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Home-based behavioral family treatment of the impaired elderly
n~I~WOR THERAPY19, 331-344, 1988
Home-Based Behavioral Family Treatment of the Impaired Elderly ELSIE M. PINKSTON University of Chicago
NATHAN L. LINSK University of Illinois at Chicago ROSEMARY NELSON YOUNG
Stanford University This research was designed to examine the utility of training caregivers to effectively manage behavior problems of impaired elderly persons. Of primary interest was whether caregivers could be trained to use procedures, based on operant theory, to manage behavior problems of sufficient severity to threaten continued home care. Both the caregivers and the impaired individuals were targets of study: behavior change of the impaired individual was monitored and caregiver's perceptions of burden and competence were measured pre- and postintervention. Data were analyzed on a case-by-case basis using single-subject designs. Improvement was observed in 76% of the targeted behaviors. Careglvers acknowledged improvements in their interactions with their relatives and reported that they were satisfied with their abilities to learn to change their relative's behavior.
Families are major contributors to the well-being of the elderly (Brody, 1985; Shanas, 1960; 1978; 1980; Sussman, 1965; Treas, 1977). Approximately 83070 of men and 6007o of women over the age of 65 live with a family member; incidence increases with age (U.S. Bureau of Census, 1983). Family-provided aid
The research reported in this paper was supported by the National Institute on Aging (ROI AGO2612). The authors are indebted to the practitioner/scientists responsible for the implementation of the interventions and whose sensitive observations contributed to our development of this and future research. We are very proud of their continued contributions to behavioral gerontology. We list them here in gratitude and so that we may share in their future contributions: Robin Goldberg-Glen, Glenn R. Green, Patricia Hanrahan, Eleanora Keane-Hagerty, Marta Lundy, Brenda McGadney, Christine Marlow, Steven Roskamp, and Jack Schipke. Reprint requests should be addressed to Professor Elsie M. Pinkston, The School of Social Service Administration, The University of Chicago, 969 E. 60th St., Chicago, 1L 60637.
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Copyright 1988 by Association for Advancementof Behavior Therapy All rights of reproduction in any form reserved.
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is diverse, including personal care (e.g., running errands and supervision), financial assistance, and help with household upkeep. It is clear that elderly family members are recipients of considerable assistance when family ties are strong (Brody, 1967; Brody, Poulshock, & Masciocchi, 1978; Sussman, 1965), and that the vast majority of elderly people, across cultures, turn first to their families for care. This is convincingly illustrated by the findings that family presence predicts discharge home following hospitalization better than level of disability (Brody, 1978) and the absence of family places an elderly person at great risk of being institutionalized (Maddox, 1975). In spite of the fact that family support is critical to the well-being of seriously impaired individuals and that caregiving itself can bring many rewards, elderly spouses and family members frequently experience considerable strain (Cantor, 1983; Zarit, Orr, and Zarit, 1985; Zarit, Todd & Zarit, 1986). Coppell, Burton, Becker, & Fiore (1985) recently documented that the incidence of depression among caregivers of Alzheimer's disease parents is dramatically higher than the incidence in the general population. Management of behavior problems is the most troublesome component; Johnson and Johnson (1983) reported that difficult behavior problems of relatives were the most likely precursors to placement in a nursing facility. The basic premise underlying this investigtion is that interventions are required that include both support for the caregiver and the elderly client. These interventions should be directed toward treatment of behaviors that are likely to reduce high levels of stress. Although several interventions have been developed that target caregivers, empirical demonstration of effectiveness is limited. Behavioral family treatment of the elderly includes methods derived from parent training research reported in the child literature, as well as behavioral procedures that were developed in institutional settings that take into consideration the physical condition and learning history of the client. Implementation of the techniques by the caregiver at home have shown promise for aiding in the solution of the dilemmas faced by caregivers of the frail elderly (Green, Linsk, & Pinkston, 1986; Linsk, Pinkston, & Green, 1982; Pinkston & Linsk, 1984a; 1984b). This research was designed to examine the effectiveness of operant procedures applied to a wide variety of problems of seriously impaired elderly individuals living at home, and to evaluate the effectiveness of behavioral parent training procedures for teaching their caregivers to use operant procedures (Linsk, Pinkston & Green, 1982; Pinkston & Linsk, 1984a, 1984b). The questions that follow then, are" a) Can family caregivers of the elderly be taught to implement behavioral methods? b) Are behavioral techniques, specifically stimulus control and reinforcement, useful for alleviating behavioral problems serious enough to place continued home care in jeopardy? c) Does learning behavioral methods alter caregiver perception of burden? d) Do caregivers report improvement in their perceptions of caregiving competency? e) How can single case methods be incorporated in planning and implementing interventions as well as evaluating results?
