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Evaluation of multiple component relaxation training with developmentally disabled persons
CopyrIght
089 l-4222/ 87 53 “0 + 00 1987 Pergamon .lournalr Ltd
Evaluation of Multiple Component Relaxation Training With Developmentally Disabled Persons Glen 0. Ceist
John E. Calamari Waukegan
Developmental
\%ukegan,
lilinois
Center
lllinois
InMute
of
Technology
Mary J. Shahbazian Budge
Vfew Extended Northfield,
Day School
Illinois
Prior studies evaluating the response of developmentally disabled persons to relaxation training procedures are largely limited to case study reports. Most often relaxation training procedures are vaguely described in these studies, and limited outcome measures are employed. In the present comparative group outcome study a specific progressive muscle relaxation training procedure was combined with auditory electromyographic (EMG) biofeedback, modeling, and reinforcement procedures in an attempt to teach relaxation skills to mentally retarded persons /N = 32) who functioned in the profound to mild range. The procedure was effective in reducing experimental group subjects’ EMG levels, F (1,28) = 6.39, p c .05, and activity level as measured with an interval recording behavior rating procedure, F (1,28) -58.05, p< .05. No effect was found on peripheral skin temperature. Additionally, no srgnificant difference between the response of low functioning and high functioning subjects was seen indicating that intellectual level and adaptive behavior level failed to predict success in treatment. Scoring on a simple behavioral ussessment designed to measure receptive language skills and modeling abilities thought to relate to relaxation training success also failed to correlate with outcome measures. The need to develop other predictors of relaxation training success with a mentally retarded population is discussed.
Reprint requests should be sent to John E. Calamari, Dugdale Circle, Waukegan, IL 60085. 55
PhD, Waukegan
Developmental
Center,
56
J E. Calamvi,
G. 0. Geist, and M. J Shahbazian
A multitude of studies have been conducted evaluating the impact of various relaxation training procedures on a wide range of clinical problems. The utility of adapting relaxation training procedures for use with mentally retarded persons has been discussed by Harvey (1979). To date, only a limited number of studies have been carried out which examine the feasibility of employing relaxation training with mentally retarded persons. Webster and Azrin (1973) evaluated a relaxation like training procedure, required relaxation, with mentally retarded and severely mentally ill persons. The procedure employed in the study involved requiring subjects to put on night clothing and lie in bed for a two hour period following the occurrence of agitated, disruptive behavior. Although the procedure was found effective in reducing disruptive behaviors, no direct measures of relaxation induction were taken. The obvious punitive nature of this type of contingency was acknowledged. Relaxation training procedures more similar to those employed with intellectually unimpaired populations have been evaluated in a number of small N or single subject design studies. Guralnick (1973) reported success in desensitizing a developmentally disabled man who was reported to be acrophobic. Steen and Zuriff (1977) used relaxation training along with a guidance fading technique, tangible reinforcement, and contingent release from restraint to modify the self-injurious behavior of a 21 year-old, profoundly developmentally disabled woman. In a novel application of relaxation training procedures, Wells, Turner, Bellack, and Hersen (1977) reported successfully reducing the frequency of the psychomotor seizures of a 22 year-old female functioning within the borderline intelligence range. In each of these studies improvements in the targeted maladaptive behaviors were noted, but no direct measure of relaxation induction was made, making it unclear as to the role relaxation training played in producing observed behavior change. A direct measure of relaxation induction was included in a study conducted by Schroeder, Peterson, Solomon, and Artley (1977). Two severely developmentally disabled adolescent males who chronically head-banged served as subjects for the experiment. A combination of EMG biofeedback and edible and verbal reinforcement produced maximum reductions in selfinjurious behavior and mean EMG amplitude. In a similar study Hughes and Davis (1980) reported success in reducing the aggressive behavior of a 27 year-old developmentally disabled individual using a combination of auditory EMG biofeedback and positive reinforcement. Mean EMG levels were reduced as well as the frequency of aggressive behavior. Two group statistic design studies, evaluating at least indirectly the effectiveness of relaxation training with developmentally disabled persons, have been conducted. Peck (1977) examined the effectiveness of a number of systematic desensitization variations on the avoidance behavior of a sample
Multiple Component Relaxation Training
57
of mildly developmentally disabled individuals. The relaxation training was effective in reducing targeted avoidance behavior, but because the study was designed to compare desensitization procedures, an avoidance behavior measure was the only dependent variable included in the experiment. The author indicated that Bernstein and Borkovec’s (1973) progressive muscle relaxation training procedure was used as the relaxation induction method. A more direct evaluation of the effects of relaxation training with developmentally disabled persons was completed by Frankenberger (1979). Although the primary goal of the investigation was to evaluate the impact of relaxation training procedures on aggressive behavior, the relaxation producing effects of the treatment approaches were also assessed by comparing resultant EMG levels. Frankenberger found that aggressive, developmentally disabled subjects who received relaxation training were able to reduce EMG levels below baseline. No improvement was found when EMG biofeedback was added to the treatment procedure following the modified progressive muscle relaxation training. A differential effect across intelligence levels was reported in Frankenberger’s (1979) study. Subjects ranging from the severe through the low-mild retardation ranges were included in the experiment. Subjects with higher IQs were able to reduce EMG levels further below baseline measures than subjects with lower IQs. Frankenberger’s (1979) investigation included elements missing in previously reviewed studies. A clear description of the simplified progressive muscle relaxation training procedure and the EMG biofeedback procedure used in the study were provided. In Frankenberger’s study a direct measure of relaxation training effectiveness was made, and an examination of the relationship between success in training and subject’s functioning level completed. But certain aspects of Frankenberger’s design limit the study’s utility as a general evaluation of the effectiveness of relaxation training procedures with a developmentally disabled population. Because Frankenberger was primarily concerned with the effects of relaxation training on aggressive behavior, only subjects displaying aggressive behavior were included in the relaxation training phase of the study. Additionally, only a single direct measure of relaxation induction, EMG levels, was used. Investigators have recommended that multiple direct measures of relaxation induction success be made (cf. Luiselli, Marholin, Steinman, & Steinman, 1979; Hillenberg & Collins, 1982). In the present study a specific progressive muscle relaxation training procedure was combined with auditory electromyographic biofeedback, modeling, and reinforcement procedures in an attempt to teach relaxation skills. Developmentally disabled subjects from a wide range of functioning levels were included in the study making possible determination of the relationships between functioning level and response to the relaxation training
58
J. E. Calaw7ari, G. 0. Geist, and M. J Shahbazian
procedure being evaluated. Additionally, the completion of a simple behavioral assessment, intended to measure skills thought directly relevant to relaxation training, was carried out to determine if performance on this simple assessment would more effectively predict response to treatment than standard intelligence and adaptive behavior measures. METHOD
Subjects’ Thirty-two developmentally disabled adults who resided at a state residential treatment facility were selected for participation in the study. Individuals were selected following a discussion with their habilitation team structured to determine whether or not potential subjects would cooperatively participate in seven experimental sessions lasting almost one hour each. During the course of the experiment it was necessary to discontinue the participation of only one subject. This profoundly developmentally disabled individual appeared to find the connecting of physiological monitoring equipment and sitting in the reclining chair used in the study fear arousing. For purposes of the experiment, subjects were classified as high functioning or low functioning on the basis of both measured intelligence and adaptive behavior levels. Intellectual functioning was determined from scores on individually administered intelligence tests. Adaptive behavior levels were assigned using scores obtained from administration of the Fairview SelfHelp Scale (Ross, 1970), an adaptive behavior score available for all residents of the treatment facility. Subjects classified as high functioning had a mean IQ of 49.44 (range 31 to 70) and a mean Behavioral Quotent of 63.44 (range 36 to 97). The low functioning group’s mean IQ was 19.63 (range 10 to 38) and mean Behavioral Quotient 44.81 (range 32 to 68).
