f f e c t i v e n e s s b y t e a c h e r s a n d p a r e n t s o f e l e m e n t a r y s c h o o l a g e c h i l d r e n . S u b j e c t s r e a d a d e s c r i p t i o n o f a c h i l d w h o h a d b e e n e n g a g i n g i n d i s r u p t i v e b e h a v i o r s . C a s e d e s c r i p t i o n s w e r e t h e s a m e e x c e p t f o r t h e s e x o f t h e c h i l d , t h e c h i l d ' s a g e ( 5 v e r s u s 1 0 y e a r s ) , a n d t h e g r a d e l e v e l o f t h e c h i l d ( k i n d e r g a r t e n v e r s u s f i f t h g r a d e ) . S u b j e c t s w e r e a s k e d t o r a t e f i v e d i f f e r e n t d i s c i p l i n e p r o c e d u r e s t h a t h a d b e e n r e c o m m e n d e d b y a p r o f e s s i o n a l . T h e s e w e r e s e l e c t i v e ( d i f f e r e n t i a l ) r e i n f o r c e m e n t , i s o l a t i o n t i m e o u t , c o n t i n g e n t o b s e r v a t i o n , i s o l a t i o n w i t h c o n t r a c t u a l a g r e e m e n t , a n d w i t h d r a w a l o f a t t e n t i o n b a c k e d b y i s o l a t i o n . E a c h p r o c e d u r e w a s e v a l u a t e d b y t w o i t e m s o n a 5 - p o i n t L i k e r t - l i k e s c a l e . O n e i t e m a s s e s s e d a c c e p t a b i l i t y w h i l e t h e o t h e r a s s e s s e d e f f e c t i v e n e s s . N o r t o n e t a l . ( 1 9 8 3 ) f o u n d t h a t a c c e p t a b i l i t y a n d p e r c e i v e d e f f e c t i v e n e s s f o r r e d u c i n g d i s r u p t i v e b e h a v i o r v a r i e d a s a f u n c t i o n o f t h e t r e a t m e n t p r o c e d u r e , t h e r a t e r o f t h e p r o c e d u r e , a n d t h e a g e o f t h e c h i l d f o r w h o m t h e p r o c e d u r e w a s 1 5 designed. Teachers evaluated all procedures as more effective than did parents. All of the procedures except reinforcement were perceived as being more effective for a younger child than an older child. Consistent with both Kazdin's and Witt's findings, positive reinforcement was rated by both teachers and parents as the most acceptable intervention. Fincham and Spettell (1984) investigated the acceptability of operant Dry Bed Training (Azrin, Sneed, & Fox, 1974) and urine alarm training for the treatment of nocturnal enuresis in two experiments. In the first experiment, a consumer satisfaction study, parents and their enuretic children were randomly assigned to either the Dry Bed Training condition or the urine alarm training condition. Each group rehearsed the components of the procedure in the clinic and were given detailed treatment manuals. After the 8-week treatment program, participants completed a modified version of the TEI (Kazdin, 1980a; 1980b) and selected adjectives representing the Evaluative, Potency, and Activity dimensions of the Semantic Differential (Osgood et al., 1957). Parents in the urine alarm group rated the treatment more favourably than those in the Dry Bed Training group. However, as noted by Fincham and Spettell, the results may have been due to the relative effectiveness of the two treatments since three quarters of the children in the urine alarm group reached criterion as compared to less than half of the Dry Bed Training group. In an attempt to eliminate this confound, undergraduate students evaluated the treatment acceptability of urine alarm training or Dry Bed Training, based on written descriptions of each procedure. In the descriptions, each intervention was administered by a professional or by parents who employed a self-help book. Professionally administered interventions were rated more favourably than the nonprofessional^  administered interventions. Students perceived no difference in 1 6 treatment acceptability between the Dry Bed Training or urine alarm training. Based on these results, Fincham and Spettell (1984) interpreted the parents' preference for the urine alarm program in the first study to be a function of differential efficacy rather than differing acceptability prior to treatment. However, the use of undergraduate students as raters in the second study reduces the confidence that may be placed in this conclusion since students and parents may perceive the treatment acceptability of these programs differently. Summary of the Treatment Acceptability Research The reviewed studies have been well-designed in that they have utilized appropriate acceptability measures and evaluated several variables than influence acceptability ratings in a systematic fashion. However, the research is limited in its generalizability. For many studies, analogue population of undergraduate students have been utilized to evaluate treatment alternatives (Fincham & Spettell, 1984; Kazdin, 1980a, 1980b, 1981; Witt, Elliott, & Martens, 1984; Witt & Martens, 1983). At best, a student population can be thought of as potential future consumers since most of them are not parents, parents of children with behavior problems, or individuals who are likely to implement the intervention (i.e., teachers, hospital staff, clinicians). Furthermore, the studies reviewed have examined the relative acceptability of various treatment techniques as entities rather than as components in a program of procedures designed to deal with various child behaviors. The behavioral treatment of child behavior problems such as conduct disorders or attention deficit disorders is not typically limited to one technique. Generally, a program of integrated procedures is recommended (e.g., Barkley, 1981; Forehand & McMahon, 1981; Patterson, 1982). 1 7 Parent Training Program Noncompliance to parental instructions is recognized as a pervasive childhood problem among children referred to clinics for treatment of deviant behavior (Forehand, 1977). A parenting program specifically designed to treat child noncompliance has been developed by Forehand and McMahon (1981). The program is designed for parents of children in the 3- to 8-year old range. Sessions are conducted in a controlled learning environment with individual families. A number of specific parenting skills based on social learning principles are taught to the parents so that they may change their maladaptive patterns of interaction with their child. Therapists use didactic instruction, modeling, and role play to instruct the parent. The parent then practices the skills with his or her child while receiving prompts and feedback from the therapist. Finally, the parent utilizes the new skills in the home. Temporal and behavioral criteria determine progression to each new skill. The parenting program has two phases. In the first phase, parents are taught to become more effective reinforcing agents by "increasing the frequency and range of social rewards and by reducing the frequency of competing verbal behavior." (McMahon & Forehand, 1984, p. 300). Three skills are taught in this phase: attends, rewards, and ignoring. Parents are taught to verbally describe and give attention to their child's appropriate behavior with attends. The parents are taught to use verbal and physical rewards (e.g., praise, hugs) contingent upon appropriate behavior and compliance with instructions. Parents are also taught to ignore minor inappropriate behavior. Phase Two is concerned with decreasing child noncompliance to parental commands. Two skills are taught. First, parents learn to give appropriate commands. These are clear and direct, given one at a time, and allow the child 1 8 sufficient time to initiate compliance. If compliance is not initiated within 5 seconds, parents are taught to employ a time-out procedure. The program has undergone extensive systematic research examining treatment outcome and generalization of effects (McMahon & Forehand, 1984). This program of research has indicated that improved mother and child behaviors generalize from the clinic training situation to the home setting. Maintenance of these positive gains in the home has been demonstrated at follow-up assessments ranging from 6 months to 4 1/2 years following the conclusion of treatment. Mothers have also been shown to generalize their skills to nontargeted children in the family without direct programming, resulting in increased compliance by the untreated child. The research suggests that generalization from treated to untreated child behaviors also occurs (McMahon & Forehand, 1984). The social validity of this parent training program has been demonstrated by several methods. By way of social comparison, maternal and child behaviors as well as maternal personal adjustment (depression) have come within normal limits by the end of treatment (Forehand, Wells, & Griest, 1980). A second social validation procedure, subjective evaluation, has been conducted. Mothers that have recieved treatment have reported significant improvements in their children's behavior by the end of treatment. By a 2-month follow-up, these mothers also perceived their children to be as well-adjusted as nonclinic mothers perceived their children (Forehand et al., 1980). Measures of consumer satisfaction with the program have been collected in several investigations. Mothers have "reported a high level of satisfaction with the overall training program, the therapists, the teaching format, and the parenting skills" (McMahon, Tiedemann, Forehand, & Griest, 1984, pp. 301-302) and generally maintained their high degree of satisfaction at a 2-month follow-up. A comparison 1 9 of mothers who received a technique-oriented version of the parenting program versus mothers who received the parenting program plus instruction in social learning principles found that mothers of the social learning group maintained their high levels of satisfaction with the parent training program at 2-month follow-up in a more consistent manner than did mothers of the technique alone group (McMahon et al., 1984). In a long-term follow-up, Baum and Forehand (1981) assessed consumer satisfaction from 1 to 4 1/2 years after treatment termination. At all follow-up periods, mothers expressed a high level of satisfaction with the treatment program. Forehand et al. (1980) found that mothers of clinic-referred children viewed the treatment procedures as appropriate for dealing with their children's problems at a 15-month follow-up assessment. An aspect of social validity that has not been evaluated in the Forehand and McMahon parent training program is that of treatment acceptability. Consumer satisfaction measures completed after treatment termination give no indication of how the same program may have been evaluated prior to treatment and, as noted earlier, such ratings are possibly affected by the perceived efficacy of the different procedures. One of the purposes of the proposed investigation is to examine the acceptability of the various component skills in this parent training program. 2 0 Use of Rationales and Modeling in Parent Training Programs Therapists in behavioral parent training programs teach parents operant techniques in order that the parents may modify their child's problem behavior in the child's natural environment (Tharp & Wetzel, 1969). Usually, parents are left to their own devices in introducing new behavior management techniques to the child. The child is often left to learn the new contingencies by trial and error since the parents employ the technique without demonstration or explanation. Traditional behavioral parent training programs have not typically made any attempts at identifying optimal methods for introducing the new behavioral techniques to the child. However, in the developmental literature there is substantial data to suggest that verbal (instructions, rationales) and performance (modeling, behavior rehearsal) methods can enhance a child's comprehension and compliance to new contingencies (Davies, McMahon, Flessati, & Tiedemann, 1984). In another investigation, 100 mothers of young children (ages 3 to 6) completed a questionnaire in which they listed and. evaluated strategies they employed with their children to elicit compliance and deal with noncompliance (McMahon et al., 1986). Lending further support for the use of verbal rationales, nearly all mothers (97.9%) reported that they frequently gave their child a rationale for a parental request. They evaluated this strategy as moderately acceptable for children of this age and as moderately useful and moderately easy to administer. The utility of providing mediational techniques in a behavioral parent training program has only been recently demonstrated (Davies et al., 1984; McMahon, Davies, & Tiedemann, 1983). In the Davies et al. study, 80 mother-child pairs were randomly assigned to one of four groups: ignoring training, ignoring plus verbal rationale, ignoring plus verbal rationale and modeling, or control. In the treatment 21 groups, mothers were taught to ignore their child following noncompliance to maternal commands. It was found that when mothers provided a verbal rationale and/or modeled the procedure on a single occasion prior to its use, children were more compliant and less inappropriate than children in the other two conditions. Mothers in the rationale and rationale plus modeling groups reported greater satisfaction with the treatment than those mothers in the ignore only group. A further investigation utilized the same methodology and extended it to the parenting technique of time-out from positive reinforcement (McMahon et al., 1983). Mothers were assigned to one of four groups: time out only, time out plus rationale, time out plus rationale and modeling, or control. The investigators found that all of the children in the treatment conditions were more compliant to maternal commands after their mothers' completion of training. The addition of a rationale or a rationale plus modeling did not increase compliance beyond time out only, possibly because of a ceiling effect. However, the behavior of the children in the two rationale groups was significantly less deviant then the behavior of the children in the time out only group. Mothers in all treatment conditions reported high levels of satisfaction with the procedures taught. In the investigations just described, maternal ratings of consumer satisfaction may have been influenced by treatment efficacy. In the McMahon et al. study (1983) in which all children in the treatment groups were more compliant, mothers reported similar levels of satisfaction. In the Davies et al. study (1984), children in the mediation groups (rationale, rationale plus modeling) were more compliant and less inappropriate than children in the ignore only group. Correspondingly, mothers in the mediation groups reported greater satisfaction with treatment than mothers in the no mediation group. Since it has been demonstrated that providing a verbal rationale and/or modeling the procedure to the child enhances child behavior and 2 2 was also "high-ranking" by mothers in a survey (McMahon et al., 1986; Davies et al., 1984; McMahon et al., 1983), it is important to determine whether inclusion of a verbal rationale and/or modeling a new parenting technique to the child might also enhance parental evaluations of treatment acceptability. 2 3 Research Purposes and Hypotheses The purposes of the present investigation were as follows: 1. To evaluate a well-validated parent training program, the Forehand-McMahon (1981) program, in terms of the treatment acceptability of its individual components and the overall program. 2. To evaluate the relative acceptability of having the parents provide their children with a verbal rationale, a verbal rationale plus modeling the procedure, or no rationale or modeling prior to use of the various parenting techniques. 