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METHOD Clients Client criteria were defined in such a way that a broad range of diagnoses and problems were included in the sample. The following specific referral criteria were distributed to agencies and hospitals in the Chicago area. Clients a) were at least 60 years of age; b) had been diagnosed as having impaired physical or psychological functioning (e.g., brain dysfunction including chronic and acute brain syndromes, reactive mental disorders, depression that would otherwise have prevented community functioning, schizophrenia, senile psychosis, paraphrenia, arteriosclerotic brain disease, acute confusional states or physical impairments such as cardiovascular accidents, arthritis, fractures, or spinal cord injuries); c) were believed by the referral source to be exhibiting excess disability, i.e., more disability than was justified by physical and mental conditions (Kahn, 1965); d) had a family member or significant other willing to participate in behavioral change efforts; e) displayed behavioral excesses or deficits in rates of appropriate or inappropriate behavior, family interaction dysfunction, interpersonal problems, communication difficulties, social isolation, or inability to engage in activities of daily living; and f) used few community activities or services.
Caregivers Even more importantly, the following criteria were used to determine the caregivers' ability and willingness to participate in the change effort: a) available with adequate time for involvement with the program; b) adequately motivated, that is, adversely affected by the present behavior of the client; c) adequate access to the client to control behavioral consequences; d) adequate skill level or ability to learn skills; e) adequate mental and physical health.
Therapists The therapists included second-year social work interns (4) or social workers with M.A.'s in social work (7) from the School of Social Service Administration at the University of Chicago. All of the therapists had completed at least one basic course in behavioral procedures. They were supervised in weekly meetings by the three authors of this paper. All sessions were audiotaped and used for supervision when difficulties in implementing the program occurred. Training was provided by using materials later formulated into a practice guide book, Care of the elderly: A family approach (Pinkston & Linsk, 1984b). After a review of interviewing techniques, behavioral procedures, and a basic introduction to facts about aging, training was conducted during weekly clinic supervision sessions.
Procedures Subject Recruitment The Elderly Support Project (ESP) was introduced to the client by the refer-
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ring agency staff. A checklist of information about the program was provided to the referral source to standardize how the program was introduced to clients. During the first meeting in the client's home, the ESP therapist described the program along with the confidential nature of the research and obtained permission from both the elderly client and the caregiver regardless of the mental status of the client. If there was reluctance on the part of the impaired client to sign anything, this was usually solved by an additional home visit to become better acquainted with the therapist. If either the client or the caregiver refused to give signed informed consent, they were not engaged. This conservative approach was used to avoid violating the rights of the elderly person who had not been declared incompetent through due legal process. (If this were not a research project, the authors would see no ethical reasons for not engaging the caregiver as the sole client to aid him or her with caregiving responsibilities.)
Intervention Although relationship building was not systematically studied, it was the usual procedure to develop the relationships with clients and caregivers by using reinforcement procedures during the engagement and assessment period. Specifically, the therapist praised the attempts that the clients and caregivers were making to solve their problems. Generally positive statements regarding the home and sympathetic statements regarding their dilemma were made. Because of the high response requirements on the caregivers in most cases, it was assumed that some anger might be present and that it was a valid response to their difficulty. During the questionnaire interview part of the assessment, therapists were taught to discontinue the interview if the client or caregiver became fatigued or anxious. Praise and supportive statements were continued across all experimental conditions. The intervention was implemented through a seven-step program summarized below (For a more detailed description of the intervention methods, see Pinkston and Linsk, 1984b): Step L Referral. Referrals came from social agencies, hospital social workers, and medical staff. The project staff and referring personnel assessed the client's eligibility for the project as measured against the established criteria. Step 2. Assessment. The therapist used a home interview to evaluate caregivers' and clients' abilities and problems and to determine desired outcomes. The interview questions focused on the older person's strengths and deficits, current behaviors, dally activities, and goals for change. Typical goals were increased social behaviors, correct toileting behavior, medication monitoring, and independent self-care. The therapists used a caregiver checklist (see sample in Pinkston & Linsk, 1984b) to determine the degree to which the caregiver was able and willing to participate in the program and to develop an appropriate focus for the initial part of the intervention. The older person's physical and mental capabilities, demographic characteristics, health, medication, attitudes, and activities were evaluated using standardized questionnaires and checklists.