Instrumentation Physiological measures. Electromyographic recordings were obtained using a Myosome 404 EMG Monitor (Bio-Logic Devices, Plainview, New York). A standard frontalis muscle surface electrode placement was used. The Myo-
1 For each subject, informed consent was obtained from the subject himself, or from his or her legal guardian in cases where an individual had been adjudicated incompetent. In addition to obtaining consent for the participation of each subject, the experiment was reviewed by the residential facility’s Human Rights and Behavior Management Committees following the granting of administrative approval. The project was also reviewed by the Institutional Review Board of the Illinois Institute of Technology.
59
Multiple Component Relaxation Training
some 404 EMG Monitor provided analogue auditory feedback during the appropriate treatment conditions. Peripheral skin temperature was measured from a thermistor probe tape to the right index finger of the subject’s hand. Subjects were asked to keep this hand stationary during recording periods. A GSR 508 Monitor (Bio-Logic Devices, Plainview, New York), a device capable of assessing skin conductance or peripheral skin temperature, was used as the recording instrument. Both the Myosome 404 EMG Monitor and the GSR 508 Monitor have been designed to interface with permanent product recording devices. A two channel strip-chart recording unit (MFE Corporation) was used to provide a permanent record of the subject’s performance throughout the experiment. The strip-chart records were quantified by taking readings of both EMG and peripheral skin temperature levels at five second intervals. Relaxation behavior outcome assessment. Because self-report relaxation measures (e.g. Spielberger, Gorsuch, & Lushene, 1970, State-Trait Anxiety Inventory; and Derogatis, Lipman, & Covi, 1973, SCL-90) were judged to be unusable with the severely intellectually impaired individuals who participated in the experiment, a behaviorally anchored interval recording scale was developed for us in the study. The assessment instrument, the Relaxation Training Rating Scale,‘was designed to measure specific components of the relaxation behaviors being taught to subjects. A similar approach for quantifying relaxation behavior had previously been employed by Marhoin, Steinman, Luiselli, Schwartz and Townsend (1979) to measure the effectiveness of a relaxation training procedure used with a group of autistic adolescents. The Relaxation Training Rating Scale required raters to assess the presence of arm, leg or other body movement and whether or not the subjects remained quiet and seated in a reclining chair as instructed. Subject’s behavior during five minute pre and posttreatment measurement periods was video taped. Three raters blind to experimental conditions evaluated video tapes using the Relaxation Training Rating Scale. A 10 second interval recording procedure was used to quantify video tapes. All video tape raters participated in a structured training procedure involving the use of prepared training tapes until an 85% accuracy level was achieved. Rater accuracy levels were re-evaluated at the end of each scoring session. Relaxation skills evaluation.3 Each subject was assessed using a simple behavioral evaluation developed for use in the study. The evaluation was de-
‘Copies author.
of the Relaxation
Training
Rating
‘Copies of the Relaxation Skills Evaluation
Scale can be obtained can be obtained
upon
request
from the first
upon request from the first author.
60
J. E. Calcrrnuri,
G. 0. Geist, and M. J. Shahbaziun
signed to test skills thought to be relevant to success in relaxation training. The assessment procedure was similar to a strategy recommended by Cautela and Groden (1978, p. 41). Subjects were asked to sit in a chair, to follow a series of simple verbal commands where the appropriate response was modeled, and to follow simple commands where only verbal prompts were provided. Each evaluation item was graded on a pass-fail basis with specific behavioral criteria being provided to the evaluators for each of the items of the assessment. The assessment was administered following completion of the sixth and seventh training sessions by the two individuals who functioned as relaxation training instructors during the study. Procedure. Subject’s treatment programs, general education and vocational training, and behavioral medications were held constant throughout the experiment. Once consent had been obtained for a subject’s participation, a determination of the individual’s functioning level was made. Subjects within the same functioning level were paired dependent upon their availability for participation in the study. A flip of a coin was used to assign one subject of each pair to the treatment or control group with the other subject simply being assigned to the other group. The sequence of subject participation was structured so that for each eight consecutive participants, all treatment conditions and functioning levels were represented. This procedure was carried out to prevent the confounding of any improvement, or decrease, in the relaxation training instructor’s skill with treatment condition or functioning level variables. All sessions were conducted by one or two instructors. Each session was begun with the presentation of a standardized rationale to the subject. Experimental subjects were told that cooperation with the relaxation training procedure would help them feel more relaxed, a feeling most people indicate is enjoyable. Control subjects were presented an identical rationale with the exception that they were told that listening to music would help them feel more relaxed. Each subject was then connected to the physiological monitoring and biofeedback equipment. Successful connection of the equipment was followed by a 10 minute adaptation period for all subjects. Following the adaptation period a five minute pretreatment measurement period was begun. During this period subject EMG and peripheral skin temperature measures were recorded and subject behavior video taped. Following this period subjects experienced either 20 minutes of relaxation training or the control procedure. The relaxation training procedure involved the presentation of a specified sample of six of the tensing and relaxing exercises described by Cautela and Groden (1978, pp. 24-29). The exercises presented were for muscle groups in the forehead area, eye area, nose area, arms, legs, and back. Initially presented face and forehead exercises were most likely to produce a significant
Multiple Component Relaxation Training
61
tension-relaxation contrast in the frontalis muscle. Because the analogue feedback mode of the Myosome EMG Trainer was activated throughout each relaxation training session for experimental subjects, these subjects experienced differential auditory feedback on the status of frontalis muscle contractions. It was hoped that this differential feedback would be helpful in teaching subjects to discriminate between tension and relaxation. Each of the relaxation-tension cycles was repeated twice for each muscle group. Each of the tensing and relaxation exercises was modeled by the relaxation training instructor who was present in the training room with the subject, sitting in a similar reclining chair. During the tension phase the trainer reminded the subjects of at least one of the following points: 1) that the tension he/she experienced in the particular muscle group was not relaxation; or 2) that the high levels of the clicking sound provided by the EMG feedback apparatus indicated that he/ she was not relaxed. The tensing of each muscle group was followed by a prompt to the subjects to relax. The relaxation phase of each cycle lasted a minimum of 10 seconds. During the relaxation phase the instructor, in a soft tone, reminded the subjects of at least one of the following points: 1) that he/she was now doing a better job relaxing the muscle group or that he/she appeared very relaxed; 2) that the low rate or absence of clicking from the EMG feedback apparatus indicated a relaxed state; 3) the lack of tension in previously relaxed muscle groups; 4) to breath slowly and deeply; or 5) that he/she was now relaxing well enough to earn a reward. Subjects were verbally praised and told that they had earned a tangible reward when their EMG level remained below a specified level. The Myosome 404 EMG Monitor is equipped with an adjustable threshold setting switch and a light display which is activated as long as the subject’s EMG level remains below a threshold value. The pretreatment EMG level of the first session was used as the basis for determining the initial setting of the threshold switch, and an attempt was made to reduce the setting across training sessions for each subject. The EMG monitor was positioned so only the instructor was able to see the light display which served as a cue to the instructor that reinforcement could be provided for the subject. Control subjects’ experiences were identical to those of experimental subjects except that during the 20 minute control procedure they sat in a reclining chair listening to melodic classical music. As mentioned above, control subjects were presented a rationale intended to create expectations of improved relaxation as a result of listening to music. Each control subject was provided verbal praise or a tangible reward, based on a reinforcement schedule yoked to the performance of the previous experimental subject. For example, if the previous experimental subject received reinforcement during the seven to eight minute interval, the following
62
J. E. Calamari, G. 0. Geist, and M. J. Shahbazian
control subject received reinforcement during this interval also. Each control subject remained yoked to the same experimental subject throughout the seven sessions of the study. Following the 20 minute treatment or control procedure, subjects were asked to remain seated in the chair and remain as relaxed as they could. A five minute posttreatment recording period was conducted with both physiological measures being taken and the period video taped for behavior rating purposes. Treatment condition subjects continued to receive auditory feedback on muscle contraction levels during this phase. Each subject experienced six relaxation training or six control procedure sessions. These six sessions were conducted over a period of time no greater than nine days with only a single session conducted each day. A four day delay occurred between the completion of the last training session and a follow-up evaluation session. During the follow-up session subjects experienced the 10 minute adaptation period and the five minute pretreatment measurement period. Both control and treatment subjects were then prompted to relax for the next 20 minutes vghile a melodic classical music recording was played. A posttreatment recording period followed. All sessions were conducted in a 9.75 foot by 7.67 foot room.