3. To formally compare two treatment evaluation measures, that of the TEI (Kazdin, 1980a) and the usefulness/difficulty measures used by McMahon and Forehand in their consumer satisfaction investigations (Forehand & McMahon, 1981; McMahon et al., 1984). It was hypothesized that: 1. Ratings of acceptability of the individual components, the mediational teaching method, and the overall program would fall within the positive range. Since scores on the TEI can range from 15 to 105, the positive range was defined as a score between 60 and 105. 2. While all parenting skills would be rated as acceptable, attends, rewards, and commands would be rated as more acceptable than ignoring and time out. The work of Kazdin and Witt (Elliott et al., 1984; Kazdin, 1980a; 1980b; 1981; Kazdin et al., 1981; Witt, Elliott, & Martens, 1984) has indicated that interventions designed to increase appropriate behavior are generally evaluated as more acceptable than interventions that attempt to decrease inappropriate behavior. As well, McMahon et al. (1986) found that praise for compliance and clear instructions (commands) were rated as more acceptable than time out and ignoring in their survey of nonclinic mothers. Finally, consumer satisfaction measures administered after 2 4 completion of the Forehand-McMahon parent training program have indicated that mothers view rewards as most useful and least difficult while ignoring is perceived to be one of the least useful and most difficult skills to implement (McMahon et al., 1984). 3. The individual techniques, the mediational teaching method, and the overall program within the rationale plus modeling condition will be evaluated more favourably than the individual techniques, the mediational teaching method, and the overall program within the rationale only condition, which will be evaluated more favourably than the individual techniques, the mediational teaching method, and the overall program within the technique alone condition. 4. A significant mediation by technique interaction will occur when relative levels of acceptability are assessed within each of the three conditions (rationale, rationale plus modeling, technique alone). Only in the technique alone group will there be a significant difference among the acceptability ratings of skills. That is, it is hypothesized that mediation (rationale or rationale plus modeling) will eliminate, or greatly reduce, the hypothesized disparity of acceptability ratings between procedures. 5. The TEI score will be positively correlated with the ratings of usefulness and negatively correlated with ratings of difficulty for each dependent measure. 2 5 Overview of the Investigation Ninety nonclinic mothers of young (3- to 8-year old) children evaluated the overall parenting program, its individual components (attends, rewards, ignoring, commands, time out) and the method of introducing each new skill to the child (rationale, rationale plus modeling, no rationale or modeling). Nonclinic mothers were recruited since they represent potential consumers of the parent training program. The measures employed to assess treatment acceptability were the Treatment Evaluation Inventory (TEI; Kazdin, 1980a) and the usefulness/difficulty measures of the Parent's Consumer Satisfaction Questionnaire (Forehand & McMahon, 1981). The Semantic Differential was not employed since it has not typically added any new information to that obtained by the TEI. The TEI was selected because it has relatively good psychometric properties (Kazdin, 1980a) and its use facilitated comparison between the outcome of Kazdin's work and this investigation. The usefulness/difficulty measure was added due to the similarity of the present investigation with investigations of consumer satisfaction for this particular parent training program (McMahon et al., 1984). Mothers were randomly assigned to one of three mediation groups: parent training program only, parent training plus verbal rationale, or parent training plus verbal rationale and modeling. Mothers evaluated the program's individual components (attends, rewards, ignoring, commands, time out), the teaching method (verbal rationale, verbal rationale plus modeling, or no verbal rationale or modeling), and the overall parenting program. Therefore, the design was a 3 x 7 mixed factorial with repeated measures on the second factor. 2 6 Method Subjects Ninety mothers of children aged 3 to 8 served as subjects. This age range was chosen because it corresponds to the age range of children in the Forehand-McMahon parent training program. Subjects were recruited through notices published in city and community newspapers and notices posted in a variety of locations in the Lower Mainland, such as community centres, the University of British Columbia campus, libraries, and preschool centres (see Appendix A). To be eligible to participate in this study, a potential subject had to be the mother of a 3- to 8-year old child and to have never sought psychological assistance for her child's behavior, never attended a structured, long-term parent training program (e.g., Systematic Training for Effective Parenting (Dinkmeyer & McKay, 1976); Parent Effectiveness Training (Gordon, 1975)), or previously been involved in research conducted at the University of British Columbia using the Forehand-McMahon parent training program. On this basis, seven subjects who completed the study were disqualified and replaced because of their involvement in a parent training program. Additionally, one subject was replaced due to the omission of too many items on the questionnaire. Seventeen mothers included in the study indicated that they had obtained some sort of psychological assistance for their child, which included a query on toilet training, school consultation, family counselling at time of marital separation, and short-term workshops or discussion groups on a variety of child-related issues. These subjects were included in the sample since the degree of "psychological assistance" was minimal or unrelated to the child's behavior. Mothers were paid $5.00 for their participation in the project. 2 7 The modal number of children per family represented by this sample of mothers was two. Age of the subjects ranged from 21 to 54 years (M°32.78,SD=5.54). with no significant age differences amoung groups, F(2,86)=.37, j>=.695. Seventy-six (84.4%) of the mothers were married or in long-term relationships while the remaining 14 mothers (15.6%) were either single, divorced, or separated. There were no significant differences among groups on marital status, ^£^(6, N=90)=7.94, n.s. Socioeconomic status for each subject was determined by coding the occupation of the major wage earner of the household according to the index developed by Blishen and McRoberts (1976). No significant difference in socioeconomic status was found among the three groups, F(2,73)=1.27, n.s. Fulltime students and unemployed individuals were not included in the analysis since no code is designated for these categories in the Blishen and McRoberts system. This was not deemed problematic since each mediational group had an equivalent number of subjects falling into these categories (5, 5, and 4). The educational level of mothers in this sample was as follows: 32.2% (n=29) had completed high school, 17.8% (n=16) had completed college, 32.2% (n=29) had completed university, and 17.8% (n=16) had completed graduate school. No significant differences in mothers' level of education across the three conditions was found, #2(6, N=90)=6.41, n.s. Design The design was a 3 x 7 mixed factorial with one between-subjects factor with three levels (parent training only (P), parent training plus verbal rationale (PR), parent training plus verbal rationale and modeling (PRM)) and one within-subject variable with seven levels (attends, rewards, ignoring, commands, time out, mediational teaching method, overall program). 28 Dependent Measures To evaluate the acceptability of the five parenting techniques, the method of introducing each new skill to the child, and the overall parent training program, the Treatment Evaluation Inventory (TEI; Kazdin, 1980a) (see Appendix B for an example of the TEI used to assess attends, the teaching method, and overall program, items 1 through 15) and the usefulness/difficulty ratings of the Parent's Consumer Satisfaction Questionnaire (PCSQ; Forehand & McMahon, 1981) (see Appendix B, items 16 and 17) were employed. For the purposes of this investigation, the wording of the TEI was modified slightly to reflect the three domains rated by the subjects (i.e., the skills, the method of introducing each new skill to the child, and the overall program). The TEI consists of 15 items in a Likert-like format on a 1- to 7-point scale. Subjects were asked to rate how acceptable treatment is, how willing they would be to carry out the procedure, how much they would like the procedure, and so on. As detailed previously, this measure has been shown to discriminate among various treatments on the basis of acceptability (e.g., Dorsett & Hobbs, 1985; Kazdin, 1980a, 1980b; McKee, 1984). The usefulness/difficulty ratings of the PCSQ consist of two items which allow the subject to rate on 7-point scales the usefulness and difficulty of the procedures. These items discriminate between components differing in their subjective cost (difficulty) and perceived benefit (usefulness) (Yates, 1978). The PCSQ was developed to assess parental attitudes towards the treatment program parents received. The usefulness/difficulty ratings have been employed to evaluate the teaching methods of the program and parenting skills that are taught (attends, rewards, ignoring, commands, time out) (McMahon et al., 1984). The usefulness/difficulty ratings have also been shown to discriminate between mothers that have received training in the parenting techniques alone versus mothers that 29 have received additional training in social learning principles (McMahon, Forehand, & Griest, 1981; McMahon et al., 1984). Procedure Potential participants were told that the purpose of the project was to have mothers of young children evaluate the acceptability of a parent training program designed to teach parents ways to deal with their children's misbehavior and to improve the parent-child relationship by having them read about the various components of the program and completing some questionnaires. Subjects were told that the study would take approximately 60 minutes to complete and that they would be paid $5.00 for their participation. If the mother agreed to participate and met the criteria for inclusion, a convenient time and place was established either at their home or at a laboratory in the Department of Psychology at the University of British Columbia. Administration of the procedure occurred individually or in small groups. Subjects first completed a consent form which explained the purpose of the study and its procedures (see Appendix C) and a demographic information form (see Appendix D). Subjects were then randomly assigned to one of three groups by way of the packet of written materials they received. Subjects proceeded at their own pace since all instructions were contained within the packet. The packet consisted of: 1) a description of the typical child and family for whom the parent training program is designed and a rationale of the parent training program; 2) overview for Phase I; 3) description of attends; 4) evaluation of attends; 5) description of rewards; 6) evaluation of rewards; 7) description of ignoring; 8) evaluation of ignoring; 9) overview for Phase II; 10) description of commands (called "clear instructions" in the packet); 11) evaluation of commands; 12) description of time out; 13) evaluation of time out; 14) summary of the teaching method; 15) evaluation 30 of the teaching method; 16) summary of the overall program; and 17) evaluation of the overall program. The order and sequence of the techniques were not counterbalanced because in the context of the parent training program, the progression and sequence of various skills is fixed (Forehand & McMahon, 1981). The descriptions of the various parenting skills and how they are introduced to the child (items 1, 3, 5, 7, 10, 12, 14, 16 from the above listing) varied for each of the three groups (see Appendix E): Parent training only (P): The technique was described to the parent, but a rationale and demonstration were not given to the child. Parent training plus verbal rationale (PR): The technique was described to the parent and the parent gave a rationale to the child prior to its use. Parent training plus verbal rationale and modeling (PRM): In addition to giving a rationale, the parent demonstrated to the child how the technique would be used. Scoring Subjects responded to the 15 items on the TEI and the two additional usefulness/difficulty items by checking one position on the 7-point scale that most closely represented the subject's response to the described technique. For the purpose of scoring, each of the seven points was assigned a numerical value, where a value of one was assigned to the negative anchor point (e.g., not at all acceptable), a value of four represented a neutral position (e.g., moderately acceptable), and a value of seven was assigned to the positive anchor point (e.g., very acceptable). For the 15-item TEI, a total acceptability score could range from a minimum of 15 to a maximum of 105. Scores for each of the three measures (TEI, usefulness, difficulty) on each of the seven questionnaires were verified by a blind assessor and fewer than one percent errors in coding and scoring were found. 31 All scoring errors were corrected prior to analyses by agreement of the two coders. Missing items were prorated by assigning the mean item score for that particular TEI measure to the missing item. (No missing data points were found on the usefulness/difficulty ratings.) Six subjects missed a total of 31 data points. Overall, this represents less than .004% of the total number of data points. 32 Results Measures of Acceptability As predicted, the individual components, the mediational teaching method, and the overall Forehand-McMahon parent training program were all rated in the positive range (60-105) on the TEI. The mean ratings are reported in Table 1. Of the five skills described, subjects rated rewards as most acceptable, (M=94.67, SEH11.02), followed by commands (M=94.06, SD=9.94), attends (M=88.69, SD=12.44), time out (M=83.23, SD=18.43), and ignoring (M=75.11, SD=19.89). With the exception of ignoring, all techniques were rated in the upper half of the positive range (82.5-105) while ignoring was rated in the lower half of the positive range (60-82.5). Subjects in this sample also rated the mediational teaching method (M=88.20, SD=13.54) and the overall Forehand-McMahon parent training program very positively (M=89.59, SD=13.87). Table 1 also presents the mean acceptability scores separated by group (P, PR, PRM) for each of the five parenting skills, the mediational teaching method, and the overall program. Despite differences in acceptability between groups (to be presented below), again the five parenting skills, the mediational teaching methods, and the overall parent training program were rated in the positive range. With the exception of ignoring in all three groups, and time out in groups P and PRM, all parenting skills, the teaching methods, and the overall program were rated in the upper half of the positive range (i.e., 82.5-105). A repeated measures analysis of variance with one between-subjects factor with three levels (Mediational Group: parent training only, parent training plus verbal rationale, parent training plus verbal rationale and modeling) and one within-subjects factor with five levels (Technique: attends, rewards, ignoring, commands, time out) was performed on the acceptability data provided by the TEI 33 Table 1 Mean TEI Ratings Group Parenting Program P a PRa PRMa Marginal Mean Attends 90.40 91.77 83.90 88.69 ( 8.98) (10.46) (15.76) (12.44) Rewards 96.23 98.10 86.67 94.67 C 6.79) ( 5.86) (15.87) . (11.02) Ignoring 73.73 81.77 69.83 75.11 (18.46). (16.69) (22.75) (19.89) Commands 9.3.23 95.17 93.77 94.06 C 8.84). (.11.78) ( 9.17) ( 9.94) Time out 81.83 89.30 78.57 83.23 (14.07) (16.39) (22.66) (18.43) Teaching method 86.00 93.87 84.73 88.20 (13.47). (. 