Step 3. Definition o f Excesses and Deficits and Recording of Baseline Data.
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This step was designed to teach older clients and caregivers to redefine problems more objectively in terms of behavioral excesses and deficits in formulating desired outcomes. This definition provided a more specific problem focus and frequently focused on the increase in positive behaviors. The therapist devised simple measures to record baseline data on the rate of occurrence of client behaviors. Each family member who was to record data first practiced with, and received corrective feedback from the therapist. Within a week another staff member visited the home to conduct a reliability observation with the caregiver. Data were then used to evaluate behavioral difficulties and to provide the basis for the design of interventions. These data enabled the therapist to assess variables likely to be functional in the client's interactions with people and environmental events. Step 4. Behavioral Education o f Support Persons. To prepare the caregivers for intervention, the therapist taught them to use behavioral procedures. This instruction included applications of operant principles and procedures through modeling, role-play, corrective feedback, written procedures, and discussion of data. These training methods were continued throughout the intervention phases. Behavioral language was kept to a minimum level; instead, more naturalistic language was used. Step 5. Development of Intervention. Following the recording and graphing of baseline data, the therapist along with the client and caregivers developed an intervention plan from their joint analysis of the data. The intervention incorporated the differential consequences and cues needed to foster positive behaviors and, to the greatest extent possible, fit naturally into the home context. These interventions included reinforcement, stimulus control, and community linkages. Contracts were then drawn up using specific reinforcement and stimulus control procedures such as praise contingent on the occurrence of desired behavior, prompts, scheduled activities, and differential attending. Step 6. Maintenance. The maintenance plans included behaviors most likely to be valued and actually reinforced in the client's environment. The deterioration of behavioral improvement was avoided by using clear antecedent cues and fading. A planned decrease of the therapist's involvement as the reinforcing agent and the simultaneous increase of the natural caregiver in that role (fading) helped to avoid abruptly changing consequences. Step Z Termination and Follow-Up. Termination guidelines for completed cases included: a) stable levels of behaviors appropriate to the goals of treatment; b) the transfer of all monitoring and intervention responsibilities to the caregiver, c) the gradual decrease in frequency (fading) of the therapist's visits from weekly to monthly sessions; and d) termintion of practitioner's visits after 2 months of successful goal achievement and monitoring.
RESEARCH AND EVALUATION METHODS Research Designs Single-case designs (Baer, Wolf, & Risley, 1968; Hersen & Barlow, 1976) were used in each case to evaluate the effects of intervention on behavioral targets. These designs made it possible to analyze each individual's treatment
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plan by comparing baseline observation data with intervention data. Clinical multiple-baseline (Pinkston et al., 1982), multiple baseline, and AB (baseline, treatment) designs were used most frequently to evaluate interventions. Where behavior problems were not too serious or disruptive, and to demonstrate to caregivers the power of their intervention, reversal designs were used to evaluate the intervention.
Instruments Observational data recording methods involved a combination of direct observations of frequency and/or duration by clients, families, and research staff. The primary observers were usually family members with reliability observations recorded by staff members other than the therapist. These observations were recorded in two forms: time-sampling techniques (Baer et al., 1968; Polster & Lynch, 1981) and checklists (Pinkston et al., 1982; Pinkston & Linsk, 1984b). In the time-sampling technique the observer watched the elderly person and recorded the occurrence of behaviors at a specified time. The observer used checklists to record the occurrence or nonoccurrence of specific behaviors or behavioral interactions with others within a specified time, from, for instance, time spent out of bed between 7 am and 7 pm, number of social initiations that occurred within a specified time, activities such as bathing, engaging in household chores, or going out for a newspaper. The client's specific problem determined the definition of the observation codes. In order to encourage reliable recording, the practitioner wrote these codes in clear, objective terms using the client's language as much as possible. Instruments used to assess demographic characteristics included the Mental Status Questionnaire, (Kahn, Goldfarb, Pollock, & Peck, 1960); the Family Burden Scale (Zarit, Reever, & Bachman-Peterson, 1980); and the Older Americans Resource and Services Program (OARS) multidimensional assessment (Pfeiffer, 1976). These instruments were administered pre- and postintervention.