RESULTS In order to determine whether subjects initially differed on any of the thre measures used as dependent variables in the study, session 1 pretreatment levels on each of the three dependent measures were examined. Completion of three, two-way independent groups analyses of variance revealed no initial significant differences between treatment or control groups or between high and low functioning individuals. Evaluation of the main hypotheses of the study resulted in examination of differences between control and experimental subjects in their response to the relaxation training procedure, examination of differences in the response of high and low functioning subjects to this treatment, and determination of the occurrence of any across sessions change in the subjects’ responses. These issues were evaluated by completing three, 2 x 2 x 7, split-plot analysis of variance tests on pretest to postest difference scores. Although problems have been identified in using difference scores as a unit of analysis (e.g., Cohen & Cohen, 1975) these scores were used in the present study in an attempt to partially control for intrasubject pretreatment dependent measure variability across sessions (pretreatment measures were taken at the beginning of each session as previously described). A significant difference, F (1,28) = 6.39, p< .05, was found between treatment and control groups when EMG differences scores (pretest minus posttest) were evaluated. No other significant main effects or interactions
Multiple Component Relaxation Training
63
were present. Treatment and control group EMG difference scores (in microvolts) are shown across sessions in Figure 1. Because the Relaxation Training Rating Scale was developed for use in the present study, a number of the psychometric qualities of the scale were assessed. Interobserver agreement was evaluated by determining overall percentage agreement, percentage agreement for occurrence, and percentage agreement non-occurrence as described by Kelly (1977). Mean overall percentage agreement was determined to be 92.84%, standard deviation 3.97, percentage agreement for occurrence was 64.32070, standard deviation 25.08, and for non-occurrence 90.40, standard deviation 5.88. The percentage of observation intervals in which either rater indicated that targeted behaviors occurred was 22.65. Because a wide range of interobserver agreement estimates resulted when occurrence, nonoccurrence, and overall agreement procedures were compared, interobserver data was further evaluated as recommended by Birkimer and Brown (1979). A mean disagreement rate (lOO-overall mean percentage agreement) of 7.16% was calculated for the 52 interobserver agreement measures. According to Birkimer and Brown (1979) this obtained
2 5 e .I! E,
15.00
-
10.00
-
f_:.’
Treatment Group
p
Control Group
a-0
- -_1
;
:
%
- 15.00 1
2
3
4
5
6
Follow-Up
Sessions
FIGURE 1. Mean differences (pretreatment minus posttreatment lustrated for treatment and control subjects.
score) in EMG levels are il-
64
J. E. Calarnari, G. 0. Geist, und M. J. Shahbazian
percentage agreement level would occur by chance less than one time in a hundred. In addition to examining interval-by-interval interobserver agreement, the correlation between total scores was examined. A Pearson product-moment correlation of .956 was obtained, indicating a high level of interrate reliability when total scores are evaluated. Before analysis of scores on the Relaxation Training Rating Scale could be completed, four difference scores had to be estimated as a result of equipment problems. Kirk’s (1968) formula was extended for this purpose for the three-way analysis employed in the present study. Analysis of the Relaxation Training Rating Scale difference scores (pretest minus posttest) revealed two significant main effects. A significant difference was found between treatment and control groups, F (1,28) = 58.05, pc.05 with treatment group subjects relaxing better than control group subjects. Additionally, a significant main effect for sessions was found, F (6,164) = 3.00, p< .05, indicating that an overall difference for the combined scoring of groups across sessions was present. The failure to find significant interactions between treatment and sessions or between functioning level and sessions indicates performance changed at the same rate across sessions independent of treatment or functioning level. These results are illustrated in Figure 2. Follow-up evaluations using Tukey’s (1953) procedure were conducted to determine if pairwise across session difference existed. No significant differences were found when the most disparate session means (sessions seven and six) were compared: 4 (6,164)= 3.61, p> .05. Examination of peripheral skin temperature difference scores (session posttest scores minus pretest scores) revealed no significant main effects or interactions. Means and standard deviations for each of the dependent measures are shown in Table 1. The relationship between scoring on the Relaxation Training Skills Assessment and experimental subjects response to treatment was evaluated next. Pearson product-moment correlations between subject’s Relaxation Training Skills Assessment score and the mean pretest to postest difference scores (sessions one through six) for each of the three dependent measures were computed. These correlation coefficients are shown in Table 2 along with the intercorrelations between IQ scores and adaptive behavior level. As can be seen, the correlation between scoring on the Relaxation Training Skills Assessment and each of the dependent variables was low indicating that this assessment instrument was not a good predictor of success in treatment. The failure to find a relationship between scoring on the Relaxation Training Skills Assessment and dependent variables did not result because this test was unreliable. The instrument’s reliability was evaluated by computing interobserver agreement levels and test-retest intercorrelations. Interobserver agreement (the Pearson product-moment correlation between
Mdtiple
Component Treatment
High
30.00
-
20.00
-
10.00
-
0.00
-
Functioning:
Control
0 -m
65
Training
Group
---
Functioning:
m-m
Low
Relaxation
Group
0
-
e i u 5 0 2 ” CT 2 ‘Z
P
s
c
z B -1000
-
5
-20.00
-
FIGURE
2. Mean differences
(pretreatment
minus posttreatement)
in relaxation rating scores
are shown. the two evaluators’ scoring of a subject’s behavior) was .958. The test-retest correlation was computed by averaging the two test-retest correlations obtained from the two experimenters (each experimenter completed the evaluation for each subject at the end of sessions six and seven). The resultant Pearson product-moment correlation was .788. Thus, although interobserver agreement reliability was found to be high with this assessment instrument and subject scoring on the evaluation was determined to be fairly stable, scores were of no utility in predicting subject’s response to the relaxation training procedure. The failure to find a relationship between scoring on the Relaxation Training Skills Assessment and any of the dependent measures may have resulted from the limited variability in subject’s scoring on this instrument (Mean, 9.24; Standard Deviation, 1.29). Although none of the intercorrelations in Table 2 were found to be statistically significant, further examination revealed a relatively high positive correlation between two of the dependent measures, EMG and scoring on the Relaxation Training Rating Scale. Examination of the intercorrelation between mean difference scores through session six for both experimental and control subjects resulted in a Pearson product-moment correlation of
J. E. Calamuri,
66
G. 0. Geist, and M. .I Shahbazian
‘TABLE 1. Mean Difference
Scores for Dependent
EMG (.klicrovolts) Treurtnenr Group High Functioning L.ovv Functioning
Sessions 1 1.49 8.68 - 0.25 6.30
2 3.26 5.15 4.53 6.54
3 0.30 1.94 4.37 11.88
4 - 1.32 11.05 0.49 8.74
3.47 13.37 8.76 17.67
6 0.71 7.50 7.80 12.95
-2.51 15.50 ~ 2.51 21.73
1.02 8.31 -0.14 2.19
- 3.13 6.58 - 6.30 10.86
- 2.75 10.97 0.51 3.04
3.48 8.45 3.12 10.90
- 2.22 5.03 ~ 1.92 9.57
2.37 5.22 ~ 2.56 6.54
~ 6.58 12.65 -3.27 10.38
4.44 17.29 12.61 14.94
8.93 22.31 7.75 26.58
19.00 24.28 6.63 28.18
11.95 24.19 8.11 18.71
9.30 17.87 12.86 17.85
10.47 14.67 21.87 19.62
-0.36 18.26 -3.21 29.55
- 8.45 12.59 0.24 10.98
-8.00 13.43 -2.50 12.69
-4.67 1.65 4.66 16.90
- 3.72 11.46 - 1.13 9.64
-4.93 13.83 -2.41 24.48
~ 9.92 15.98 8.90 16.03
-7.94 14.62 -6.10 14.04
SD M SD
7.03 13.91 - 8.78 24.53
~ 4.08 12.95 - 0.07 19.31
14.28 19.29 3.32 18.30
-2.17 6.29 ~ 10.92 11.59
-7.51 3.40 - 8.66 17.82
- 7.22 9.61 2.59 10.54
- 8.46 10.80 ~ 0.22 12.42
M SD M SD
-4.10 10.66 -5.33 9.24
- 7.41 9.42 2.86 13.80
2.37 15.68 3.01 17.86
~ 12.80 17.60 - 0.57 22.62
-5.99 14.04 ~ 4.58 11.30
-0.33 11.23 -5.59 11.53
-3.35 18.91 -5.78 10.77
,M SD M
SD Control Group High Functioning L.ow Functioning
M SD
M SD
Rehxution Rulings Treatment Group High Functioning Low Functioning
Conrrol Group High Functioning Low Functioning
Skin Tetnperuture Treatment Group High Functioning Low Functioning
Conrrol Group High Functioning Lo\v Functioning
Measures
‘$4
SD M SD
M
SD M SD
M
5
I
.45. With the increased N (32) resulting from the addition of control group subjects, this correlation was found to be significant (p < .05). Finally, the relative effectiveness of the two relaxation training instructors was compared. Separate two-way independent group analysis of variance tests were completed for each of the three dependent measures. Mean difference scores through session six were included in the analysis. A two-way analysis, collapsing data across the functioning level factor, was chosen because the second instructor was available to teach only one low functioning treatment group subject, thereby making the obtaining of an error vari-
Mulliple
Component
Relaxation
67
Paining
ante estimate for this factor impossible. No differences on any of the dependent measures were found in subjects’ response to the two instructors.