9.61) (15.44) (13.54) Overall program 90.80 95.23 82.73 89.59 C 7.85) ( 7.98) (19.55) (13.87) Note. P=parent training only; PR=parent training plus verbal rationale; PRM=parent training plus verbal rationale and modeling. Numbers in parentheses are standard deviations. an=30. b"N=90. 34 scores. The analysis yielded a significant main effect for mediational group, F(2,87)=4.15, £=.019, and a significant main effect for technique, F(4,348)=50.70, £<.001. The predicted mediational group by technique interaction was not found to be significant, F(8,348)=1.53, n.s. (see Appendix F). Follow-up analyses of the main effect for mediational group by Newman-Keuls procedures indicated no significant differences between groups. However, visual inspection of Figure 1 suggests that much of the differences between groups can be accounted for by the difference between group PRM (M=83.15) and PR (M=91.22> while the differences between the means of PRM and P (M=87.09), and P and PR appear equivalent. Newman-Keuls tests were performed to evaluate the sources of differences among ratings of the five parenting techniques (see Appendix G) and indicated that rewards (M=94.67) and commands (M=94.06) (which were not rated significantly different from each other) were rated as significantly more acceptable than attends (M=88.69), time out (M=83.23), and ignoring (M=75.11), each of which was rated as significantly different from one another (£<.01). The a priori hypothesis that attends, rewards, and commands (M=92.47) would be rated as more acceptable than ignoring and time out (M=79.17) was confirmed by a test of planned comparisons, t(85)=12.74, £<.01. A one-way analysis of variance was performed to analyze the treatment acceptability data for the mediational teaching method (see Appendix F). Results indicated significant differences between mediational groups, F(2,87)=4.30, £=.017. Newman-Keuls multiple comparison procedures were performed to evaluate differences among the three groups. As seen in Appendix H, PR (M=93.87) was rated as significantly more acceptable than P (M=86.00) and PRM (M=84.73), which did not differ from each other (E<.05). 3 5 Figure Caption Figure 1. Mean TEI score for each mediational group collapsed across techniques. (P=parent t r a i n i n g only; PR=parent t r a i n i n g plus verbal r a t i o n a l e ; PRM=parent t r a i n i n g plus verbal r a t i o n a l e and modeling; n=30 per group). 92 90-Mediational Group 3 7 T r e a t m e n t a c c e p t a b i l i t y r a t i n g s f o r t h e o v e r a l l p r o g r a m w e r e a n a l y z e d b y w a y o f a o n e - w a y a n a l y s i s o f v a r i a n c e ( s e e A p p e n d i x F ) . T h e e f f e c t o f t h e m e d i a t i o n a l g r o u p w a s s t a t i s t i c a l l y s i g n i f i c a n t , F ( 2 , 8 7 ) = 7 . 1 2 , £ < . 0 0 2 . F o l l o w - u p N e w m a n - K e u l s m u l t i p l e c o m p a r i s o n p r o c e d u r e s i n d i c a t e d t h a t P R ( M = 9 5 . 2 3 ) a n d P ( M = 9 0 . 8 0 ) w e r e n o t r a t e d s i g n i f i c a n t l y d i f f e r e n t f r o m e a c h o t h e r b u t b o t h w e r e r a t e d a s s i g n i f i c a n t l y m o r e a c c e p t a b l e t h a n P R M ( M = 8 2 . 7 3 ) ( s e e A p p e n d i x H ) . U s e f u l n e s s / D i f f i c u l t y M e a s u r e s E v a l u a t i o n s o f t h e u s e f u l n e s s o f t h e i n d i v i d u a l t e c h n i q u e s , t h e t e a c h i n g m e t h o d , a n d t h e o v e r a l l p r o g r a m w e r e a l l i n t h e " u s e f u l " r a n g e o f t h e 7 - p o i n t L i k e r t - l i k e r a t i n g s c a l e a n d a r e r e p o r t e d i n T a b l e 2 . T h e o r d e r i n g o f m e a n s f o r t h e f i v e p a r e n t i n g s k i l l s b e g i n n i n g w i t h t h e m o s t u s e f u l c o n s i s t e d o f c o m m a n d s ( M = 6 . 2 7 , S E H . 9 1 ) , r e w a r d s ( M = 6 . 1 4 , S D = 1 . 1 2 ) , a t t e n d s ( M = 5 . 9 6 , S E H 1 . 2 2 ) , t i m e o u t ( M = 5 . 8 0 , S D = 1 . 2 9 ) , a n d i g n o r i n g ( M = 5 . 3 0 , S E H 1 . 4 6 ) . B o t h t h e t e a c h i n g m e t h o d ( M = 5 . 9 8 , S D = 1 . 0 6 ) a n d t h e o v e r a l l p r o g r a m ( M = 6 . 1 7 , S E H 1 . 0 0 ) w e r e r a t e d a s v e r y u s e f u l . W i t h t h e e x c e p t i o n o f i g n o r i n g , m e a n r a t i n g s o f d i f f i c u l t y f e l l i n t h e " e a s y " r a n g e o f t h e 7 - p o i n t s c a l e f o r t h e i n d i v i d u a l t e c h n i q u e s , t h e t e a c h i n g m e t h o d , a n d t h e o v e r a l l p r o g r a m ( s e e T a b l e 3 ) . T h e o r d e r i n g o f m e a n s f o r t h e f i v e p a r e n t i n g s k i l l s b e g i n n i n g w i t h t h e e a s i e s t c o n s i s t e d o f r e w a r d s ( M = 2 . 5 4 , S D = = 1 . 5 4 ) , c o m m a n d s ( M = 2 . 9 8 , S D = 1 . 7 4 ) , a t t e n d s ( M = 3 . 1 1 , S D = 1 . 7 6 ) , t i m e o u t ( M K J . 6 0 , S D = 1 . 8 8 ) , a n d i g n o r i n g ( M = 4 . 1 9 , S j D = 1 . 9 5 ) . B o t h t h e t e a c h i n g m e t h o d ( M = 3 . 2 0 , S D = 1 . 6 3 ) a n d t h e o v e r a l l p r o g r a m ( M = 3 . 4 6 , S D = 1 . 5 7 ) w e r e r a t e d i n t h e " e a s y " r a n g e b y s u b j e c t s i n t h i s s a m p l e . S e p a r a t e 3 x 5 r e p e a t e d m e a s u r e s a n a l y s e s o f v a r i a n c e w i t h o n e b e t w e e n - s u b j e c t s f a c t o r ( M e d i a t i o n a l G r o u p : p a r e n t t r a i n i n g o n l y , p a r e n t t r a i n i n g p l u s v e r b a l r a t i o n a l e , p a r e n t t r a i n i n g p l u s v e r b a l r a t i o n a l e a n d m o d e l i n g ) a n d o n e w i t h i n - s u b j e c t s f a c t o r ( T e c h n i q u e : a t t e n d s , r e w a r d s , i g n o r i n g , c o m m a n d s , t i m e o u t ) T a b l e 2 M e a n R a t i n g s o f P e r c e i v e d U s e f u l n e s s G r o u p P a r e n t i n g P r o g r a m P a P R 3 P R M 3 M a r g i n a l M e a n A t t e n d s 5 . 9 3 6 . 1 7 5 . 7 7 5 . 9 6 ( 1 . 1 1 ) ( 1 . 0 5 ) ( 1 . 4 6 ) ( 1 . 2 2 ) R e w a r d s 6 . 0 0 6 . 3 3 6 . 1 0 6 . 1 4 ( 1 . 3 1 ) ( . 5 5 ) ( 1 . 3 2 ) ( 1 . 1 2 ) I g n o r i n g 5 . 0 3 5 . 6 0 5 . 2 7 5 . 3 0 ( 1 . 4 5 ) ( 1 . 1 6 ) ( 1 . 7 0 ) ( 1 . 4 6 ) C o m m a n d s 6 . 1 7 6 . 2 3 6 . 4 0 6 . 2 7 C . 8 3 ) ( 1 . 0 7 ) ( . 8 1 ) ( - 9 1 ) T i m e o u t 5 . 5 7 6 . 0 7 5 . 7 7 5 . 8 0 ( 1 . 3 6 ) ( 1 . 1 7 ) ( 1 . 3 3 ) ( 1 . 2 9 ) T e a c h i n g m e t h o d 5 . 8 0 6 . 1 3 6 . 0 0 5 . 9 8 ( 1 . 0 0 ) . ( 1 . 0 4 ) ( 1 . 1 5 ) ( 1 . 0 6 ) O v e r a l l p r o g r a m 6 . 0 3 6 . 4 3 6 . 0 3 6 . 1 7 ( . . 8 5 ) ( - 7 3 ) ( 1 . 3 0 ) ( 1 . 0 0 ) N o t e . P = p a r e n t t r a i n i n g o n l y ; P R = p a r e n t t r a i n i n g p l u s v e r b a l r a t i o n a l e ; P R M = p a r e n t t r a i n i n g p l u s v e r b a l r a t i o n a l e a n d m o d e l i n g . R a t i n g s c a l e a n c h o r s : e x t r e m e l y u s e l e s s = l , n e u t r a l = 4 , e x t r e m e l y u s e f u l = 7 . N u m b e r s i n p a r e n t h e s e s a r e s t a n d a r d d e v i a t i o n s . a n = 3 0 . b N = 9 . 0 . Table 3 Mean Ratings of Perceived Difficulty Group Parenting Program P a PRa PRM3 Marginal Mean Attends 3.07 2.60 3.67 3.11 (1.68) (1.45) (2.01) (1.76) Rewards 2.30 2.27 3.07 2.54 (1.47) (1.36) (1.68) (1.54) Ignoring 4.13 4.07 4.37 4.19 (1.70) (2.13) (2.04) (1.95) Commands 3.03 2.40 3.50 2.98 (1.65) (1.30) (2.06) (1.74) Time out 3.90 2.93 3.97 3.60 (1.75) (1.55) (2.17) (1.88) Teaching method 3.27 2.73 3.60 3.20 (1.46) (1.39) (1.92) (1.63) Overall program 3.67 3.00 3.70 3.46 (1.35) (1.37) (1.90) (1.57) Note. P=parent training only; PR=parent training plus verbal rationale; PRM=parent training plus verbal rationale and modeling. Rating scale anchors: extremely easy=L neutral=4, extremely difficult=7. Numbers in parentheses are standard deviations. an=30. bN=90. 40 were conducted for both the usefulness and difficulty ratings. With respect to the usefulness ratings, a significant main effect of technique was found, F(4,348)=12.59, £<.01. Neither a main effect of mediational group, F(2,87)=1.35, n.s., nor a mediational group by technique interaction, F(8,348)=.59, n.s., was found (see Appendix I). Newman-Keuls tests to evaluate the differences between techniques indicated that ignoring (M=5.30) was rated as significantly less useful than all other techniques while time out (M=5.80) was rated significantly less useful than commands (M=6.27) (see Appendix G). Regarding the analysis of variance conducted on ratings of difficulty, both a main effect of group, F(2,87)=3.78, p_<.027, and technique, F(4,348)=17.70, £<.01, were found. No significant group by technique interaction was found, F(8,348)=.85, n.s. (see Appendix J). Despite the statistically significant omnibus F, no significant differences among groups were detected by follow-up Newman-Keuls procedures. Visual inspection of Figure 2 suggests that a large portion of the differences between groups would be accounted for by the difference between groups PRM (M=3.71) and P (M=3.29), while the differences between groups PR (M=2.85) and P, and P and PRM appear equivalent. Newman-Keuls tests were performed to evaluate the sources of differences among ratings of difficulty of the five parenting techniques (see Appendix G). Ignoring (M=4.19) was rated as significantly more difficult than all other parenting techniques. Time out (M=3.60) was rated as significantly more difficult than rewards (M=2.54), commands (M=2.98), and attends (M=3.11). Commands and attends did not differ from each other but both were rated significantly more difficult than rewards. Four separate one-way analyses of variance were conducted on the usefulness and difficulty ratings for the teaching method and overall program. No significant 41 Figure Caption Figure 2. Mean ratings of d i f f i c u l t y for each mediational group collapsed across techniques. (P=parent t r a i n i n g only; PR=parent t r a i n i n g plus v e r b a l r a t i o n a l e ; PRM=parent t r a i n i n g plus verbal r a t i o n a l e and modeling; n=30 per group.) 43 differences among mediational groups were found either for the teaching method or overall program on measures of usefulness (see Appendix I) or difficulty (see Appendix J). Relationship Between Usefulness/Difficulty Ratings and Ratings of Acceptability Pearson correlation coefficients were calculated for the relationships between TEI score and ratings of usefulness, and TEI score and rating of difficulty for each of the seven measures (attends, rewards, ignoring, commands, time out, teaching method, overall program) (see Table 4). Usefulness ratings for each of the seven dependent measures were positively correlated with the corresponding TEI scores, ranging from r=.606 (rewards) to r=.816 (ignoring). In order to control for inflation of Type I error, the alpha level was reduced to .007 (.05/7). All correlations between TEI and usefulness ratings were significant (see Table 4). All of the difficulty ratings were negatively correlated with TEI scores ranging from r=-.139 (rewards) to r=-.342 (teaching method). With the exception of rewards, all correlations were significant at the £<.007 level (see Table 4). In order to summarize the data, each subject's seven TEI scores, seven usefulness scores, and seven difficulty scores were totalled to obtain three summary TEI, usefulness, and difficulty scores. Correlations among these measures indicated a strong positive correlation between usefulness ratings and the TEI (r=.802, £<.001), a negative correlation between difficulty ratings and the TEI (r=-.390, £<.001), and a negative correlation between usefulness and difficulty ratings (r=-.280, £<.01). 4 4 Table 4 I n t e r c o r r e l a t i o n s Between TEI and Usefulness and D i f f i c u l t y Ratings TEI Usefulness D i f f i c u l t y Attends .794* -.268* Rewards .606* -.139 Ignoring .816* -.299* Commands .667* -.283* Time out .798* -.263* Teaching method .656* -.342* Overal l program .700* -.314* Note. N=90. *£<.007. 45 Discussion This study evaluated the treatment acceptability of a behavioral parent training program in terms of its individual techniques, three teaching methods, and the program as an entity. A sample of potential consumers of treatment composed of 90 nonclinic mothers of 3- to 8-year old children rated their acceptance of each parenting skill, the mediational teaching method, and the overall parent training program by way of a standardized measure of treatment acceptability (TEI; Kazdin, 1980a) and ratings of usefulness and difficulty previously employed in evaluations of consumer satisfaction (Forehand & McMahon, 1981; McMahon et al., 1984). Major findings of this study will be addressed in terms of the acceptability, usefulness, and difficulty of the parenting skills, teaching methods, and overall program; the differential acceptability of the parenting skills; the differential acceptability of the teaching methods; the relationship between the teaching method and parenting skills; and the relationship between ratings of acceptability and usefulness/difficulty. Finally, conclusions and recommendations for future research will be discussed. Hypothesis 1 proposed that the individual components, the teaching methods, and the overall Forehand-McMahon parent training program would be rated very positively on the TEI. This hypothesis was supported in that mothers in this sample found the individual parenting techniques, the teaching methods, and overall program to be appropriate for the problem described, fair, sensible, effective, and concurring with common ideas of what treatment should be. This finding lends further support to the social validity of the Forehand-McMahon parent training program. Ratings of acceptability as measured by the TEI have previously been reported for specific behavioral procedures such as reinforcement (Dorsett & Hobbs, 1985; 46 Kazdin, 1980a, 1980b, 1981; Kazdin et al., 1981; Mckee, 1984), ignoring (withdrawl of attention; Kazdin, 1980b), and time out (Dorsett & Hobbs, 1985; Frentz & Kelley, 1986; Kazdin, 1980a, 1980b, 1981, 1984; Kazdin et al., 1981; McKee, 1984). It is of interest to note that in all cases, the techniques of the Forehand-McMahon program were rated as more acceptable than those reported in the literature (except Kazdin, 1984, in which time-out from reinforcement (M=83.50) was equivalent to ratings of time out in this study (M=83.23)). While many variations between this study and those cited must be acknowledged (e.g., differences in the case description, technique specifications, and sample), an important difference which may account for higher ratings of acceptability of the Forehand-McMahon techniques is that they were described as part of an integrated