RESULTS AND CONCLUSIONS Elderly Clients and Caregivers Clients. The average age of the clients was 73 years, with 45°70 male and 5507o female and 6607o white and 3407o black. The marital status of the clients was 5807o married and 3607o widowed; the rest were divorced or single. Their mean income was $13,020; 56070 were living in their own homes. The seriousness of the 66 clients' impairments was established clearly by the following data from the OARS pretest. On scales ranging from 6 (positive) to 1 (negative), the following average data were obtained. Physical health was rated a mean of 5.57, mental health a mean of 4.12, and activities of daily living a mean of 4.77. Social resources earned a mean of 3.00, and economic resources a mean of 2.36. As compared with previous data on institutionalized samples (Kane & Kane, 1981), clients yielded a similar profile except they were more physically impaired than were nursing home comparison samples. Mental Status scores ranged from 0 to 100 (below 80 shows mental impair-
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ment) with means of 63 at pretest and 71 at posttest, a significant but expected change over time, (one-tailed tp < .03). An analysis of early client data showed that improved performance on the Mental Status Questionnaire occurred only for those who showed serious impairment at the onset. Caregivers. The mean age of the caregivers was 64 years; 75 % of them were female, 45% were spouses; 28% were adult children of the clients, and the remaining relationships were distributed evenly across siblings, friends, or other relatives. In keeping with the theory and philosophy of the behavioral clinical approach, 86% of the 96 behaviors treated were designed to increase desirable behaviors with only 14% of problems defined as decreasing negative behaviors. The behaviors defined as negative were extreme in nature and demanded intervention in order for the clients to improve along other dimensions. Exemplars of single-case graphs are presented in Figures 1-4 and are representative of how single case designs were used to monitor and evaluate interventions. Figures 1-3 illustrate the analysis and intervention with multiple problems of Client 1, a 66-year-old male diagnosed as clinically depressed and agitated with intermittent contact with reality. He was cared for by his spouse who complained of poor personal care, aggressive behavior, and social withdrawal. The first intervention addressed his personal care in three phases (Figure 1). In phase 1, his wife was asked to bring him a warm wet washcloth while he was still in bed, and to talk with him in a soothing manner when she washed and dried his hands and face. In phase 2, the client began to bathe weekly and, in phase 3, on request he washed his hands and face in the bathroom and usually bathed at least once a week. During follow-up calls for 1 year, his wife reported being able to maintain these behaviors with occasional outside hired help for haircuts and bathing.
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forcement procedure but to store needed objects elsewhere and to reduce their visits to his room to an average of 3 times per day. As depicted in Figures 2 and 3 this resulted in an increase in positive social behavior and a reduction in aggression. Client 2 was 84 years old and living with his wife who was his primary caretaker. He was referred to the Elderly Support Project because of depression and inactivity. Following baseline, the worker set a goal with the client and his wife to take one walk together around the block; during the second week the goal was altered to two short walks halfway around the block together. After returning home from their walk the client was given a glass of juice. During the fourth week of intervention, the number of walks was increased to three, and it was agreed the client could walk inside the apartment building in bad weather. In response to the client's complaints, his wife agreed to massage her husband's lower legs after they returned from walking (weeks 8 thru 11). An adjunct gain that was not measured was the increased opportunity for social contact between the couple. The data indicate a mean weekly frequency of 2 walks during baseline and about 4 walks during maintenance (Figure 4). Although gains observed in each individual behavior analysis are not particularly large, the changes across multiple clients support some causal inference and provide an excellent practitioner-researcher model for evaluating practice. Over all, clients' behavioral improvement occurred in 76070of the behaviors treated although compared to behavioral improvement with younger clients these improvements were sometimes small. Small improvements, however, tended to be valued more by the caregivers of the elderly than by parental change agents of children. In fact, some caregivers were comforted by graphs