DISCUSSION In the present study progressive muscle relaxation training, auditory EMG biofeedback, modeling, and positive reinforcement procedures were combined as a single relaxation training procedure. This combination of relaxation induction techniques was found effective in relaxing developmentally disabled persons as operationalized both physiologically and behaviorally. The response of the subjects was not dependent on assessed intellectual or adaptive behavior levels. The study was designed to increase understanding of the effects of relaxation training on the behavior of developmentally disabled persons. The group design employed and the structuring of direct measures of relaxation induction made it possible to determine that the specific relaxation training procedure used in the experiment could effectively function to teach a broad sample of institutionalized developmentally disabled persons how to relax. In the experiment, a relaxation induction procedure which simultaneously combined progressive muscle relaxation training and EMG biofeedback was evaluated. In Frankenberger’s (1979) previous investigations progressive muscle relaxation training had been carried out initially and biofeedback procedures introduced after training in progressive muscle relaxation. The reported failure to find any increased relaxation induction with the addition of EMG biofeedback techniques may have resulted from the sequential presentation procedure chosen in the study. It should be pointed out through, that the design of the present investigation does not make it possible to determine whether the progressive muscle relaxation training, the EMG biofeedback procedure, the modeling of relaxation behavior, the rein-
TABLE 2. Pearson Product-Moment Correlations Between Two Independent and Four Dependent Measures for Experimental Subjects ABL
IQ ABL RTSA TEMP EMG RTRS
1.00 0.16 0.37 0.06 -0.11 - 0.08
0.16 1.oo 0.34 0.14 -0.40 ~ 0.46
RTSA 0.37 0.34
I .oo 0.24 -0.10 - 0.04
TEMP
EMG
RTRS
0.06 0.14 0.24 1.00 - 0.44 - 0.36
-0.11 - 0.40 -0.10 - 0.44 1.oo 0.48
PO.08 PO.46 -0.04 - 0.36 0.48 1.00
Adaptive Behavior Level (ABL) Relaxation Training Skills Assessment (RTSA) Relaxation Training Rating Scale (RTRS)
68
J. E. Calamuri, G. 0. GeisI, and M. J. Shahbazian
forcement procedure, or whether a combination of these techniques was responsible for the observed changes in outcome measures. The lack of observed differences in the response of individuals from different functioning levels to the relaxation training procedure employed in this experiment is contrary to Frankenberger’s (1979) findings. This discrepancy may be explained by the differences in the populations sampled, or by dissimilarity in relaxation training procedures used. It is possible that the addition of auditory EMG biofeedback in the current study was helpful in making the concepts of relaxation and tension more understandable for lower functioning persons, thus diminishing differences between groups. In the present experiment some subjects functioning within even the profound range were found to respond to treatment. What factors then do predict response to treatment? Scores on the Relaxation Training Skills Assessment, an instrument designed to measure subjects’ receptive language, modeling and compliance skills, failed to correlate with any of the outcome measures used in the investigation. Borkovec and Sides (1979) have suggested that clients’ clinical needs (i.e., the presence of a disorder likely to be impacted by relaxation training) are positively correlated with changes in physiological outcome measures in relaxation training studies. Scoring on an assessment designed to measure clinical pathologies such as general anxiety level could identify individuals in need of relaxation training who would also be more likely to show significant changes in outcome measures. But as has been previously discussed, most of the assessment instruments currently available for measuring such constructs as anxiety have largely been designed for use with general psychiatric populations and require that subjects possess substantial language skills, thus limiting their utility with developmentally disabled persons. The failure to obtain changes in peripheral skin temperature measures may have resulted from a number of methodological features of the study: short duration measurement periods, use of a measurement instrument which produced only a change score, and the absence of feedback and reinforcement made contingent on this response. It should be noted, also, that when multiple physiological measures are employed in a single study, it is not unusual for these measures to fail to correlate well (cf. Borkovec and Sides, 1979). The results of this investigation call into question the sometimes held assumption that developmentally disabled persons are not good candidates for psychological treatments involving techniques other than simple behavior management procedures. More complex behavior therapy techniques, as well as nonbehavioral psychotherapies, may prove adaptable for use with this population. Reiss, Levitan, and McNally (1982) have previously discussed the need to make available a broader range of clinical treatment procedures for developmentally disabled persons.
Multiple
Component
Relaxation
Training
69
Acknowledgement -This study was submitted by the first author to the Graduate School of the Illinois Institute of Technology, Department of Psychology, in partial fulfillment of the requirement for a PhD degree. 1 thank Donald Cardy and Daniel Giffort for their critical review of earlier drafts of this manuszript.
REFERENCES Bernstein, D. A., & Borkovec, T. D. (1973). Progressive relaxation: A manuul for therapisi. Champaign, IL: Research Press. Birkimer, J. C., & Brown, J. H. (1979). Back to basics: Percentage agreement measures are adequate, but there are easier ways. Journal of Applied Behavior Analysis, 12, 535-543. Borkovec, T. D., & Sides, J. K. (1979). Critical procedural variables related to the physiological effects of progressive relaxation: A review. Behaviour Research und Therapy, 17, 119-125. Cautela, J. R., & Groden, J. (1978). Relaxaiion: A comprehensive manualfor adults, children, und children with special needs. Champaign, IL: Research Press. Cohen, J. & Cohen, P. (1975). Applied muliiple regression/correlation analysis for the behaviorul sciences. New York: Wiley. Derogatis, L. R., Lipman, R. S., & Covi, L. (1973). SCL-90: An outpatient psychiatric rating scale- preliminary report. Psychopharmacological Bulletin, 9, 13-27. Frankenberger, W. R. (1979). Effects of progressive muscle relaxation and electromyographic feedback training or aggressive institutionalized mentally retarded adults. Dissertation Abstracts Infernational, 40, 3342-B. (University Microfilms No. 8001729). Guralnick, N. H. (1973). Behavior therapy with an acrophobic mentally retarded young adult. Journal of Behavior Therapy and Experimental Psychiatry, 4, 263-265. Harvjey, J. R. (1979). The potential of relaxation training for the mentally retarded. Mental Rerurdation, 17, 7 l-76. Hillenberg, J. B., & Collins, F. L. (1982). A procedural analysis and review of relaxation training research. Behaviour Research und Therapy, 20, 251-260. Hughes, H., & Davis, R. (1980). Treatment of aggressive behavior: The effect of EMG response discrimination biofeedback training. Journal ofAutism and Deve/opmen/a/ Disorders, IO, 193-202. Kelly, M. B. (1977). A review of observational data collection and reliability procedures reported in the Journal of Applied Behavior Analysis. Journal ofApplied Behuwior Analysis, 10, 97-101. Kirk, R. E. (1968). Experimentul design: Procedures for the Behavioral Sciences. Belmont, CA: Wadsworth. Luiselli, J. K., Marholin, D., Steinman, D. L., & Steinman, W. M. (1979). Assessing the effects of relaxation training. Behavior Therapy, 10, 663-668. Marholin, D., Steinman, W. M., Luiselli, J. K., Scwartz, C. S., & Townsend, N. M. (1979). The effects of progressive muscle relaxation on the behavior of autistic adolescents: A preliminary analysis. Child Behavior Therapy 1, 75-84. Peck, C. L. (1977). Desensitization for the treatment of fear in the high level adult retardate, Behariour Research and Therupy, 15, 137-148. Reiss, S., Levitan, G. W., & McNally, R. J. (1982). Emotionally disturbed mentally retarded People, an underserved population. American Psychologist, 37, 361-367. ROSS, R. T. (1970). Manual for the Fairview Self-Help Scale. Sacramento, CA: California Office of State Printing. Schroeder, S. R., Peterson, C. R., Solomon, L. J., & Artley, J. J. (1977). EMG feedback and the contingent restraint of self-injurious behavior among the severely retarded: Two case illustrations. Behavior Therapy, 1977, 8, 738-741.