program of procedures designed to deal with the child's behavior rather than as single isolated techniques. With respect to the usefulness/difficulty ratings, the individual components, the teaching methods, and overall parent training program were rated as very useful on ratings of usefulness and with one exception, as easy on ratings of difficulty by mothers in this study. Only ignoring was rated as neutral on the difficulty dimension. It is of interest to compare these ratings with those of actual consumers of the Forehand-McMahon parent training program and with nonclinic mothers rating their own parenting strategies. These comparisons highlight the influence of experience on such evaluations. The potential consumers of treatment in the present study read about the rationale for the program, the typical family for whom it is appropriate, and its individual skills while actual consumers have had the advantage of direct "hands-on" experience with the program and its components. Subjects in the current study consistently evaluated the individual techniques of 47 the parent training program as less useful and more difficult than actual consumers of this treatment program at post-treatment (cf. McMahon et al., 1984). Although the samples in these investigations likely vary in other dimensions in addition to whether they are potential or actual consumers (e.g., nonreferred mothers of "normal" children versus mothers referred for treatment of child noncompliance), this comparison suggests that direct experience with the actual treatment program may improve satisfaction in terms of perceived usefulness and difficulty. Comparisons of ratings made by mothers in this study and nonclinic mothers who rated their own naturally-occurring parental strategies for child compliance (McMahon et al., 1986) again suggests that experience may influence ratings of usefulness and difficulty. Nonclinic mothers who had experience with the techniques but who had not participated in a systematic parent training program rated clear instructions (commands), time out, and ignoring as less useful than did the mothers in the present study, while praise for compliance (rewards) was rated as more useful. For ratings of difficulty, mothers with experience using the techniques (McMahon et al., 1986) rated praise for compliance (rewards), clear instructions (commands), and ignoring as easier and only time out as more difficult than the mothers in the present study. The foregoing comparisons suggest that experience influences satisfaction with the various strategies. However, this influence is not consistent since actual consumers of the treatment program rated the techniques as more useful and less difficult (McMahon et al., 1984) than potential consumers, whereas mothers rating their own naturally-occurring strategies varied from this pattern (McMahon et al., 1986). This inconsistency may be due to the manner in which the mothers were taught the parenting skills or their subsequent employment of those skills, or it may be a function of differences between clinic and nonclinic mothers. 48 In support of Hypothesis 2, which proposed that the parenting skills would be differentially acceptable, interventions of this program that attempt to increase deficit behavior (rewards, commands, attends) were evaluated as more acceptable than the interventions designed to reduce behavioral excesses (time out, ignoring). This finding is also consistent with previous research in treatment acceptability (Dorsett & Hobbs, 1985; Elliott et al., 1984; Kazdin, 1980a, 1980b, 1981; Kazdin et al., 1981; Witt, Elliott, & Martens, 1984). This ordering of techniques from most acceptable to least acceptable (rewards, commands, attends, time out, ignoring) directly parallels that of ratings of nonclinic mothers' naturally occurring parental strategies (McMahon et al., 1986), although attends were not rated by mothers in the McMahon et al. (1986) study. This differential acceptability of techniques based on whether they increase deficit behavior or reduce excessive behavior has also been validated in consumer satisfaction studies (McMahon et al., 1984). The ordering of techniques from most acceptable to least acceptable directly corresponds to their ordering of usefulness and difficulty, with the exception of the reversal of commands and rewards on usefulness. Techniques designed to increase deficit behavior were rated as most acceptable, most useful, and least difficult while techniques designed to decrease behavioral excesses were rated as least acceptable, least useful, and most difficult. Hypothesis 3 proposed that presenting a rationale and modeling each new skill to the child would be rated as more acceptable than presenting a rationale, which would be rated as more acceptable than no rationale or modeling. In the three descriptive analyses of parenting skills, mediational teaching method, and overall program, the rationale condition was rated as more acceptable than the technique alone condition, which was rated as more acceptable than the rationale plus 49 modeling condition. The analysis of teaching method provided the most direct assessment of the mediational group since subjects evaluated only the method of introducing new parenting skills to the child. In that analysis, the rationale condition was rated as significantly more acceptable than the remaining conditions, which did not differ from each other. Thus, Hypothesis 3 was not supported. With few exceptions, the greatest variability in all ratings was found in the rationale plus modeling group. This suggests that subjects in this group were in far less agreement in their evaluations than subjects in the remaining groups. Why this occurred is unclear but suggests that for some consumers, the addition of a modeling component detracts from the acceptability of the skills and the program. Two studies have examined the utility of providing mediational techniques for introducing new parenting techniques to the child (Davies et al., 1984; McMahon et al., 1983). Both studies compared the introduction of ignoring (Davies et al., 1984) or time out (McMahon et al., 1983) by way of providing a verbal rationale, providing a verbal rationale and modeling the procedure, or no rationale or modeling. In terms of consumer satisfaction, the Davies et al. (1984) study found that mothers in the rationale and rationale plus modeling conditions expressed higher satisfaction with the skill than mothers who presented the technique without these adjuncts. No difference in satisfaction was found between the two mediational groups. The present study found only a superiority of the rationale condition, with no difference between the remaining two conditions. In the McMahon et al. (1983) study, mothers in all three groups expressed similar levels of satisfaction with the parenting technique (time out). However, the influence of experience, in this case a ceiling effect of high child compliance to maternal commands due to the efficacy of the time-out procedure, again emphasizes the contrast between treatment acceptability and consumer satisfaction. 50 Several explanations are possible for the greater acceptability of the rationale condition. First subjects in this study based their evaluations on the written descriptions provided. Descriptions were identical for all groups except that additional descriptions were appended to describe how rationales were employed and to describe how the technique would be modeled to the child. Consequently, the rationale plus modeling descriptions were quite lengthy and may have been perceived by raters as inordinately time consuming. Had this study employed videotaped instead of written demonstrations, the results may have been as hypothesized and consistent with previous research, since the addition of modeling is not as time consuming as it might appear when verbally described. In addition to being perceived as time consuming, the rationale plus modeling condition might also have been perceived as more difficult to employ. Though not statistically significant, the rationale plus modeling condition was consistently rated as more difficult than the other two groups in the analyses of teaching method and overall program. Also, the analysis of difficulty ratings for the parenting techniques suggested that much of the differences between groups could be accounted for by the difference between the rationale and rationale plus modeling conditions. This suggests that in rating the individual skills, subjects perceived that it was easy to explain the new skill to the child, but the addition of modeling was perceived as more difficult. Finally, subjects in the rationale plus modeling condition may have judged that the addition of modeling may have been too complex and unnecessary for the age group and type of child behavior problem for whom this program is designed. Further research is needed to determine whether these or other unknown factors account for the lower ratings given to the rationale plus modeling mediational procedure. 51 Differential ratings of acceptability of the parenting skills remained consistent across the three mediational groups, thus failing to support Hypothesis 4, which proposed that mediation (either rationale or rationale plus modeling) would reduce the disparity of acceptability between techniques. As well, there were no interactions between the mediational teaching method and techniques on ratings of usefulness and difficulty. While teaching method influenced the relative ratings of acceptability across groups, it did not reduce acceptability ratings across techniques within groups. It would appear then that even having a very acceptable method of introducing each new parenting skill to the child does not affect the differential acceptability of the techniques. Techniques that are designed to increase deficit behavior will continue to be perceived as that much more acceptable than techniques designed to reduce excess behavior unless, as Kazdin demonstrated with variations of isolation (1980b), the actual techniques are modified so as to make them more acceptable to the potential consumer. Due to the limitations of the methodology employed, however, it is possible that the written descriptions were not able to portray as vividly the various teaching methods, individual parenting skills, and how they would be employed in a comprehensive treatment program. Again, it might be useful to utilize videotaped demonstrations that would approximate actual clinical use of these mediational procedures more realistically. With respect to the relationship between ratings of acceptability and usefulness/difficulty, ratings of treatment acceptability were positively correlated with ratings of usefulness and negatively correlated with ratings of difficulty, supporting Hypothesis 5. The ordering of techniques on usefulness and difficulty dimensions parallelled ratings of acceptability with the exception that the ordering 52 of commands and rewards was reversed with respect to usefulness. Generally, the most acceptable technique was also rated as the most useful and least difficult technique. It was not unexpected that ratings of treatment acceptability and ratings of usefulness were strongly correlated. Items on the TEI address effectiveness, acceptability, fairness, likeability, and suitability that in many ways are captured in the benefits or "usefulness" of the technique. Similarly, the costs or "difficulty" of the technique are assessed in items that address fairness, risks, and discomforts associated with the technique. These two single-item ratings of usefulness and difficulty produced very similar patterns to that of the TEI, which by Kazdin's report (1980a) captures an overall evaluative component. This suggests that these simplified scales have the potential to provide a quick assessment of treatment acceptability and thereby insure the cooperation of the raters. However, while these single-item ratings were able to differentiate among techniques, they were not as sensitive as the TEI in detecting potential differences among the three teaching methods. Several conclusions and recommendations can be made from the present investigation. First, this study lends further support to the social validity of the Forehand-McMahon parent training program. The social validity of the parent training program has been previously demonstrated by social comparison, subject evaluation, and consumer satisfaction methods. These three social validation procedures are based on clients' actual experience with the intervention rather than an evaluation of treatment procedures by potential consumers before treatment begins. By assessing treatment acceptability, the three types of social validity described by Wolf (1978) have been addressed. Taken together, the social validity research suggests that the teaching methods employed in this program, the specific 53 parenting skills, and the overall program are generally viewed as very acceptable and appropriate by potential and actual consumers alike. Second, unlike previous treatment acceptability research that has examined single, isolated treatment procedures, this study attempted to examine a comprehensive program of integrated procedures designed to deal with a particular child behavior problem, which would be the more typical approach taken by family therapists. Comparisons with previous research suggests that techniques within a program may be perceived as more acceptable than techniques presented separately, but this issue must be addressed further by systematic and controlled research. Third, this study directly assessed the relative acceptability of three methods of introducing new parenting skills to a child. Presenting a verbal rationale was viewed as more acceptable than either presenting no rationale or presenting a rationale and modeling its use. Further research is required to determine the factors accounting for the perceived superiority of this mediational technique. The use of stimuli that portray the mediational techniques in a more comprehensive fashion (e.g., videotaped demonstrations) appears warranted. Finally, a comparison of the results of this study with results of consumer satisfaction studies of the same parent training program indicate the important role of experience in the evaluation of treatment. Comparisons between potential and actual consumers of this treatment program suggest that potential consumers may be conservative in their estimates of usefulness and difficulty but are similar to actual consumers in distinguishing between techniques that decrease excess behavior versus those that increase deficit behavior. Additional research is needed in order to compare ratings of treatment acceptability with consumer satisfaction for individuals before, during, and after treatment intervention. This research may identify specific factors that influence changes in treatment evaluation and its 54 relationship to treatment outcome and produce a better theoretical understanding of the therapeutic process. 55 References Azrin, N. H., Sneed, T. J., & Foxx, R. M. (1974). Dry Bed Training: Rapid elimination of childhood enuresis. Behaviour Research and Therapy. 12. 147-156. Barkley, R. A. (1981). Hyperactive children: A handbook for diagnosis and treatment. New York: Guilford. Barlow, D. H. (1981). On the relation of clinical research to clinical practice: Current issues, new directions. Journal of Consulting and Clinical Psychology. 