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showing the maintenance of existing levels of positive behavior even when no improvement was shown. Four questions provided the basis for the analysis of the impact of the intervention on caregivers: (1) What were the initial consequences of caregiving? (2) Were consequences altered by the program? (3) What were the caregivers' abilities to alter consequences for the impaired elderly clients? (4) Did the ESP interventions alter caregivers' feelings of burden? Beginning with the initial consequence of caregiving, we found that 61% of our caregivers provided personal care or assistance to the elderly person, with 78 % providing medication, 80% help with managing finances, 65 % help with housekeeping, 83°70 help with meal preparation, 45% help with transportation, and 70% providing help with shopping. These percentages indicated that caregivers supplied a substantial amount of assistance; therefore, taking on additional responsibilities became one of the initial consequences of caregiving. Those tasks reported to be most burdensome were new tasks that caregivers had not performed in the past; for example, a wife who had not managed the budget or money found herself entirely responsible for finances, or a husband suddenly had to take responsibility for cooking, personal care, and housekeeping. Even the degree of task difficulty was not as taxing as were demands for changes in accustomed roles. In addition to asking about the kinds of services promised we asked caregivers to rate their own mental and physical health both of which earned means of "fair" ("3" on a five-point scale where 5 = excellent and 1 -- very poor). There were no significant changes either in physical or mental health scores from pre- to posttest, nor in the kinds of help which caregivers provided. An additional set of questions using a scale from 0 (completely dissatisfied) to l0 (completely satisfied), asked if the ESP interventions altered the caregivers' feelings of competence. At pre- and posttest caregivers were asked how satisfied they were with how they currently managed undesirable or problem behavior. On satisfaction with current ability to learn to change their relative's behaviors, caregivers rose from a rating of 4.4 at pretest to 6.6 at posttest, p < .001. Our final question of caregivers addressed alteration in their feelings of burden by comparing their pre- and posttest scores on the Zarit Burden Scale. There were no significant differences on the overall scores. Caregivers did report being less embarrassed by relative's behavior, on a scale of 1-5 (5 indicating extremely embarrassed) with responses changing from 1.8 at pretest to 1.5 at posttest, a significant improvement, p < .03. There was also some improvement on how much caregivers perceived the elderly person as having negative effects on their own relationships with family members and friends. On the same 1-5 scale, average interference dropped from 2.3 before to 1.6 after intervention, p < .01. Likewise, caregivers reported feeling less strain interacting with their elderly relative, a pre- to posttest drop of only 0.6 points but still significant, p < .03 level. While the foregoing results indicate some improvement, it is interesting that caregivers perceived their elderly relative as more dependent after the intervention with score changes from 4 to 4.4, p < .03. A primary factor influencing the caregivers' ability to alter consequences
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was availability to spend time with the client. This was considered within the context of competing demands. No competing demands were reported by 50°70 of our caregivers, 21°70 were engaged in part-time activities outside the home; 25°70 were employed part-time, plus having additional activities; and 4°7o reported extensive activities outside the home. Pains were taken to insure that adequate time was available to carry out procedures before the behavioral intervention was scheduled. An important factor determining caregivers' willingness to use their ability to alter behavioral consequences was how they viewed the elderly person's behavior. Most caregivers, 70070, were rated as having a realistic view of the elderly person's behavior; 1507o, however, did not understand the behavior nor how it was related to the elderly person's impairment; 10°70 thought the elder was being punitive to them; and 5 °7othought the elderly person was helpless and couldn't improve. In cases where change was not obtained, failure usually was due to poor health of the caregiver, nonreversible physical condition of the client and/or an inability to engage the caregiver to record data or implement the program. The number of program failures was small but, clearly, a therapist should assess a number of variables carefully before attempting an intervention. In general, the most effective caregivers were those who had 1) a realistic view of the elderly person's behavior, 2) a historically reciprocal relationship, 3) time available to spend with the elderly person, and 4) continued at least some positive activities both in and outside the home.