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Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970). Mrmual for the State-Tnit Anxiely Inventory (STAIT). Palo Alto, CA: Consulting Psychologtists Press. Steen, P. L., & Zuriff, G. E. (1977). The use of relaxation in the treatment of self-injurious behavior. Journal qf Behuvior Therap.v und Experimental Psychratry, 8, 447-448. Tukey, .I. W. (1953). The problem of multiple comparisons. Biometrics, 5, 81-199. Webster, D. R., & Azrin, N. H. (1973). Required relaxation: A method of inhibiting agitativedisruptive behavior of retardates. Behuvior Research md Therapy, II, 67-78. Wells, K. C., Turner, S. M., Bellack, A. S., & Hersen, M. (1977). Effects of cue-controlled relaxation on psychomotor scizurcs: An expel-imcntal analysis. Behmiour Re.trarch and Therupv, 16, 51-53.
089 l-4222/ 87 53 “0 + 00 1987 Pergamon .lournalr Ltd
Evaluation of Multiple Component Relaxation Training With Developmentally Disabled Persons Glen 0. Ceist
John E. Calamari Waukegan
Developmental
\%ukegan,
lilinois
Center
lllinois
InMute
of
Technology
Mary J. Shahbazian Budge
Vfew Extended Northfield,
Day School
Illinois
Prior studies evaluating the response of developmentally disabled persons to relaxation training procedures are largely limited to case study reports. Most often relaxation training procedures are vaguely described in these studies, and limited outcome measures are employed. In the present comparative group outcome study a specific progressive muscle relaxation training procedure was combined with auditory electromyographic (EMG) biofeedback, modeling, and reinforcement procedures in an attempt to teach relaxation skills to mentally retarded persons /N = 32) who functioned in the profound to mild range. The procedure was effective in reducing experimental group subjects’ EMG levels, F (1,28) = 6.39, p c .05, and activity level as measured with an interval recording behavior rating procedure, F (1,28) -58.05, p< .05. No effect was found on peripheral skin temperature. Additionally, no srgnificant difference between the response of low functioning and high functioning subjects was seen indicating that intellectual level and adaptive behavior level failed to predict success in treatment. Scoring on a simple behavioral ussessment designed to measure receptive language skills and modeling abilities thought to relate to relaxation training success also failed to correlate with outcome measures. The need to develop other predictors of relaxation training success with a mentally retarded population is discussed.
Reprint requests should be sent to John E. Calamari, Dugdale Circle, Waukegan, IL 60085. 55
PhD, Waukegan
Developmental
Center,
56
J E. Calamvi,
G. 0. Geist, and M. J Shahbazian
A multitude of studies have been conducted evaluating the impact of various relaxation training procedures on a wide range of clinical problems. The utility of adapting relaxation training procedures for use with mentally retarded persons has been discussed by Harvey (1979). To date, only a limited number of studies have been carried out which examine the feasibility of employing relaxation training with mentally retarded persons. Webster and Azrin (1973) evaluated a relaxation like training procedure, required relaxation, with mentally retarded and severely mentally ill persons. The procedure employed in the study involved requiring subjects to put on night clothing and lie in bed for a two hour period following the occurrence of agitated, disruptive behavior. Although the procedure was found effective in reducing disruptive behaviors, no direct measures of relaxation induction were taken. The obvious punitive nature of this type of contingency was acknowledged. Relaxation training procedures more similar to those employed with intellectually unimpaired populations have been evaluated in a number of small N or single subject design studies. Guralnick (1973) reported success in desensitizing a developmentally disabled man who was reported to be acrophobic. Steen and Zuriff (1977) used relaxation training along with a guidance fading technique, tangible reinforcement, and contingent release from restraint to modify the self-injurious behavior of a 21 year-old, profoundly developmentally disabled woman. In a novel application of relaxation training procedures, Wells, Turner, Bellack, and Hersen (1977) reported successfully reducing the frequency of the psychomotor seizures of a 22 year-old female functioning within the borderline intelligence range. In each of these studies improvements in the targeted maladaptive behaviors were noted, but no direct measure of relaxation induction was made, making it unclear as to the role relaxation training played in producing observed behavior change. A direct measure of relaxation induction was included in a study conducted by Schroeder, Peterson, Solomon, and Artley (1977). Two severely developmentally disabled adolescent males who chronically head-banged served as subjects for the experiment. A combination of EMG biofeedback and edible and verbal reinforcement produced maximum reductions in selfinjurious behavior and mean EMG amplitude. In a similar study Hughes and Davis (1980) reported success in reducing the aggressive behavior of a 27 year-old developmentally disabled individual using a combination of auditory EMG biofeedback and positive reinforcement. Mean EMG levels were reduced as well as the frequency of aggressive behavior. Two group statistic design studies, evaluating at least indirectly the effectiveness of relaxation training with developmentally disabled persons, have been conducted. Peck (1977) examined the effectiveness of a number of systematic desensitization variations on the avoidance behavior of a sample
Multiple Component Relaxation Training
57
of mildly developmentally disabled individuals. The relaxation training was effective in reducing targeted avoidance behavior, but because the study was designed to compare desensitization procedures, an avoidance behavior measure was the only dependent variable included in the experiment. The author indicated that Bernstein and Borkovec’s (1973) progressive muscle relaxation training procedure was used as the relaxation induction method. A more direct evaluation of the effects of relaxation training with developmentally disabled persons was completed by Frankenberger (1979). Although the primary goal of the investigation was to evaluate the impact of relaxation training procedures on aggressive behavior, the relaxation producing effects of the treatment approaches were also assessed by comparing resultant EMG levels. Frankenberger found that aggressive, developmentally disabled subjects who received relaxation training were able to reduce EMG levels below baseline. No improvement was found when EMG biofeedback was added to the treatment procedure following the modified progressive muscle relaxation training. A differential effect across intelligence levels was reported in Frankenberger’s (1979) study. Subjects ranging from the severe through the low-mild retardation ranges were included in the experiment. Subjects with higher IQs were able to reduce EMG levels further below baseline measures than subjects with lower IQs. Frankenberger’s (1979) investigation included elements missing in previously reviewed studies. A clear description of the simplified progressive muscle relaxation training procedure and the EMG biofeedback procedure used in the study were provided. In Frankenberger’s study a direct measure of relaxation training effectiveness was made, and an examination of the relationship between success in training and subject’s functioning level completed. But certain aspects of Frankenberger’s design limit the study’s utility as a general evaluation of the effectiveness of relaxation training procedures with a developmentally disabled population. Because Frankenberger was primarily concerned with the effects of relaxation training on aggressive behavior, only subjects displaying aggressive behavior were included in the relaxation training phase of the study. Additionally, only a single direct measure of relaxation induction, EMG levels, was used. Investigators have recommended that multiple direct measures of relaxation induction success be made (cf. Luiselli, Marholin, Steinman, & Steinman, 1979; Hillenberg & Collins, 1982). In the present study a specific progressive muscle relaxation training procedure was combined with auditory electromyographic biofeedback, modeling, and reinforcement procedures in an attempt to teach relaxation skills. Developmentally disabled subjects from a wide range of functioning levels were included in the study making possible determination of the relationships between functioning level and response to the relaxation training
58
J. E. Calaw7ari, G. 0. Geist, and M. J Shahbazian
procedure being evaluated. Additionally, the completion of a simple behavioral assessment, intended to measure skills thought directly relevant to relaxation training, was carried out to determine if performance on this simple assessment would more effectively predict response to treatment than standard intelligence and adaptive behavior measures. METHOD
Subjects’ Thirty-two developmentally disabled adults who resided at a state residential treatment facility were selected for participation in the study. Individuals were selected following a discussion with their habilitation team structured to determine whether or not potential subjects would cooperatively participate in seven experimental sessions lasting almost one hour each. During the course of the experiment it was necessary to discontinue the participation of only one subject. This profoundly developmentally disabled individual appeared to find the connecting of physiological monitoring equipment and sitting in the reclining chair used in the study fear arousing. For purposes of the experiment, subjects were classified as high functioning or low functioning on the basis of both measured intelligence and adaptive behavior levels. Intellectual functioning was determined from scores on individually administered intelligence tests. Adaptive behavior levels were assigned using scores obtained from administration of the Fairview SelfHelp Scale (Ross, 1970), an adaptive behavior score available for all residents of the treatment facility. Subjects classified as high functioning had a mean IQ of 49.44 (range 31 to 70) and a mean Behavioral Quotent of 63.44 (range 36 to 97). The low functioning group’s mean IQ was 19.63 (range 10 to 38) and mean Behavioral Quotient 44.81 (range 32 to 68).