49, 147-155. Baum, C. G., & Forehand, R. (1981). Long-term follow-up assessment of parent training by use of multiple outcome measures. Behavior Therapy. 12, 643-652. 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Acceptability of positive and reductive behavioral interventions: Factors that influence teachers decisions. Journal of School Psychology. 22. 353-360. Eyberg, S. M., & Robinson, E. A. (1983). Conduct problem behavior: Standardization of a behavioral rating scale with adolescents. Journal of  Child Clinical Psychology. 12, 347-354. Eyberg, S. M., & Ross, A. W. (1978). Assessment of child behavior problems: Validation of a new inventory. Journal of Child Clinical Psychology. 7, 113-116. Fincham, F. D., & Spettel, C. (1984). Acceptability of Dry Bed Training and urine alarm training as treatments of nocturnal enuresis. Behavior Therapy, 15, 388-394. Forehand, R. L. (1977). Child noncompliance to parental requests: Behavioral analysis and treatment. In M. Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in behavior modification (Vol. 5) (pp. 111-147). San Francisco: Academic Press. Forehand, R. L., & McMahon, R. J. (1981). 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Psychotherapy outcome research: Methods of reporting variability and evaluating clinical significance. Behavior Therapy, 15, 336-352. Kazdin, A. E. (1977). Assessing the clinical or applied importance of behavior change through social validation. Behavior Modification, 1, 427-452. Kazdin, A. E. (1980a). Acceptability of alternative treatments for deviant child behavior. Journal of Applied Behavior Analysis. 13, 259-273. Kazdin, A. E. (1980b). Acceptability of time-out from reinforcement procedures for disruptive child behavior. Behavior Therapy. 11. 329-344. Kazdin, A. E. (1980c). Research design in clinical psychology. New York: Harper & Row. Kazdin, A. E. (1981). Acceptability of child treatment techniques: The influence of treatment efficacy and adverse side effects. Behavior Therapy. 12, 493-506. Kazdin, A. E. (1984). Acceptability of aversive procedures and medication as treatment alternatives for deviant child behavior. Journal of Abnormal  Child Psychology. 12, 289-302. Kazdin, A. E., French, N. H., & Sherick, R. B. (1981). Acceptability of alternative treatment for children: Evaluations by inpatient children, parents, and staff. Journal of Consulting and Clinical Psychology. 49. 900-907. Kazdin, A. E., & Wilson, G. T. (1978). Evaluation of behavior therapy: Issues,  evidence, and research strategies. Cambridge, MA: Ballinger. 58 Lebow, J. (1982). Consumer satisfaction with mental health treatment. Psychological Bulletin, 91, 244-259. Martens, B. K., Witt, J. C, Elliott, S. N., & Darveaux, D. X. (1985). Teacher judgements concerning the acceptability of school-based interventions. Professional Psychology. 16, 191-198. McMahon, R. J., Cross Calvert, S., Davies, G. R., & Flessati, E. W. (1986, May). The social validity of maternal strategies to facilitate child compliance. Paper presented at the meeting of the Western Psychological Association, Seattle. McMahon, R. J., & Forehand, R. L. (1983). Consumer satisfaction in behavioral treatment of children: Types, issues, and recommendations. Behavior  Therapy. 14. 209-225. McMahon, R. J., & Forehand, R. L. (1984). Parent training for the noncompliant child: Treatment outcome, generalization, and adjunctive therapy procedures. In R. F. Dangel & R. A. Polster (Eds.), Parent training:  Foundations of research and practice (pp. 298-328). New York: Guilford. McMahon, R. J., Tiedemann, G. L., Forehand, R. L., & Griest, D. L. (1984). Parental satisfaction with parent training to modify child noncompliance. Behavior Therapy, 15, 298-303. McKee, W. T. (1984). Acceptability of alternative classroom treatment  strategies and factors affecting teacher's ratings. Unpublished master's thesis, University of British Columbia. Norton, G. R., Austen, S., Allen, G. E., & Hilton, J. (1983). Acceptability of time out from reinforcement procedures for disruptive child behavior: A further analysis. Child and Family Behavior Therapy. 5, 31-41. Osgood, L. E., Suci, G. J., & Tannenbaum, P. H. (1957). Measurement of  meaning. Urbana: University of Illinois Press. 59 Parloff, M. B. (1983). Who will be satisfied by "consumer satisfaction" evidence? Behavior Therapy. 14, 242-246. Patterson, G. R. (1982). A social learning approach. Vol. 3: Coercive family process. Eugene, OR: Castalia. Robinson, E. A., Eyberg, S., & Ross, A. W. (1980). The standardization of an inventory of child conduct problem behaviors. Journal of Child Clinical Psychology. 9, 22-28. Strupp, H. H., & Hadley, S. W. (1977). A tripartite model of mental health and therapeutic outcomes. American Psychologist. 32, 187-196. Tharp, R. G., & Wetzel, R. J. (1969). Behavior modification in the natural environment. New York: Academic Press. Walle, D. L., Hobbs, S. A., & Caldwell, H. S. (1984). Sequencing of parent training procedures: Effects of child noncompliance and treatment acceptability. Behavior Modification, 8, 540-552. Witt, J. C, & Elliott, S. N. (1985). Acceptability of classroom management strategies. In T. R. Kratochwill (Ed.), Advances in school psychology (Vol. 4) (pp. 251-288). Hillsdale, NJ: Lawrence Erlbaum Associates. Witt, J. C, Elliott, S. N., & Martens, B. K. (1984). Acceptability of behavioral interventions used in classrooms: The influence of amount of teacher time, severity of behavior problem, and type of intervention. Behavior Disorders, 9, 95-104. Witt, J. C, & Martens, B. K. (1983). Assessing the acceptability of behavioral interventions used in classrooms. Psychology in the Schools. 20, 510-517. Witt, J. C, Martens, B. K., & Elliott, S. N. (1984). Factors affecting teachers' judgements of the acceptability of behavioral interventions: Time involvement, behavior problem severity, and type of intervention. Behavior  Therapy. 15, 204-209. 60 Witt, J. C, Moe, G., Gutkin, T. B., & Andrews, L. (1984). The effect of saying the same thing in different ways: The problem of language and jargon in school-based consultation. Journal of School Psychology. 22. 361-367. Witt, J. C, & Robbins, J. R. (1985). Acceptability of reductive interventions for the control of inappropriate child behavior. Journal of Abnormal Child Psychology. 13, 59-67. Wolf, M. M. (1978). Social validity: The case for subjective measurement or how applied behavior analysis is finding its heart. Journal of Applied Behavior Analysis. 11, 203-214. Yates, B. T. (1978). Improving the cost-effectiveness of obesity programs: Three basic strategies for reducing the cost per pound. International Journal of Obesity. 2, 249-266. 61 Appendix A 62 Notice Mothers of children between the ages of 3 and 8 are required for a research project associated with the Department of Psychology of the University of British Columbia. The project involves evaluating a program that teaches parenting skills. Approximately 60 minutes are required and $5.00 will be paid for your participation. For additional information, contact Susan Cross Calvert, Clinical Psychology, University of British Columbia, 321-4346. 63 Appendix B ATTENDS 64 Please complete the items l i s t e d below. The items should he completed by placing; a checkmark on the l i n e under the question that best ind ica tes how you f e e l about ATTENDS. Please read the items very c a r e f u l l y because, a checkmark a c c i d e n t a l l y placed on one space rather than another may not represent the meaning you intended. REMEMBER, EVALUATE THIS PARENTING SKILL AS IF YOU WERE THE PARENT OF A CHILD IN THE FAMILY SITUATION DESCRIBED EARLIER. 1. How acceptable do you f i n d th is procedure to be for the c h i l d ' s problem behavior? not at a l l moderately very acceptable acceptable acceptable 2. How w i l l i n g would you be to carry out t h i s procedure yourse l f i f you had to change the c h i l d ' s problems? not at a l l moderately very w i l l i n g w i l l i n g w i l l i n g 3. How su i tab le is th is procedure fo r c h i l d r e n who might have other behaviora l problems than those descr ibed for th is c h i l d ? not at a l l moderately very su i tab le su i tab le s u i t a b l e 4. I f c h i l d r e n had to be assigned to th is program without the i r consent, how bad would i t be to give them th is procedure? very bad moderately not bad bad at. a l l 5. How c r u e l or unfa i r do you f i n d th is procedure? very c r u e l moderately not c r u e l c rue l at a l l 6 . Would i t be acceptable to apply th is procedure to i n s t i t u t i o n a l i z e d c h i l d r e n , the mental ly re tarded, or other i n d i v i d u a l s who are not given an opportuni ty to choose treatment for themselves? not at a l l moderately very acceptable acceptable acceptable to apply t h i s to apply procedure th is procedure 65 7. How consistent, i s th i s procedure with common sense or everyday notions about what a treatment should bs? very d i f f e r e n t or inconsistent moderately consistent very consistent with everyday notions 8. To what, extent does this procedure treat the c h i l d humanely? does not treat humanely at a l l treats them moderately humanely treats them very humanely 9. To what extent do you think there might, be r i s k s in undergoing this kind of procedure? l o t s of r i s k s some r i s k s are no r i s k s are l i k e l y l i k e l y are l i k e l y 10. How much do you l i k e the procedure? do not. l i k e moderately l i k e i t i t at a l l l i k e i t very ranch 11. How e f f e c t i v e i s t h i s procedure l i k e l y to be? not at a l l moderately very e f f e c t i v e e f f e c t i v e e f f e c t i v e 12. How l i k e l y is this procedure to make permanent improvements in the chi l d ? u n l i k e l y moderately very l i k e l y l i k e l y 13. To what, extent are undesirable side e f f e c t s l i k e l y to result, from t h i s procedure? many undesirable side e f f e c t s l i k e l y some undesirable side e f f e c t s l i k e l y no undesirable side e f f e c t s would occur 14. How much discomfort i s the c h i l d l i k e l y to experience during the procedure? very much discomfort moderate discomfort. no discomfort, at a l l 66 15. O v e r a l l , what i s your general r e a c t i o n to t h i s procedure? very negative ambivalent very p o s i t i v e 16. How d i f f i c u l t would t h i s procedure be to put i n t o p r a c t i c e ? extremely n e u t r a l extremely easy d i f f i c u l t 17. How u s e f u l would t h i s procedure be? extremely useless n e u t r a l e x t r e m e l y u s e f u l 67 TEACHING METHOD Please complete the items listed below. The items should be completed by placing a checkmark on the line under the question that best indicates how you feel about the TEACHING METHOD. Please read the items very carefully because a checkmark accidentally placed on one space rather than another may not represent, the meaning you intended. REMEMBER, EVALUATE THE TEACHING METHOD AS IE' YOU WERE THE PARENT OF A CHILD IN THE FAMILY SITUATION DESCRIBED EARLIER. 1. How acceptable do you find this teaching method to be for the child's problem behavior? not at a l l moderately very acceptable acceptable acceptable 2. How willing would you be to carry out this teaching method yourself i f you had to change the child's problems? not at a l l moderately very willing willing willing 3. How suitable is this teaching method for children who might have other behavioral problems than those described for this child? not at. a l l moderately very suitable suitable suitable 4. If children had to be assigned to this program without their consent, how bad would i t be to give them this teaching method? very bad moderately not bad bad at a l l How cruel or unfair do you find this teaching method? very cruel moderately not cruel cruel at a l l 6. Would i t be acceptable to apply this teaching method to institutionalized children, the mentally retarded, or other individuals who are not given an opportunity to choose treatment for themselves? not at a l l moderately very acceptable acceptable acceptable to apply this to apply teaching method this teaching method 68 7. How consistent is this teaching method with common sense or everyday notions about how new parenting procedures should be introduced to a child? very moderately very different, or consistent consistent inconsistent with everyday notions 8. To what extent does this teaching method treat the child humanely? does not treats them treats them treat moderately very humanely at humanely humanely a l l 9. To what, extent do you think there might be risks in undergoing this kind of teaching method? lots of risks some risks are no risks are l ike ly l ike ly are l ike ly 10. How much do you l ike the procedures used in this teaching method? do not l ike moderately l ike them them at a l l l ike them very much 11. How effective is this teaching method l ike ly to be? not at a l l moderately very effective effective effective 12. How l ike ly is this teaching method to make permanent, improvements in the child? unlikely moderately very l ike ly l ike ly 13. To what extent are undesirable side effects l ike ly to result from thii kind of teaching method? many undesirable side effects l ike ly some undes irable. side effects l ike ly no undesirable side effects would occur 14. How much discomfort is the chi ld l ike ly to experience during the course of this teaching method? very much discomfort moderate discomfort. no discomfort at a l l 69 15. O v e r a l l , what i s your, general r e a c t i o n to t h i s teaching method? very negative ambivalent very p o s i t i v e 16. How d i f f i c u l t would t h i s teaching method be to put i n t o p r a c t i c e ? extremely n e u t r a l easy 17. How usefu l would t h i s teaching method, be? extremely d i f f i c u l t . extremely useless n e u t r a l extremely u s e f u l OVERALL PARENT TRAINING PROGRAM 70 Please complete the items l i s t e d below. The items should be completed by placing a checkmark on the l i n e under the question that best indicates how you f e e l about the OVERALL PARENT TRAINING PROGRAM. Please read the items very c a r e f u l l y because a checkmark acc i d e n t a l l y placed on one space rather than another may not represent the meaning you intended. REMEMBER, EVALUATE THE OVERALL PARENT TRAINING PROGRAM AS IF YOU WERE THE PARENT OF A CHILD IN THE FAMILY SITUATION DESCRIBED EARLIER. 