DISCUSSION Findings from this research contribute to a growing literature that suggests that operant procedures are valuable tools in the treatment of impairments associated with old age. Procedures based on reinforcement theory were used to create opportunities for elders to receive positive consequences for their behavior and to establish more prosthetic environments that are effective in regaining and supporting improved levels of functional behavior. Although difficult to demonstrate experimentally, it appeared to us that the procedures also helped to maintain existing levels of adaptive behavior in our clients. A central question addressed in this respect project was whether or not family members, often elderly themselves, are able to acquire the skills necessary to implement interventions with their relatives. Project staff worked with both caregivers and clients initially, but quickly faded from the treatment as the caregivers became proficient in conducting the intervention. As has been found with other impairments, some reinforcement procedures must continue in force even after the behavioral goal has been attained. In such cases, practitioners must carefully fade themselves from the program while maintaining systematic availability to the caregivers. Since maintenance of treatment goals is essential to treatment effectiveness, efforts aimed at fading are especially important. We felt strongly that another element central to the success of the project was the extensiveness of the assessment conducted prior to the implementation of behavior change procedures. Caution must be exercised when designing
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interventions for this frail group of elders to conduct a proper assessment of the caregivers' total situation and to insure that adequate resources, both physical and material, are available for a positive outcome. A trial and error approach must be avoided in order to minimize the risk of adding stress to the caregivers and decreasing the probability that they will seek help in the future. Care of seriously impaired individuals brings with it profound alterations in consequences for the caregiver. These consequences not only include an increase in response demands on the caregiver. These consequences not only include an increase in response demands on the caregiver, but also a loss of opportunity to engage in reinforcing and pleasurable activities. Many caregivers find themselves unable to even think of things they would enjoy doing. It is, of course, reasonable to place emphasis on pleasurable activities and respites to offset the taxing demands of caregiving. But, it is also important to study the naturalistic reinforcers that currently maintain caregiving behaviors, and to identify reinforcing consequences that caregivers desire from their friends, families, and society. A second question addressed in this project was whether behavioral techniques, specifically stimulus control and reinforcement, are useful in alleviating behavioral problems serious enough to place continued home care in jeopardy. Although the maintenance phase in our research is not complete, it seems clear that the interventions were effective in allowing caregivers to maintain efforts in providing care for their elderly relatives. We believe that results will sustain the promise of early intervention with depressed and demented clients. We were also interested in whether or not learning intervention skills would alter caregivers' perceptions of burden and competence. The answer in this domain was complex. Following training, caregivers reported increased competence and stated that they felt better able to cope with their problems. Overall scores on our measure of burden did not change, however; in fact, caregivers saw their relatives as more dependent on them after the intervention. Perhaps focus on the influence of the caregiver's behavior on the client contributed to this change. Alternatively, once caregivers felt more competent to manage and change behavior, they may have become more willing to admit the elderly person's dependendence on them. Clearly, more research is needed in this area. Finally, we studied the utility of single-case methods in the planning and implementation of interventions. Not only were these methods useful in the analysis of results, they were particularly helpful in assessing the problems and programming maintenance. As in behavioral parent training programs, the graphs were used to show caregivers the progress being made, and to demonstrate the functional relationships that behavior change efforts had on their relative's behavior. The recording of behavioral data and their figural depiction appeared to have great clinical value. The caregivers enjoyed this aspect of the project more often than not, and the graphs clearly aided in the development of interventions. In conclusion, results of this research suggest that operant procedures can be used to effectively modify the problems displayed by seriously impaired elderly persons. In our project, caregivers of elderly individuals suffering from a wide range of conditions, including dementia and depression, learned be-
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havioral technologies that allowed them to alleviate targeted problems and increase their own feelings of competence. We feel strongly that interventions with the frail elderly should involve and support the caregivers who frequently serve as their primary link to the least restrictive living environments. Our future research efforts will be directed at caregiver maintenance using operant theory to analyze the positive and negative consequences of caregiving and the value of providing increased rewards for caregivers combined with daycare or other forms of respite.