Instrumentation Physiological measures. Electromyographic recordings were obtained using a Myosome 404 EMG Monitor (Bio-Logic Devices, Plainview, New York). A standard frontalis muscle surface electrode placement was used. The Myo-
1 For each subject, informed consent was obtained from the subject himself, or from his or her legal guardian in cases where an individual had been adjudicated incompetent. In addition to obtaining consent for the participation of each subject, the experiment was reviewed by the residential facility’s Human Rights and Behavior Management Committees following the granting of administrative approval. The project was also reviewed by the Institutional Review Board of the Illinois Institute of Technology.
59
Multiple Component Relaxation Training
some 404 EMG Monitor provided analogue auditory feedback during the appropriate treatment conditions. Peripheral skin temperature was measured from a thermistor probe tape to the right index finger of the subject’s hand. Subjects were asked to keep this hand stationary during recording periods. A GSR 508 Monitor (Bio-Logic Devices, Plainview, New York), a device capable of assessing skin conductance or peripheral skin temperature, was used as the recording instrument. Both the Myosome 404 EMG Monitor and the GSR 508 Monitor have been designed to interface with permanent product recording devices. A two channel strip-chart recording unit (MFE Corporation) was used to provide a permanent record of the subject’s performance throughout the experiment. The strip-chart records were quantified by taking readings of both EMG and peripheral skin temperature levels at five second intervals. Relaxation behavior outcome assessment. Because self-report relaxation measures (e.g. Spielberger, Gorsuch, & Lushene, 1970, State-Trait Anxiety Inventory; and Derogatis, Lipman, & Covi, 1973, SCL-90) were judged to be unusable with the severely intellectually impaired individuals who participated in the experiment, a behaviorally anchored interval recording scale was developed for us in the study. The assessment instrument, the Relaxation Training Rating Scale,‘was designed to measure specific components of the relaxation behaviors being taught to subjects. A similar approach for quantifying relaxation behavior had previously been employed by Marhoin, Steinman, Luiselli, Schwartz and Townsend (1979) to measure the effectiveness of a relaxation training procedure used with a group of autistic adolescents. The Relaxation Training Rating Scale required raters to assess the presence of arm, leg or other body movement and whether or not the subjects remained quiet and seated in a reclining chair as instructed. Subject’s behavior during five minute pre and posttreatment measurement periods was video taped. Three raters blind to experimental conditions evaluated video tapes using the Relaxation Training Rating Scale. A 10 second interval recording procedure was used to quantify video tapes. All video tape raters participated in a structured training procedure involving the use of prepared training tapes until an 85% accuracy level was achieved. Rater accuracy levels were re-evaluated at the end of each scoring session. Relaxation skills evaluation.3 Each subject was assessed using a simple behavioral evaluation developed for use in the study. The evaluation was de-
‘Copies author.
of the Relaxation
Training
Rating
‘Copies of the Relaxation Skills Evaluation
Scale can be obtained can be obtained
upon
request
from the first
upon request from the first author.
60
J. E. Calcrrnuri,
G. 0. Geist, and M. J. Shahbaziun
signed to test skills thought to be relevant to success in relaxation training. The assessment procedure was similar to a strategy recommended by Cautela and Groden (1978, p. 41). Subjects were asked to sit in a chair, to follow a series of simple verbal commands where the appropriate response was modeled, and to follow simple commands where only verbal prompts were provided. Each evaluation item was graded on a pass-fail basis with specific behavioral criteria being provided to the evaluators for each of the items of the assessment. The assessment was administered following completion of the sixth and seventh training sessions by the two individuals who functioned as relaxation training instructors during the study. Procedure. Subject’s treatment programs, general education and vocational training, and behavioral medications were held constant throughout the experiment. Once consent had been obtained for a subject’s participation, a determination of the individual’s functioning level was made. Subjects within the same functioning level were paired dependent upon their availability for participation in the study. A flip of a coin was used to assign one subject of each pair to the treatment or control group with the other subject simply being assigned to the other group. The sequence of subject participation was structured so that for each eight consecutive participants, all treatment conditions and functioning levels were represented. This procedure was carried out to prevent the confounding of any improvement, or decrease, in the relaxation training instructor’s skill with treatment condition or functioning level variables. All sessions were conducted by one or two instructors. Each session was begun with the presentation of a standardized rationale to the subject. Experimental subjects were told that cooperation with the relaxation training procedure would help them feel more relaxed, a feeling most people indicate is enjoyable. Control subjects were presented an identical rationale with the exception that they were told that listening to music would help them feel more relaxed. Each subject was then connected to the physiological monitoring and biofeedback equipment. Successful connection of the equipment was followed by a 10 minute adaptation period for all subjects. Following the adaptation period a five minute pretreatment measurement period was begun. During this period subject EMG and peripheral skin temperature measures were recorded and subject behavior video taped. Following this period subjects experienced either 20 minutes of relaxation training or the control procedure. The relaxation training procedure involved the presentation of a specified sample of six of the tensing and relaxing exercises described by Cautela and Groden (1978, pp. 24-29). The exercises presented were for muscle groups in the forehead area, eye area, nose area, arms, legs, and back. Initially presented face and forehead exercises were most likely to produce a significant
Multiple Component Relaxation Training
61
tension-relaxation contrast in the frontalis muscle. Because the analogue feedback mode of the Myosome EMG Trainer was activated throughout each relaxation training session for experimental subjects, these subjects experienced differential auditory feedback on the status of frontalis muscle contractions. It was hoped that this differential feedback would be helpful in teaching subjects to discriminate between tension and relaxation. Each of the relaxation-tension cycles was repeated twice for each muscle group. Each of the tensing and relaxation exercises was modeled by the relaxation training instructor who was present in the training room with the subject, sitting in a similar reclining chair. During the tension phase the trainer reminded the subjects of at least one of the following points: 1) that the tension he/she experienced in the particular muscle group was not relaxation; or 2) that the high levels of the clicking sound provided by the EMG feedback apparatus indicated that he/ she was not relaxed. The tensing of each muscle group was followed by a prompt to the subjects to relax. The relaxation phase of each cycle lasted a minimum of 10 seconds. During the relaxation phase the instructor, in a soft tone, reminded the subjects of at least one of the following points: 1) that he/she was now doing a better job relaxing the muscle group or that he/she appeared very relaxed; 2) that the low rate or absence of clicking from the EMG feedback apparatus indicated a relaxed state; 3) the lack of tension in previously relaxed muscle groups; 4) to breath slowly and deeply; or 5) that he/she was now relaxing well enough to earn a reward. Subjects were verbally praised and told that they had earned a tangible reward when their EMG level remained below a specified level. The Myosome 404 EMG Monitor is equipped with an adjustable threshold setting switch and a light display which is activated as long as the subject’s EMG level remains below a threshold value. The pretreatment EMG level of the first session was used as the basis for determining the initial setting of the threshold switch, and an attempt was made to reduce the setting across training sessions for each subject. The EMG monitor was positioned so only the instructor was able to see the light display which served as a cue to the instructor that reinforcement could be provided for the subject. Control subjects’ experiences were identical to those of experimental subjects except that during the 20 minute control procedure they sat in a reclining chair listening to melodic classical music. As mentioned above, control subjects were presented a rationale intended to create expectations of improved relaxation as a result of listening to music. Each control subject was provided verbal praise or a tangible reward, based on a reinforcement schedule yoked to the performance of the previous experimental subject. For example, if the previous experimental subject received reinforcement during the seven to eight minute interval, the following
62
J. E. Calamari, G. 0. Geist, and M. J. Shahbazian
control subject received reinforcement during this interval also. Each control subject remained yoked to the same experimental subject throughout the seven sessions of the study. Following the 20 minute treatment or control procedure, subjects were asked to remain seated in the chair and remain as relaxed as they could. A five minute posttreatment recording period was conducted with both physiological measures being taken and the period video taped for behavior rating purposes. Treatment condition subjects continued to receive auditory feedback on muscle contraction levels during this phase. Each subject experienced six relaxation training or six control procedure sessions. These six sessions were conducted over a period of time no greater than nine days with only a single session conducted each day. A four day delay occurred between the completion of the last training session and a follow-up evaluation session. During the follow-up session subjects experienced the 10 minute adaptation period and the five minute pretreatment measurement period. Both control and treatment subjects were then prompted to relax for the next 20 minutes vghile a melodic classical music recording was played. A posttreatment recording period followed. All sessions were conducted in a 9.75 foot by 7.67 foot room.