1. How acceptable do you fi n d t h i s program to be for the ch i l d ' s problem behavior? not at a l l moderately very acceptable acceptable acceptable 2. How w i l l i n g would you be to carry out this program yourself i f you had to change the ch i l d ' s problems? not at a l l moderately very w i l l i n g w i l l i n g w i l l i n g 3. How suitable is t h i s program for children who might have other behavioral problems than those described for this child? not at a l l moderately very suitable suitable suitable 4. I f children had to be assigned to t h i s program without t h e i r consent, how bad would i t be to give them t h i s program? very bad moderately not bad bad at. a l l 5. How cruel or unfair do you f i n d this program? very cruel moderately not c r u e l cruel at a l l 6. Would i t be acceptable to apply this program to i n s t i t u t i o n a l i z e d c h i l d r e n , the mentally retarded, or other i n d i v i d u a l s who are not given an opportunity to choose treatment for themselves? not at a l l acceptable to apply t h i s program moderately acceptable very acceptable to apply this program 71 7. How consistent is this program with common sense or everyday notions about what a program should be? very moderately very different or consistent consistent inconsistent with everyday notions 8 . To what extent does this program treat, the child humanely? does not treat. humanely at a l l treats them moderately humanely treats them very humanely 9. To what extent do you think there might be risks in undergoing this kind of program? lots of risks some risks are no risks are likely l i k e l y are likely 10. How much do you like the procedures used in this program? do not like moderately like them them at a l l like them very much 11. How effective is this program li k e l y to be? not at a l l moderately very effective effective effective 12. How likely is this program to make permanent improvements in the child? unlikely moderately very likely l i k e l y 13. To what extent are undesirable side effects l i k e l y to result from this program? many undesirable side effects l i k e l y some undesirable side effects likely no undesirable side effects would occur 14. How much discomfort is the child l i k e l y to experience during the course of this program? very much discomfort moderate discomfort no discomfort at a l l 72 15. O v e r a l l , what i s your general r e a c t i o n to t h i s program? very negative ambivalent very p o s i t i v e 16. How d i f f i c u l t would t h i s program be to put i n t o p r a c t i c e ? extremely n e u t r a l extremely easy d i f f i c u l t 17. How u s e f u l would t h i s program be? extremely useless n e u t r a l extremely u s e f u l 73 Appendix C 75 Appendix D DEMOGRAPHIC DATA FORM 76 We would like to learn more about the participants in this study. Please help by answering the following questions. 1. What are the ages and sex of your children? Sex Birthdate (Include year of birth) 2. What is your current marital status? (Check) single divorced widowed married/long-term relationship separated 3. What is your age? 4. What is the highest level of education you have completed? (Check) Grade School High School College University Graduate School 5. What is your occupation? 6. Who is the major wage earner of your household? IF SELF, OMIT QUESTIONS 7 AND 8 AND GO TO QUESTION 9. 7. What is the occupation of the major wage earner in your household? 8. What is the highest level of education completed by the major wage earner? Grade School High School College University Graduate School 9. Have you ever sought psychological assistance for your child's behavior or attended parenting courses? (Check) Yes No 10. If yes, what was the nature of this assistance? 77 Appendix E INTRODUCTION 78 Thank you for your willingness to p a r t i c i p a t e i n t h i s study. The purpose of t h i s study i s to have you, as mothers of c h i l d r e n i n the 3- to 8-year-old range, evaluate a widely used parent t r a i n i n g program and the i n d i v i d u a l s k i l l s taught in i t . Parents of c h i l d r e n in t h i s age range who seek p r o f e s s i o n a l assistance for t h e i r c h i l d ' s behavior frequently complain that t h e i r c h i l d does not obey t h e i r requests. This disobedience i s a common component of many behavior disorders of young c h i l d r e n . The type of c h i l d that i s excessively disobedient i s usually also i r r i t a b l e , negative, d e s t r u c t i v e , aggressive, stubborn, and frequently resorts to y e l l i n g , whining, and crying. He or she may also f i g h t with brothers, s i s t e r s , or other c h i l d r e n ; break r u l e s ; tease others; and have temper tantrums. In these f a m i l i e s , the parent-child i n t e r a c t i o n has deteriorated over time to the point where i t has become very negative and i s usually characterized by frequent scolding, nagging, threatening, y e l l i n g , and spanking. When fa m i l i e s become t h i s disrupted, i t i s l i k e l y that family members view each other and themselves very negatively. As a r e s u l t of t h i s whole process, family members tend to avoid each other and share very few a c t i v i t i e s together. The parenting program you w i l l be evaluating has been developed s p e c i f i c a l l y as 'a treatment f o r f a m i l i e s who f i n d themselves in t h i s s i t u a t i o n . WHEN EVALUATING THIS PROGRAM, TRY TO IMAGINE YOURSELF AS THE PARENT OF AN EXCESSIVELY DISOBEDIENT CHILD IN THE FAMILY SITUATION JUST DESCRIBED. This parent t r a i n i n g program i s based on the premise that much of a - 2 -79 c h i l d ' s behavior i s learned and the best approach in dea l ing with the c h i l d ' s undesirable* behavior i s by teaching the c h i l d more acceptable behaviors . Young ch i l d ren are most in f luenced by t h e i r parents , so the goal of parent t r a i n i n g i s to teach the parents more e f f e c t i v e ways of i n t e r a c t i n g with t h e i r c h i l d r e n . This p a r t i c u l a r program is most e f f e c t i v e f o r parents of young c h i l d r e n (ages 3 to 8 y e a r s ) . There are two ways to reduce a c h i l d ' s undesirable behavior . The f i r s t i s by focus ing on the inappropr ia te (or "bad") behavior d i r e c t l y . This usua l l y involves some form of punishment. The disadvantage of t h i s approach i s that appropr iate or "good" behavior does not n e c e s s a r i l y increase s ince punishment only t e l l s the c h i l d what not to do. A d d i t i o n a l l y , the parent has to punish the c h i l d f requent ly , which can be d i s t r e s s i n g for both parent and c h i l d . The second and more advantageous method i s to focus f i r s t on inc reas ing the c h i l d ' s des i rab le or "good" behavior . By doing so, undesirable behavior automat ica l ly decreases. Since the c h i l d spends more time being "good", there i s l e ss time ava i l ab le to be "bad". This method teaches the c h i l d exact ly what behavior is. appropr ia te . The parent can then punish l ess f requent ly and punishment can be more e f f e c t i v e when i t i s used. A l s o , focus ing on the "good" behavior improves the p a r e n t - c h i l d r e l a t i o n s h i p and makes fo r a more pleasant fami ly l i f e . *By undesirable or inappropr ia te behavior we mean behavior that you as a parent would l i k e to see decreased or e l iminated ( for example, h i t t i n g , whin ing) . S i m i l a r l y , d e s i r a b l e and appropr iate behavior re fe rs to behavior that a parent sees as acceptable behavior or behavior you would l i k e to see increased ( for example, toothbrushing, sharing t o y s ) . - 3 -80 Parents in t h i s two-part program are taught a ser ies of parenting s k i l l s that help to change t h e i r way of i n t e r a c t i n g with t h e i r c h i l d . The program is taught in a c l i n i c with i n d i v i d u a l f a m i l i e s . Fami l ies usua l l y come to the c l i n i c once a week for 8 to 12 weeks. Parents progress to each new parent ing s k i l l at t h e i r own speed. New s k i l l s are not taught u n t i l parents are p r o f i c i e n t and comfortable with the previous s k i l l . Each new s k i l l bu i lds upon the previous s k i l l s . For each new s k i l l , the therap is t expla ins and demonstrates i t s use to the parent . The parent then p rac t i ces the new s k i l l in the c l i n i c with the t h e r a p i s t r o l e - p l a y i n g (ac t ing the part of) the c h i l d . This way the parent can become very s k i l l f u l and comfortable with the technique before using i t with t h e i r own c h i l d . P [The parent does not exp la in or demonstrate the new s k i l l to the c h i l d before i t i s a c t u a l l y used with the c h i l d . This allows the c h i l d to l earn n a t u r a l l y by experience and by t r i a l and e r r o r how the new s k i l l w i l l be used.] PR [The parent then v e r b a l l y explains the new s k i l l to the c h i l d before i t i s a c t u a l l y used with the c h i l d . By having the s k i l l descr ibed f i r s t , the c h i l d understands the new procedure and learns to change h i s or her behavior more qu i ck ly than l ea rn ing by experience and t r i a l and e r r o r . ] PRM [The parent then v e r b a l l y expla ins and demonstrates the new s k i l l to the c h i l d before i t i s a c t u a l l y used with the c h i l d . By having the s k i l l descr ibed f i r s t , the c h i l d understands the new procedure and learns to change h is or her behavior more qu i ck ly than l ea rn ing by experience and t r i a l and e r r o r . Showing the c h i l d how the new s k i l l w i l l be used re in fo rces what has already been exp la ined .] The parent then p rac t i ces the new s k i l l with the c h i l d in the c l i n i c , r e c e i v i n g feedback and encouragement from the t h e r a p i s t . Once the parent is - 4 -81 comfortable with the new parent ing s k i l l and is using i t s u c c e s s f u l l y in the c l i n i c with the c h i l d , then the parent uses the new s k i l l in the home. Parents are assigned s p e c i f i c homework exerc ises at each sess ion to enable them to use the new s k i l l s s u c c e s s f u l l y at home. INSTRUCTIONS In t h i s study, you w i l l read about the two parts of the parent ing program and the s k i l l s taught in each par t . A f te r each s k i l l i s descr ibed , you w i l l evaluate i t by ra t ing i t on the quest ionnaire that fo l lows. In the f i n a l segment, you w i l l evaluate the teaching method and the en t i re parent t r a i n i n g program as a whole. Please read the desc r ip t ions c a r e f u l l y and proceed at your own pace. REMEMBER, EVALUATE THIS PROGRAM AS IF YOU WERE THE PARENT OF A CHILD IN THE FAMILY SITUATION DESCRIBED ON PAGE 1. - 5 -82 OVERVIEW FOR PART I The goal of Part I of the program is to teach the parent s k i l l s that w i l l help to increase the c h i l d ' s appropriate or "good" behavior and help the c h i l d learn which behaviors need to be decreased. There are two assumptions under ly ing Part I : 1. When a behavior gets p o s i t i v e consequences immediately a f t e r i t occurs , the behavior i s l i k e l y to occur again. For example, i f you t e l l a joke at a party and everyone laughs, you are more l i k e l y to t e l l another joke . 2. For c h i l d r e n , a t tent ion from others , e s p e c i a l l y parents, i s the most powerful consequence. Ch i ldren w i l l work to get t h e i r parent ' s a t t e n t i o n . I f the c h i l d i s not get t ing p o s i t i v e a t tent ion ( for example, pra ise) the c h i l d w i l l a lso work fo r negative a t ten t ion ( for example, s co ld ing , c r i t i c i s m ) , which to the c h i l d , i s considered better than no a t tent ion at a l l . Parenta l a t t e n t i o n , there fo re , i s very powerful to the c h i l d and can be used to change the c h i l d ' s behavior . In Part I , the parent i s taught to use p o s i t i v e at tent ion fo r appropriate behavior and to withhold a t tent ion for undesirable behavior. The s k i l l s taught in Part I help the parent learn to in te rac t with t h e i r c h i l d in a more p o s i t i v e manner and improve that r e l a t i o n s h i p . Three parenting s k i l l s are taught in Part I : 1. attends 2. rewards 3. ignor ing . E f f e c t i v e use of these three s k i l l s together w i l l e l iminate a large por t ion of the c h i l d ' s undesirable behavior , and improve the r e l a t i o n s h i p between parent and c h i l d . - 6 -83 ATTENDS The f i r s t s k i l l taught in Part I i s attends. B a s i c a l l y , attends are a running verbal commentary of the c h i l d ' s a c t i v i t y and supply the c h i l d with a constant source of attention. Attends can simply be descriptions of the c h i l d ' s behavior (for example, "You're p i l i n g the blocks on top of each other.") or they can be used to emphasize a behavior the parent would l i k e to see more of (for example, "You're playing a l l by y o u r s e l f ! " or "You're sharing your toys with your s i s t e r . " ) . To attend w e l l , the parent is taught to: 1. Be attentive to the c h i l d ' s a c t i v i t y . Attends are not e f f e c t i v e when the parent i s t r y i n g to do something else ( f o r example, reading the newspaper). The c h i l d ' s a c t i v i t y must be followed c l o s e l y . 2 . Avoid asking the c h i l d questions, teaching, or giving the c h i l d d i r e c t i o n s on how to play. 3 . Attend only to desirable behavior. Do not give attention to behavior that i s inappropriate or that the parent would l i k e to decrease. The parent may at f i r s t f e e l awkward in using t h i s new s t y l e of i n t e r a c t i n g with the c h i l d . However, th i s uncomfortableness quickly passes as the parent uses t h i s s k i l l in many si t u a t i o n s . S i m i l a r l y , once c h i l d r e n become accustomed to being attended to, they enjoy i t immensely. The r a t i o n a l e f or attends i s explained to the parent by the t h e r a p i s t . The therapist then demonstrates to the parent how attends are used. The parent then practices using attends with the therapist playing the r o l e of the c h i l d . P [Once the parent i s s k i l l e d at using attends with the t h e r a p i s t , the parent begins to use attends with the c h i l d without explaining or demonstrating i t f i r s t . The parent prac t i ces the use of attends with the c h i l d in the c l i n i c and at home in s p e c i a l play times set aside d a i l y fo r t h i s purpose.] .PR [Once the parent i s s k i l l e d at using attends with the t h e r a p i s t , the parent then explains the use of attends to the c h i l d before they are a c t u a l l y used with the c h i l d . Depending on the c h i l d ' s age, the parent might introduce attends by saying: " (Name) from now on when we are p lay ing together , I'm going to be watching very c l o s e l y and when you play n i c e l y i t w i l l make me very happy. I w i l l be t a l k i n g about the good things you are doing. Y o u ' l l l i k e i t ! " A f te r exp la in ing attends to t h e i r c h i l d , the parent p rac t i ces the use of attends with the c h i l d in the c l i n i c and at home in s p e c i a l p lay times set aside d a i l y for t h i s purpose.] PRM [Once the parent i s s k i l l e d at using attends with the t h e r a p i s t , the parent then explains and demonstrates the use of attends to the c h i l d before they are ac tua l l y used with the c h i l d . Depending on the c h i l d ' s age, the parent might introduce attends by say ing: " (Name) , from now on when we are p lay ing together, I'm going to be watching very c l o s e l y and when you play n i c e l y i t w i l l make me very happy. I w i l l be t a l k i n g about the good th ings you are doing. Y o u ' l l l i k e i t ! To show you what i t s going to be l i k e , l e t ' s p r a c t i c e . Pretend you're p lay ing with these b locks . (Parent guides c h i l d . ) I might say things l i k e , 'You're gathering a l l of the blocks together . Now • you're stacking them on top of each o t h e r . . . f i r s t the blue one, then the green o n e . . . ' Do you understand?" A f t e r exp la in ing and demonstrating attends to the c h i l d , the parent p rac t i ces the use of attends with the c h i l d in the c l i n i c and at home in s p e c i a l play times set aside d a i l y fo r t h i s purpose.] PLEASE EVALUATE ATTENDS ON THE FOLLOWING QUESTIONNAIRE. 