RESULTS In order to determine whether subjects initially differed on any of the thre measures used as dependent variables in the study, session 1 pretreatment levels on each of the three dependent measures were examined. Completion of three, two-way independent groups analyses of variance revealed no initial significant differences between treatment or control groups or between high and low functioning individuals. Evaluation of the main hypotheses of the study resulted in examination of differences between control and experimental subjects in their response to the relaxation training procedure, examination of differences in the response of high and low functioning subjects to this treatment, and determination of the occurrence of any across sessions change in the subjects’ responses. These issues were evaluated by completing three, 2 x 2 x 7, split-plot analysis of variance tests on pretest to postest difference scores. Although problems have been identified in using difference scores as a unit of analysis (e.g., Cohen & Cohen, 1975) these scores were used in the present study in an attempt to partially control for intrasubject pretreatment dependent measure variability across sessions (pretreatment measures were taken at the beginning of each session as previously described). A significant difference, F (1,28) = 6.39, p< .05, was found between treatment and control groups when EMG differences scores (pretest minus posttest) were evaluated. No other significant main effects or interactions
Multiple Component Relaxation Training
63
were present. Treatment and control group EMG difference scores (in microvolts) are shown across sessions in Figure 1. Because the Relaxation Training Rating Scale was developed for use in the present study, a number of the psychometric qualities of the scale were assessed. Interobserver agreement was evaluated by determining overall percentage agreement, percentage agreement for occurrence, and percentage agreement non-occurrence as described by Kelly (1977). Mean overall percentage agreement was determined to be 92.84%, standard deviation 3.97, percentage agreement for occurrence was 64.32070, standard deviation 25.08, and for non-occurrence 90.40, standard deviation 5.88. The percentage of observation intervals in which either rater indicated that targeted behaviors occurred was 22.65. Because a wide range of interobserver agreement estimates resulted when occurrence, nonoccurrence, and overall agreement procedures were compared, interobserver data was further evaluated as recommended by Birkimer and Brown (1979). A mean disagreement rate (lOO-overall mean percentage agreement) of 7.16% was calculated for the 52 interobserver agreement measures. According to Birkimer and Brown (1979) this obtained
2 5 e .I! E,
15.00
-
10.00
-
f_:.’
Treatment Group
p
Control Group
a-0
- -_1
;
:
%
- 15.00 1
2
3
4
5
6
Follow-Up
Sessions
FIGURE 1. Mean differences (pretreatment minus posttreatment lustrated for treatment and control subjects.
score) in EMG levels are il-
64
J. E. Calarnari, G. 0. Geist, und M. J. Shahbazian
percentage agreement level would occur by chance less than one time in a hundred. In addition to examining interval-by-interval interobserver agreement, the correlation between total scores was examined. A Pearson product-moment correlation of .956 was obtained, indicating a high level of interrate reliability when total scores are evaluated. Before analysis of scores on the Relaxation Training Rating Scale could be completed, four difference scores had to be estimated as a result of equipment problems. Kirk’s (1968) formula was extended for this purpose for the three-way analysis employed in the present study. Analysis of the Relaxation Training Rating Scale difference scores (pretest minus posttest) revealed two significant main effects. A significant difference was found between treatment and control groups, F (1,28) = 58.05, pc.05 with treatment group subjects relaxing better than control group subjects. Additionally, a significant main effect for sessions was found, F (6,164) = 3.00, p< .05, indicating that an overall difference for the combined scoring of groups across sessions was present. The failure to find significant interactions between treatment and sessions or between functioning level and sessions indicates performance changed at the same rate across sessions independent of treatment or functioning level. These results are illustrated in Figure 2. Follow-up evaluations using Tukey’s (1953) procedure were conducted to determine if pairwise across session difference existed. No significant differences were found when the most disparate session means (sessions seven and six) were compared: 4 (6,164)= 3.61, p> .05. Examination of peripheral skin temperature difference scores (session posttest scores minus pretest scores) revealed no significant main effects or interactions. Means and standard deviations for each of the dependent measures are shown in Table 1. The relationship between scoring on the Relaxation Training Skills Assessment and experimental subjects response to treatment was evaluated next. Pearson product-moment correlations between subject’s Relaxation Training Skills Assessment score and the mean pretest to postest difference scores (sessions one through six) for each of the three dependent measures were computed. These correlation coefficients are shown in Table 2 along with the intercorrelations between IQ scores and adaptive behavior level. As can be seen, the correlation between scoring on the Relaxation Training Skills Assessment and each of the dependent variables was low indicating that this assessment instrument was not a good predictor of success in treatment. The failure to find a relationship between scoring on the Relaxation Training Skills Assessment and dependent variables did not result because this test was unreliable. The instrument’s reliability was evaluated by computing interobserver agreement levels and test-retest intercorrelations. Interobserver agreement (the Pearson product-moment correlation between
Mdtiple
Component Treatment
High
30.00
-
20.00
-
10.00
-
0.00
-
Functioning:
Control
0 -m
65
Training
Group
---
Functioning:
m-m
Low
Relaxation
Group
0
-
e i u 5 0 2 ” CT 2 ‘Z
P
s
c
z B -1000
-
5
-20.00
-
FIGURE
2. Mean differences
(pretreatment
minus posttreatement)
in relaxation rating scores
are shown. the two evaluators’ scoring of a subject’s behavior) was .958. The test-retest correlation was computed by averaging the two test-retest correlations obtained from the two experimenters (each experimenter completed the evaluation for each subject at the end of sessions six and seven). The resultant Pearson product-moment correlation was .788. Thus, although interobserver agreement reliability was found to be high with this assessment instrument and subject scoring on the evaluation was determined to be fairly stable, scores were of no utility in predicting subject’s response to the relaxation training procedure. The failure to find a relationship between scoring on the Relaxation Training Skills Assessment and any of the dependent measures may have resulted from the limited variability in subject’s scoring on this instrument (Mean, 9.24; Standard Deviation, 1.29). Although none of the intercorrelations in Table 2 were found to be statistically significant, further examination revealed a relatively high positive correlation between two of the dependent measures, EMG and scoring on the Relaxation Training Rating Scale. Examination of the intercorrelation between mean difference scores through session six for both experimental and control subjects resulted in a Pearson product-moment correlation of
J. E. Calamuri,
66
G. 0. Geist, and M. .I Shahbazian
‘TABLE 1. Mean Difference
Scores for Dependent
EMG (.klicrovolts) Treurtnenr Group High Functioning L.ovv Functioning