85 REWARDS Rewards, the second s k i l l taught in Part I , help to increase a c h i l d ' s appropriate or "good" behavior and is use fu l in teaching new behav iors . There are three types of rewards: 1. Phys i ca l a f f e c t i o n . For example, k i s s , hug, pat on the back. 2. General p r a i s e . For example, "Thanks!" "Good g i r l ! " "Great !" Though these pra ise statements are p o s i t i v e , they do not s p e c i f i c a l l y t e l l the c h i l d what behavior they are being rewarded f o r . 3. S p e c i f i c p r a i s e . For example, "Thanks fo r b r ing ing my shoes!" "I r e a l l y l i k e i t when you share your toys with your b r o t h e r . " These types of rewards are s p e c i f i c statements which t e l l the c h i l d which behavior i s being rewarded and are most u s e f u l in teaching the c h i l d appropriate behaviors . To maximize the e f fec t i veness of rewards, i t i s important to give s p e c i f i c pra ise immediately fo l lowing the behavior. When a c h i l d i s f i r s t l ea rn ing a new behavior, give rewards c o n s i s t e n t l y . Once the c h i l d has learned the new behavior , reduce the frequency of rewards. Rewards are most e f f e c t i v e when used with attends. Rewards can lose t h e i r power i f used too f requent l y . Attends can be used f l e x i b l y in many s i t u a t i o n s whi le rewards are best used for e s p e c i a l l y good behavior . Once rewards are expla ined to the parent, the t h e r a p i s t demonstrates t h e i r use. The parent then p rac t i ces using attends and rewards with the t h e r a p i s t act ing as the c h i l d . P [When the parent i s s k i l l e d at using attends and rewards together , the parent begins to use the new s k i l l with the c h i l d , but does not exp la in or demonstrate i t f i r s t . - 9 -86 The parent p rac t i ces using rewards with the c h i l d in the c l i n i c and then at home in d a i l y play t imes .] PR [When the parent i s s k i l l e d at using attends and rewards together , the parent v e r b a l l y expla ins to the c h i l d how rewards w i l l be used. Depending on the age of the c h i l d , the parent might introduce rewards by saying to the c h i l d : " (Name) from now on when I see you doing something I r e a l l y l i k e , I ' l l be happy and I ' l l t e l l you r i g h t away how much I l i k e what you d i d . " Once rewards have been explained to the c h i l d , the parent p rac t i ces using rewards with the c h i l d in the c l i n i c and then at home in d a i l y play t imes .] PRM [When the parent i s s k i l l e d at using attends and rewards together , the parent v e r b a l l y expla ins and demonstrates to the c h i l d how rewards w i l l be used. Depending on the age of the c h i l d , the parent might introduce rewards by saying to the c h i l d : "(Name) from now on when I see you doing something I r e a l l y l i k e , I ' l l be happy and I ' l l t e l l you r i g h t away how much I l i k e what you d i d . L e t ' s pretend that you are p lay ing r e a l l y q u i e t l y over there with that t ruck . (Parent guides c h i l d . ) I r e a l l y l i k e i t when you play q u i e t l y so I'm going to come over to you and t e l l you. (Parent goes over to the c h i l d . ) I ' l l say something l i k e , ' I r e a l l y l i k e i t when you play so q u i e t l y , (name) ! ' " Once rewards have been explained and demonstrated to the c h i l d , the parent p rac t i ces using rewards with the c h i l d in the c l i n i c and then at home in d a i l y play t imes .] PLEASE EVALUATE REWARDS ON THE FOLLOWING QUESTIONNAIRE. KEEP IN MIND THAT REWARDS WOULD BE USED IN CONJUNCTION WITH ATTENDS IN ORDER TO INCREASE POSITIVE OR "GOOD" BEHAVIOR. IGNORING 87 An important and e f f e c t i v e way to decrease a c h i l d ' s minor inappropr iate behavior i s to ignore i t . Ignor ing the behavior means that abso lute ly no a t ten t ion at a l l i s given to i t . Behaviors that do not rece ive a t ten t ion of any type (e i ther p o s i t i v e or negative) w i l l tend to decrease. One aspect that makes ignor ing d i f f i c u l t fo r parents i s that when a parent ignores an undesirable behavior, the c h i l d w i l l o f ten increase the behavior in an attempt to get the a t tent ion he or she once r e c e i v e d . However, i f the parent can c o n s i s t e n t l y ignore the behavior , i t w i l l soon decrease. In order to make ignor ing as e f f e c t i v e as p o s s i b l e , the parent i s taught to : 1. Begin ignor ing as soon as the undes irable behavior s t a r t s . 2. Avoid making eye contact or g i v i n g nonverbal cues such as smi l ing or frowning to the c h i l d . To prevent the c h i l d from seeing the parent ' s f a c i a l express ion , the parent i s i ns t ruc ted to turn at l e a s t 90 degrees away from the c h i l d . 3. Avoid t a l k i n g to the c h i l d whi le the c h i l d i s behaving inappropr ia te l y . 4. Avoid phys i ca l contact with the c h i l d whi le the c h i l d i s behaving i nappropr i a te l y . 5. Stop ignor ing as soon as the c h i l d i s behaving appropr ia te ly . Ignoring can be extremely e f f e c t i v e and use fu l but should NOT be used~ in s i t u a t i o n s where the c h i l d ' s behavior i s harmful or p o t e n t i a l l y could cause harm to the c h i l d , o thers , or property ( for example, co lour ing the w a l l s ) . A more appropriate technique fo r these s i t u a t i o n s is taught in Part I I . - I I -SS A f t e r the ignor ing s k i l l i s explained to the parent, the therap i s t demonstrates how the procedure is used. The parent then p rac t i ces the procedure with the t h e r a p i s t r o l e - p l a y i n g the c h i l d . P [When the parent i s p r o f i c i e n t at using t h i s s k i l l with the t h e r a p i s t , the parent uses the new procedure without exp la in ing or demonstrating i t f i r s t to the c h i l d . The parent p r a c t i c e s us ing ignor ing , when appropr iate , in the c l i n i c and then at home.] PR [When the parent i s p r o f i c i e n t at using t h i s s k i l l with the t h e r a p i s t , the parent then exp la ins the new procedure to the c h i l d before i t i s used with the c h i l d . To introduce ignor ing to the c h i l d , the parent might exp la in : "_ (Name) . from now on when you do things I l i k e , I ' l l be very happy. I f you do things I don' t l i k e to see, I w i l l be unhappy and I ' l l ignore you. That means I ' l l turn away and not look at you or t a l k to you. When you s t a r t to do things I l i k e , I ' l l s t a r t t a l k i n g to you again. Do you understand?" A f t e r ignor ing has been explained to the c h i l d , the parent p rac t i ces using ignor ing , when appropr ia te , in the c l i n i c and then at home.] PRM [When the parent i s p r o f i c i e n t at using t h i s s k i l l with the t h e r a p i s t , the parent then exp la ins and demonstrates the new procedure to the c h i l d before i t i s used with the c h i l d . To introduce ignor ing to the c h i l d , the parent might e x p l a i n : " (Name) from now on when you do things I l i k e , I ' l l be very happy. I f you do things I don't l i k e to see,^I w i l l be unhappy and I ' l l ignore you. That means I ' l l turn away and not look at you or ta lk to you. When you s t a r t to do things I l i k e , I ' l l s t a r t t a l k i n g to you again. Do you understand? To make sure you understand what ignor ing i s , l e t ' s pretend you want to get my a t t e n t i o n . Instead of asking n i c e l y , you use your baby voice (that i s , whin ing) . So I ' l l pretend you're whining. I don' t l i k e you to - 12 -89 do that, so I'm going to ignore you l i k e t h i s . (The parent then demonstrates ignoring f o r about 10 seconds.) The only way to get me to stop ignoring you i s to t a l k i n your normal voice. (When the c h i l d talks in t h e i r regular voice, the parent stops ignoring). Now you know what ignoring i s . " Af t e r ignoring has been explained and demonstrated to the c h i l d , the parent practices using ignoring, when appropriate, in the c l i n i c and then at home. ] Parents pra c t i c e the use of attends, rewards, and ignoring at home i n s p e c i a l play times set aside for t h i s purpose. Parents are also asked to think of three behaviors they would l i k e to see t h e i r c h i l d do more often (for example, pick up t h e i r toys, get dressed by themselves in the morning). Parents are taught how to use the Part I s k i l l s in meeting these goals. As the parents become more p r o f i c i e n t with the s k i l l s , they are encouraged to apply them to everyday s i t u a t i o n s . PLEASE EVALUATE IGNORING ON THE FOLLOWING QUESTIONNAIRE. KEEP IN MIND THAT IGNORING (TO DECREASE UNDESIRABLE OR "BAD" BEHAVIOR) WOULD ONLY BE USED IN CONJUNCTION WITH ATTENDS AND REWARDS (TO INCREASE POSITIVE OR "GOOD" BEHAVIOR). OVERVIEW FOR PART II 90 In Part I I , the parent i s taught how to deal d i r e c t l y with any disobedience that remains. The s k i l l s of Part II are e f f e c t i v e only when used in combination with the s k i l l s of Part I (attends, rewards, ignor ing) and there fo re , Part II s k i l l s are never taught f i r s t or alone. They are taught only a f t e r the parent i s e f f e c t i v e l y using attends, rewards, and ignor ing . The s k i l l s of Part II focus on things parents can do to increase the l i k e l i h o o d of t h e i r c h i l d obeying and decrease the l i k e l i h o o d that t h e i r c h i l d w i l l d isobey. The s k i l l s of Part II are: 1. G iv ing c l ea r i n s t r u c t i o n s . 2. Using a time-out sequence for disobedience to i n s t r u c t i o n s . CLEAR INSTRUCTIONS 91 How a parent gives ins t ruc t ions often inf luences whether or not the c h i l d w i l l obey. Parents of ten f a l l into the habit of g i v ing i n s t r u c t i o n s that are d i f f i c u l t to obey. For example: "Watch out ! " "Be good!"—too vague. These i n s t r u c t i o n s do not t e l l the c h i l d s p e c i f i c a l l y what i s expected. "P ick up your b locks , put them on the she l f , then make your bed and put your c lothes away."—too many to remember! "Would you l i k e your bath now?"—offers the c h i l d a choice where no choice was intended. " L e t ' s put the dishes away."—often the parent has no in ten t ion of h e l p i n g . Parents are ins t ruc ted to avoid these kinds of i n s t r u c t i o n s and ins tead , to give c l e a r , d i r e c t i ns t ruc t ions so that i f t h e i r c h i l d does not obey, i t i s because the c h i l d chooses not to obey, rather than not being able to understand the i n s t r u c t i o n s . The parent is taught to give p o s i t i v e a t t e n t i o n (attends, rewards) as soon as the c h i l d begins to fo l low the i n s t r u c t i o n . Since obeying the parent 's i n s t r u c t i o n is d e s i r a b l e , the parent should be sure to give the c h i l d p o s i t i v e a t ten t ion . A procedure fo r handl ing disobedience i s taught in the next s e c t i o n . The parent i s taught to give good i n s t r u c t i o n s . These are charac te r i zed by: 1. Deciding ahead of time whether the i n s t r u c t i o n i s necessary. Often the parent can use the s k i l l s of Part I of the program to get the same r e s u l t . 2. ^Giv ing ins t ruc t i ons only when the parent i s prepared to fo l low through should t h e i r c h i l d decide not to obey. 3. Get t ing the c h i l d ' s a t ten t ion . The parent c a l l s the c h i l d ' s name and waits u n t i l he or she i s looking at the parent . - 15 -92 4. Voice should be f i rm and s l i g h t l y louder than u s u a l . This helps the c h i l d understand that these i n s t r u c t i o n s are important to l i s t e n t o . 5. The ins t ruc t ion should be s p e c i f i c and d i r e c t and should be phrased in a way the c h i l d can understand. 6. Instruct ions should be phrased as "do" rather than "stop" s ince t h i s t e l l s the c h i l d what is expected. For example, "Tommy, share the toys with your s i s t e r " , rather than "Stop h i t t i n g your s i s t e r . " 7. Inst ruct ions should be given one at a t ime. 8. A f te r g iv ing the i n s t r u c t i o n s , wait 5 seconds to give the c h i l d the opportunity to begin to obey. (Research has shown that a f t e r 5 seconds, the l i k e l i h o o d that the c h i l d w i l l obey the i n s t r u c t i o n sharply decreases.) To avoid d i s t r a c t i n g the c h i l d from s t a r t i n g the task, the parent does not speak to the c h i l d during these 5 seconds. 9. As soon as the c h i l d s ta r t s to fo l low the i n s t r u c t i o n , the parent uses attends and rewards to ensure that the c h i l d completes the i n s t r u c t i o n and to provide p o s i t i v e a t ten t ion for obeying. ("Now you're gathering the blocks to put in the toy b o x . . . y o u ' r e checking to make sure you haven't missed any. . .Thank you for put t ing the toys away. I r e a l l y l i k e i t when you do what I ask .") A f t e r the s k i l l has been explained and demonstrated to the parent, the parent prac t i ces g iv ing c l ea r i ns t ruc t i ons to the the rap i s t in the c l i n i c . P [The parent then begins to use the new s k i l l with the c h i l d , but does not exp la in or demonstrate i t f i r s t . The parent pract i ces g iv ing c l ea r i n s t r u c t i o n s in the c l i n i c and then at home.] PR [The parent then explains to the c h i l d how c l e a r i n s t r u c t i o n s w i l l be used. To introduce c lear i ns t ruc t i ons to the c h i l d , the parent might e x p l a i n : - 16 -93 " (Name) when I want you to do something for me, I'm going to c a l l your name f i r s t , and then t e l l you what I 'd l i k e you to do. I'm only going to say i t once. I t ' s very important to me and w i l l make me happy i f you do what I ask q u i c k l y . A f te r I ask you to do t h i s fo r me I ' l l wait 5 seconds. When you s t a r t to do what I asked, I ' l l t a l k about what you're doing and t e l l you r i g h t away how much I l i k e i t . " Once c l ear i n s t r u c t i o n s are explained to the c h i l d , the parent p rac t i ces g iv ing c l e a r i ns t ruc t i ons in the c l i n i c and then at home.] PRM [The parent then expla ins and demonstrates to the c h i l d how c l e a r i n s t r u c t i o n s w i l l be used. To introduce c l ear i n s t r u c t i o n s to the c h i l d , the parent might exp la in : " (Name) , when I want you to do something fo r me, I'm going to c a l l your name f i r s t , and then t e l l you what I ' d l i k e you to do. I'm only going to say i t once. I t ' s very important to me and w i l l make me happy i f you do what I ask q u i c k l y . A f te r I ask you to do t h i s f o r me I ' l l wait 5 seconds. When you s t a r t to do what I asked, I ' l l t a l k about what you ' re doing and t e l l you r i gh t away how much I l i k e i t . L e t ' s pretend I want you to put your coat on. F i r s t I ' l l c a l l your name and then I ' l l t e l l you what I ' d l i k e you to do. Ready? ' (Name) , (parent waits u n t i l the c h i l d looks at the parent) please put your coat o n . ' (Ch i ld gets coat and begins to put i t on.) 