Sessions 1 1.49 8.68 - 0.25 6.30
2 3.26 5.15 4.53 6.54
3 0.30 1.94 4.37 11.88
4 - 1.32 11.05 0.49 8.74
3.47 13.37 8.76 17.67
6 0.71 7.50 7.80 12.95
-2.51 15.50 ~ 2.51 21.73
1.02 8.31 -0.14 2.19
- 3.13 6.58 - 6.30 10.86
- 2.75 10.97 0.51 3.04
3.48 8.45 3.12 10.90
- 2.22 5.03 ~ 1.92 9.57
2.37 5.22 ~ 2.56 6.54
~ 6.58 12.65 -3.27 10.38
4.44 17.29 12.61 14.94
8.93 22.31 7.75 26.58
19.00 24.28 6.63 28.18
11.95 24.19 8.11 18.71
9.30 17.87 12.86 17.85
10.47 14.67 21.87 19.62
-0.36 18.26 -3.21 29.55
- 8.45 12.59 0.24 10.98
-8.00 13.43 -2.50 12.69
-4.67 1.65 4.66 16.90
- 3.72 11.46 - 1.13 9.64
-4.93 13.83 -2.41 24.48
~ 9.92 15.98 8.90 16.03
-7.94 14.62 -6.10 14.04
SD M SD
7.03 13.91 - 8.78 24.53
~ 4.08 12.95 - 0.07 19.31
14.28 19.29 3.32 18.30
-2.17 6.29 ~ 10.92 11.59
-7.51 3.40 - 8.66 17.82
- 7.22 9.61 2.59 10.54
- 8.46 10.80 ~ 0.22 12.42
M SD M SD
-4.10 10.66 -5.33 9.24
- 7.41 9.42 2.86 13.80
2.37 15.68 3.01 17.86
~ 12.80 17.60 - 0.57 22.62
-5.99 14.04 ~ 4.58 11.30
-0.33 11.23 -5.59 11.53
-3.35 18.91 -5.78 10.77
,M SD M
SD Control Group High Functioning L.ow Functioning
M SD
M SD
Rehxution Rulings Treatment Group High Functioning Low Functioning
Conrrol Group High Functioning Low Functioning
Skin Tetnperuture Treatment Group High Functioning Low Functioning
Conrrol Group High Functioning Lo\v Functioning
Measures
‘$4
SD M SD
M
SD M SD
M
5
I
.45. With the increased N (32) resulting from the addition of control group subjects, this correlation was found to be significant (p < .05). Finally, the relative effectiveness of the two relaxation training instructors was compared. Separate two-way independent group analysis of variance tests were completed for each of the three dependent measures. Mean difference scores through session six were included in the analysis. A two-way analysis, collapsing data across the functioning level factor, was chosen because the second instructor was available to teach only one low functioning treatment group subject, thereby making the obtaining of an error vari-
Mulliple
Component
Relaxation
67
Paining
ante estimate for this factor impossible. No differences on any of the dependent measures were found in subjects’ response to the two instructors.
DISCUSSION In the present study progressive muscle relaxation training, auditory EMG biofeedback, modeling, and positive reinforcement procedures were combined as a single relaxation training procedure. This combination of relaxation induction techniques was found effective in relaxing developmentally disabled persons as operationalized both physiologically and behaviorally. The response of the subjects was not dependent on assessed intellectual or adaptive behavior levels. The study was designed to increase understanding of the effects of relaxation training on the behavior of developmentally disabled persons. The group design employed and the structuring of direct measures of relaxation induction made it possible to determine that the specific relaxation training procedure used in the experiment could effectively function to teach a broad sample of institutionalized developmentally disabled persons how to relax. In the experiment, a relaxation induction procedure which simultaneously combined progressive muscle relaxation training and EMG biofeedback was evaluated. In Frankenberger’s (1979) previous investigations progressive muscle relaxation training had been carried out initially and biofeedback procedures introduced after training in progressive muscle relaxation. The reported failure to find any increased relaxation induction with the addition of EMG biofeedback techniques may have resulted from the sequential presentation procedure chosen in the study. It should be pointed out through, that the design of the present investigation does not make it possible to determine whether the progressive muscle relaxation training, the EMG biofeedback procedure, the modeling of relaxation behavior, the rein-
TABLE 2. Pearson Product-Moment Correlations Between Two Independent and Four Dependent Measures for Experimental Subjects ABL
IQ ABL RTSA TEMP EMG RTRS
1.00 0.16 0.37 0.06 -0.11 - 0.08
0.16 1.oo 0.34 0.14 -0.40 ~ 0.46
RTSA 0.37 0.34
I .oo 0.24 -0.10 - 0.04
TEMP
EMG
RTRS
0.06 0.14 0.24 1.00 - 0.44 - 0.36
-0.11 - 0.40 -0.10 - 0.44 1.oo 0.48
PO.08 PO.46 -0.04 - 0.36 0.48 1.00
Adaptive Behavior Level (ABL) Relaxation Training Skills Assessment (RTSA) Relaxation Training Rating Scale (RTRS)
68
J. E. Calamuri, G. 0. GeisI, and M. J. Shahbazian
forcement procedure, or whether a combination of these techniques was responsible for the observed changes in outcome measures. The lack of observed differences in the response of individuals from different functioning levels to the relaxation training procedure employed in this experiment is contrary to Frankenberger’s (1979) findings. This discrepancy may be explained by the differences in the populations sampled, or by dissimilarity in relaxation training procedures used. It is possible that the addition of auditory EMG biofeedback in the current study was helpful in making the concepts of relaxation and tension more understandable for lower functioning persons, thus diminishing differences between groups. In the present experiment some subjects functioning within even the profound range were found to respond to treatment. What factors then do predict response to treatment? Scores on the Relaxation Training Skills Assessment, an instrument designed to measure subjects’ receptive language, modeling and compliance skills, failed to correlate with any of the outcome measures used in the investigation. Borkovec and Sides (1979) have suggested that clients’ clinical needs (i.e., the presence of a disorder likely to be impacted by relaxation training) are positively correlated with changes in physiological outcome measures in relaxation training studies. Scoring on an assessment designed to measure clinical pathologies such as general anxiety level could identify individuals in need of relaxation training who would also be more likely to show significant changes in outcome measures. But as has been previously discussed, most of the assessment instruments currently available for measuring such constructs as anxiety have largely been designed for use with general psychiatric populations and require that subjects possess substantial language skills, thus limiting their utility with developmentally disabled persons. The failure to obtain changes in peripheral skin temperature measures may have resulted from a number of methodological features of the study: short duration measurement periods, use of a measurement instrument which produced only a change score, and the absence of feedback and reinforcement made contingent on this response. It should be noted, also, that when multiple physiological measures are employed in a single study, it is not unusual for these measures to fail to correlate well (cf. Borkovec and Sides, 1979). The results of this investigation call into question the sometimes held assumption that developmentally disabled persons are not good candidates for psychological treatments involving techniques other than simple behavior management procedures. More complex behavior therapy techniques, as well as nonbehavioral psychotherapies, may prove adaptable for use with this population. Reiss, Levitan, and McNally (1982) have previously discussed the need to make available a broader range of clinical treatment procedures for developmentally disabled persons.
Multiple
Component
Relaxation
Training
69
Acknowledgement -This study was submitted by the first author to the Graduate School of the Illinois Institute of Technology, Department of Psychology, in partial fulfillment of the requirement for a PhD degree. 1 thank Donald Cardy and Daniel Giffort for their critical review of earlier drafts of this manuszript.
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