'You've found your c o a t . . . You're z ipper ing i t up . . .Thank you for put t ing your coat on. I r e a l l y l i k e i t when you do what I ask . ' That ' s how I'm going to t e l l you to do things fo r me." Once c l e a r i n s t r u c t i o n s are explained and demonstrated to the c h i l d , the parent p rac t i ces g iv ing c l e a r i n s t r u c t i o n s in the c l i n i c and then at home.] - 17 -Clear i n s t r u c t i o n s can be summarized by t h i s f low char t : Obey -Attend/Reward 9 4 Ins t ruc t ions 5 sec -^Disobey >Taught in the next sec t ion PLEASE EVALUATE CLEAR INSTRUCTIONS ON THE FOLLOWING QUESTIONNAIRE. REMEMBER THAT THIS PROCEDURE INCLUDES PRAISE (ATTENDS AND REWARDS) FOR FOLLOWING THE PARENT'S INSTRUCTION AS WELL. KEEP IN MIND THAT CLEAR  INSTRUCTIONS WOULD ONLY BE USED IN CONJUNCTION WITH ATTENDS, REWARDS, AND IGNORING IN ORDER TO INCREASE POSITIVE OR "GOOD" BEHAVIOR AND DECREASE UNDESIRABLE OR "BAD" BEHAVIOR. TIME-OUT SEQUENCE 95 The l a s t s k i l l taught in the program i s a technique to handle the c h i l d ' s f a i l u r e to obey a parent 's i n s t r u c t i o n . As you have j u s t read in the preceding s e c t i o n , the parent i s taught to wait 5 seconds a f t e r g i v ing an i n s t r u c t i o n . I f the c h i l d begins to obey, the parent attends to and rewards the c h i l d . I f the c h i l d does not begin to obey wi th in 5 seconds, then the parent i s taught how to use a time-out procedure. Time out is when the c h i l d i s removed from the s i t u a t i o n by having the- c h i l d s i t on a cha i r in the corner fo r 3 minutes. Time out i s simply a more extreme form of ignor ing where the c h i l d i s removed from a l l sources of a t ten t ion (other people, parents) and entertainment ( toys , t e l e v i s i o n ) . The advantage of using time out i s that i t can be used in p lace of other forms of d i s c i p l i n e such as y e l l i n g , c r i t i c i z i n g , or h i t t i n g , and the parent can avoid reac t ing in anger. The time-out sequence cons i s t s of a se r ies of a l t e r n a t i v e steps which are determined by the c h i l d ' s responses to the parent ' s i n s t r u c t i o n s . The sequence goes as fo l l ows . The parent gives a c l e a r , d i r e c t i n s t r u c t i o n . I f the c h i l d has not s tar ted to obey wi th in S seconds, the parent gives a warning that s p e c i f i e s the i n s t r u c t i o n and the consequences of not obeying ( for example, " I f you do not p i ck up the toys , then you w i l l have to s i t in the c h a i r . " ) I f the c h i l d obeys the warning, then the parent immediately pra ises the c h i l d ( fo r example, "Thank you for . . . " ) . However, i f the c h i l d has not begun to obey wi th in 5 seconds, the parent can be sure that the c h i l d has no in ten t ion of obeying. The parent gave a c l e a r , d i r e c t i n s t r u c t i o n ; waited; and gave the c h i l d a warning in which the i n s t r u c t i o n was res tated and the - 19 -96 c h i l d was t o l d what would happen i f the he or she d id not obey. The c h i l d i s then taken f i r m l y by the hand to a cha i r fac ing the corner of a room. The c h i l d i s t o l d , "Since you d i d n ' t ( i n s t r u c t i o n ) . you w i l l have to s i t in the cha i r u n t i l I say you can ge.t up ." The parent does not argue or give any fur ther exp lanat ions . Any temper tantrums, c r y i n g , promises, or protests on the way to time out or dur ing time out should be ignored. The c h i l d should stay in time out fo r 3 minutes. Research has ind icated that 3 minutes i s an i d e a l per iod for time out. Time out fo r l e ss than 3 minutes is l e ss e f f e c t i v e whi le time out for greater than 3 minutes does not lead to greater obedience. When 3 minutes are up, the parent removes the c h i l d from the cha i r and returns to the area where the o r i g i n a l i n s t r u c t i o n was g iven . The parent then re issues the same i n s t r u c t i o n , beginning the sequence again. This i s an important step! Ch i ldren learn that they must s t i l l f o l l ow through on the o r i g i n a l i n s t r u c t i o n . I t i s extremely rare that the parent must go through the cyc le more than once for the o r i g i n a l i n s t r u c t i o n . O c c a s i o n a l l y , when f i r s t learnng the new procedure, the c h i l d may not stay in the c h a i r . The parent then uses a back-up consequence, such as two swats on the c h i l d ' s bottom or some other punishment ( for example, removal of p r i v i l e g e s ) . A f t e r the t h e r a p i s t has explained the sequence to the parent, the therap i s t demonstrates the procedure with the parent, going through the var ious a l t e r n a t i v e s teps . The parent then prac t i ces the_procedure with the therap i s t r o l e - p l a y i n g the c h i l d u n t i l the parent i s very p r o f i c i e n t at using the s k i l l . P [When the parent i s ready to use the new s k i l l with the c h i l d , the parent does not v e r b a l l y exp la in or demonstrate the new procedure to the c h i l d before using i t . - 20 -97 Once the parent i s s k i l l e d at using time out in the c l i n i c , the parent can begin using time out at home, when appropr ia te . ] PR [When the parent i s ready to use the new s k i l l with the c h i l d , the parent then v e r b a l l y expla ins the new procedure to the c h i l d before using i t . The parent might exp la in : " (Name) , when I ask you to do things for me, i t i s very important that you do what I ask you to do very qu i ck l y . I f you do things fo r me q u i c k l y , then I ' l l be happy. I f you don't do things for me, I ' l l ask you once more. I f you s t i l l don't do what I ask qu i ck l y , then I ' l l be very unhappy and I ' l l take you to the corner. Y o u ' l l have to s i t on that cha i r in the corner fo r 3 minutes. S i t t i n g in the corner w i l l help you to learn to do things more q u i c k l y . When 3 minutes are up, you can get o f f the c h a i r , but y o u ' l l have to do what I asked you to do before . Otherwise, y o u ' l l have to go back to the c h a i r . Do you understand?" Once the parent has explained the procedure to t h e i r c h i l d and i s s k i l l e d at using time out in the c l i n i c , the parent can begin using time out at home, when appropr ia te . ] PRM [When the parent i s ready to use the new s k i l l with the c h i l d , the parent then v e r b a l l y expla ins and demonstrates the new procedure to the c h i l d before using i t . The parent might exp la in : " (Name) , when I ask you to do things for me, i t i s very important that you do what I ask you to do very q u i c k l y . I f you do things for me q u i c k l y , then I ' l l be happy. I f you don't do things fo r me, I ' l l ask you once more^ I f you s t i l l don't do what I ask q u i c k l y , then I ' l l be very unhappy and I ' l l take you to the corner. Y o u ' l l have to s i t on that cha i r in the corner for 3 minutes. S i t t i n g in the corner w i l l help you to l earn to do things more qu i ck l y . When 3 minutes are up, you can get o f f the c h a i r , but y o u ' l l have to do what I asked you to do before . Otherwise, y o u ' l l have to go back to the c h a i r . Do you understand? To make - 21 -98 sure we know what to do, l e t ' s p r a c t i c e . Pretend you're p lay ing with your d o l l . (Parent guides c h i l d . ) Now I ' l l ask you to do something for me. '(Name) please put your d o l l on the s h e l f . ' (Whisper) Now pretend not to do i t . (Wait 5 seconds.) Then I ' l l say, " I f you don't put your d o l l on the s h e l f , you w i l l have to s i t on the c h a i r . ' (Whisper) Pretend not to do i t . (Wait 5 seconds.) Then I ' l l say, 'S ince you d idn ' t do what I asked, y o u ' l l have to s i t in the c o r n e r . ' Then you go over and s i t on the c h a i r . (Parent gu ides . ) That 's i t ! Then w e ' l l wait for 3 minutes. Then I ' l l say, 'You can get o f f the cha i r now.' Then I ' l l ask you to do what I asked you to do before . ' (Name) please put your d o l l on the s h e l f . ' (Whisper) Now pretend to do i t . (Ch i ld puts d o l l on the s h e l f . ) Thank you for put t ing your d o l l on the s h e l f ! " Once the parent has explained and demonstrated the procedure to the c h i l d and i s s k i l l e d at using time out in the c l i n i c , the parent can begin using time out at home, when appropr ia te . ] Once the parent i s p r o f i c i e n t in the use of time out at home, the parent i s a lso taught modi f i ca t ions of time out for other s i t u a t i o n s , such as misbehavior in pub l i c places l i k e the grocery store or fo r e s t a b l i s h i n g long standing "house r u l e s " . Part II of the program can be summarized by t h i s flow char t : -^Obey )Attend/Reward _^Obey > Attend/Reward Instructions^— s-^5 '-^Disobey ^Warning 5 sec "I f you do n o t . . . " Disobey ^Time Out PLEASE EVALUATE THE TIME-OUT SEQUENCE ON THE FOLLOWING QUESTIONNAIRE. KEEP IN MIND THAT IT WOULD BE USED ONLY IN CONJUNCTION WITH ATTENDS, REWARDS, IGNORING, AND CLEAR INSTRUCTIONS IN ORDER TO INCREASE POSITIVE OR "GOOD" BEHAVIOR AND DECREASE UNDESIRABLE OR "BAD" BEHAVIOR. TEACHING METHOD 9 9 As you have seen, t h i s parent t r a i n i n g program uses a standard method of teaching the parent the new s k i l l s and a standard method of in t roduc ing the new s k i l l s to the c h i l d . In t h i s program, the therap i s t f i r s t expla ins to the parent the ra t iona le fo r the new s k i l l , then demonstrates how i t i s used. The parent then ro le -p lays the new s k i l l with the t h e r a p i s t . We are in terested in your evaluat ion of the manner in which the new s k i l l s are introduced TO THE CHILD BY THE PARENT. P [Remember, without exp la in ing or demonstrating the new technique to the c h i l d , the parent begins to use the technique with the c h i l d in the c l i n i c and at home. This i s done so that the c h i l d can learn n a t u r a l l y how the new s k i l l w i l l be used by experience and by t r i a l and e r r o r . ] PR [Remember, when the parent i s p r o f i c i e n t at the new technique, the parent explains the technique to the c h i l d before using i t with the c h i l d in the c l i n i c and at home. This i s done so that the c h i l d understands the new procedure and learns to change h is or her behavior more qu i ck ly and with l ess "hass le" than learn ing only by experience and t r i a l and e r r o r . ] PRM [Remember, when the parent i s p r o f i c i e n t at the new technique, the parent explains the technique to the c h i l d and then demonstrates i t before using i t with the c h i l d in the c l i n i c and at home. This i s done so that the c h i l d understands the new procedure and learns to change h is or her behavior more qu i ck ly and with l ess "hass le" than learn ing only by experience and t r i a l and e r r o r . By having the parent a lso demonstrate the technique to the c h i l d , the c h i l d can be shown how the new s k i l l w i l l be used. This demonstration re in fo rces what has already been expla ined.] PLEASE EVALUATE THE METHOD OF INTRODUCING THE NEW SKILL TO THE CHILD ON THE FOLLOWING QUESTIONNAIRE. OVERALL PROGRAM 100 Before evaluat ing the parent t r a i n i n g program as a whole, th ink about the en t i re program, i t s r a t i o n a l e , i t s i n d i v i d u a l s k i l l s , and the way in which they are used together. Remember, t h i s program is designed for f a m i l i e s who have an excess ive ly disobedient c h i l d (ages 3 to 8 years) and whose i n te rac t i ons with t h e i r c h i l d have become very negat ive . Consider the program s k i l l s : PART I: improving the i n t e r a c t i o n between parent and c h i l d ; using p o s i t i v e a t tent ion fo r appropriate behavior and withhold ing a t ten t ion fo r inappropr iate behavior; takes care of a large port ion of the c h i l d ' s undesirable behavior . The s k i l l s that are taught are: Attends: prov id ing a running commentary on the c h i l d ' s a c t i v i t y and supplying a p o s i t i v e source of a t t e n t i o n . Rewards: p o s i t i v e a t tent ion for good behavior ( for example, p r a i s e ) . Ignor ing: withdrawal of at tent ion fo r undesirable behavior . PART I I : ways to increase the l i k e l i h o o d the c h i l d w i l l fo l low parenta l d i r e c t i o n s . C lear Ins t ruc t i ons : g iv ing c l e a r , s p e c i f i c i n s t r u c t i o n s ; one at a t ime; p o s i t i v e a t tent ion for obedience. Time-out sequence: g iv ing a time-out procedure fo r f a i l u r e to obey i n s t r u c t i o n s . A l s o , consider the manner and sequence in which the var ious s k i l l s are taught to the parent (explanat ion, demonstration, and ro lep lay) and to the c h i l d P [(experience, t r i a l and e r r o r ) . ] , PR [ ( e x p l a n a t i o n . ] , PRM [(explanat ion and demonstrat ion) . ] . ON THE FINAL QUESTIONNAIRE, EVALUATE THE PARENT TRAINING PROGRAM AS A  WHOLE PROGRAM. 101 Appendix F 102 Analysis of Variance Results of TEI Scores for Mediational Groups  and Techniques Source df MS E E Mediational group 2 2444.669 4.15 .019 Error 37 589.195 Technique 4 6003.681 50.70 .001 Technique x mediational group 3 180.691 1.53 .147 Error 348 118.426 Analysis of Variance Results of TEI Scores for Teaching Method Source df MS F E Mediational group 2 734.533 4.30 .017 Within groups 87 170.682 Analysis of Variance Results of TEI Scores for Overall Program Source df MS F p Mediacional group 2 1204.878 7.12 .001 Within groups 87 169.127 103 Appendix G 104 Newman-Keuls Comparisons of Techniques Dependent Technique Measure TEI Rewards Commands Attends Time out Ignoring Usefulness Commands Rewards Attends Time out Ignoring Difficulty Rewards Commands Attends Time out Ignoring Note. Any two techniques underlined by the same line are not significantly different, whereas any two techniques not underlined by the same line are significantly different. All differences are at the £<.05 level. N-90. > 105 Appendix H 106 Newman-Keuls Comparisons of Mediational Group on Ratings of  Acceptability Mediational teaching method PR P PRM Overall program PR P PRM Note. P=parent training only; PR=parent training plus verbal rationale; PRM=parent training plus verbal rationale and modeling. Any two groups underlined by the same line are not significantly different, whereas any two groups not underlined by the same line are significantly different. All differences are at the p_<.05 level . n=30 per group. 107 Appendix I 108 Analysis of Variance Results of Usefulness Ratings for Mediational  Groups and Techniques Source MS F 2 Mediational group 2 4.460 1.35 .265 Error 87 3.305 Technique 4 12.759 12.59 .001 Technique x mediational group 8 .599 .59 .785 Error 348 1.013 Analysis of Variance Results of Usefulness Ratings for Teaching Method Source df MS E 2 Mediational group 2 .844 .75 .477 Within groups 87 1.130 Analysis of Variance Results of Usefulness Ratings for Overall Program Source df MS F R Mediational group 2 1.600 1.63 .202 Within Groups 37 .981 109 Appendix J Analysis of Variance Results of Difficulty Ratings for Mediational Group and Techniques Source df MS £ 2 Mediational group 2 27.736 3.78 .027 Error 87 7.335 Technique 4 35.759 17.70 .001 Technique x mediational group 8 1.727 .85 .555 Error 348 2.021 Analysis of Variance Results of Difficulty Ratings for Teaching Method Source df MS E £ Mediational group 2 5.733 2.22 .115 Within groups 87 2.585 Analysis of Variance Results of Difficulty Ratings for Overall Program Source df MS E g Mediational group Within groups 2 4.678 87 2.425 1.93 .151 

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