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Pinkston, E. M., Levitt, J. L., Green, G. R., Linsk, N. L. & Rzepnicki, T. L. (1982). Effective social work practice" Advanced techniques for behavioral intervention with individuals, families, and institutional staff. San Francisco: Jossey-Bass Publishers. Pinkston, E. M., & Linsk, N. L. (1984a). Behavior family intervention with the impaired elderly. The Gerontologist, 6, 576-583. Pinkston, E. M., & Linsk, N. L. (1984b). Care of the elderly." A family approach. New York: Pergamon Press. Polster, R. A. & Lynch, M. A. (1981). Single-subject design. In R. M. Grinnel, Jr. (Ed.), Social work research and evaluation, ltasca, IL: E E. Peacock Publishers. Shanas, E. (1960). Family responsibility and the health of older people. Journal of Gerontology, 15, 408-411. Shanas, E. (1978). Social myth as hypothesis: The case of family relatives of older people. The Gerontologist, 19, 3-9. Shanas, E. (1980). Older people and their families: The new pioneers. Journal o f Marriage and the Family, 42, 9-15. Sussman, M. B. (1965). Relationships of adult children with their parents in the United States. In E. Shanas & G. Streib (Eds.), Social structure and the family: Generational relations. Englewood Cliffs, N J: Prentice Hall. Treas, J. (1977). Family support systems for the aged: Some social and demographic considerations. The Gerontologist, 17, 486-491. U.S. Bureau of Census (1983). America in transition: An aging society. Current population reports. (Series P-23, No. 128). Washington, DC: U.S. Government Printing Office. Zarit, S. H., Orr, N. K., & Zarit, J. M. (1985). The hidden victims of AIzheimer's disease: Families under stress. New York: New York University Press. Zarit, S. H., Reever, K. E., & Bachman-Peterson, J. (1980). The burden interview. The Gerontologist, 20, 649-655. Zarit, S. H., Todd, P. A., & Zarit, J. M. (1986). Subjective burden of husbands and wives as caregivers: A longitudinal study. The Gerontologist, 26, 260-266. RECEIVEDI November 6, 1987 FINAL ACCEPTANCE,"December 10, 1987
Home-Based Behavioral Family Treatment of the Impaired Elderly ELSIE M. PINKSTON University of Chicago
NATHAN L. LINSK University of Illinois at Chicago ROSEMARY NELSON YOUNG
Stanford University This research was designed to examine the utility of training caregivers to effectively manage behavior problems of impaired elderly persons. Of primary interest was whether caregivers could be trained to use procedures, based on operant theory, to manage behavior problems of sufficient severity to threaten continued home care. Both the caregivers and the impaired individuals were targets of study: behavior change of the impaired individual was monitored and caregiver's perceptions of burden and competence were measured pre- and postintervention. Data were analyzed on a case-by-case basis using single-subject designs. Improvement was observed in 76% of the targeted behaviors. Careglvers acknowledged improvements in their interactions with their relatives and reported that they were satisfied with their abilities to learn to change their relative's behavior.
Families are major contributors to the well-being of the elderly (Brody, 1985; Shanas, 1960; 1978; 1980; Sussman, 1965; Treas, 1977). Approximately 83070 of men and 6007o of women over the age of 65 live with a family member; incidence increases with age (U.S. Bureau of Census, 1983). Family-provided aid
The research reported in this paper was supported by the National Institute on Aging (ROI AGO2612). The authors are indebted to the practitioner/scientists responsible for the implementation of the interventions and whose sensitive observations contributed to our development of this and future research. We are very proud of their continued contributions to behavioral gerontology. We list them here in gratitude and so that we may share in their future contributions: Robin Goldberg-Glen, Glenn R. Green, Patricia Hanrahan, Eleanora Keane-Hagerty, Marta Lundy, Brenda McGadney, Christine Marlow, Steven Roskamp, and Jack Schipke. Reprint requests should be addressed to Professor Elsie M. Pinkston, The School of Social Service Administration, The University of Chicago, 969 E. 60th St., Chicago, 1L 60637.
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Copyright 1988 by Association for Advancementof Behavior Therapy All rights of reproduction in any form reserved.
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is diverse, including personal care (e.g., running errands and supervision), financial assistance, and help with household upkeep. It is clear that elderly family members are recipients of considerable assistance when family ties are strong (Brody, 1967; Brody, Poulshock, & Masciocchi, 1978; Sussman, 1965), and that the vast majority of elderly people, across cultures, turn first to their families for care. This is convincingly illustrated by the findings that family presence predicts discharge home following hospitalization better than level of disability (Brody, 1978) and the absence of family places an elderly person at great risk of being institutionalized (Maddox, 1975). In spite of the fact that family support is critical to the well-being of seriously impaired individuals and that caregiving itself can bring many rewards, elderly spouses and family members frequently experience considerable strain (Cantor, 1983; Zarit, Orr, and Zarit, 1985; Zarit, Todd & Zarit, 1986). Coppell, Burton, Becker, & Fiore (1985) recently documented that the incidence of depression among caregivers of Alzheimer's disease parents is dramatically higher than the incidence in the general population. Management of behavior problems is the most troublesome component; Johnson and Johnson (1983) reported that difficult behavior problems of relatives were the most likely precursors to placement in a nursing facility. The basic premise underlying this investigtion is that interventions are required that include both support for the caregiver and the elderly client. These interventions should be directed toward treatment of behaviors that are likely to reduce high levels of stress. Although several interventions have been developed that target caregivers, empirical demonstration of effectiveness is limited. Behavioral family treatment of the elderly includes methods derived from parent training research reported in the child literature, as well as behavioral procedures that were developed in institutional settings that take into consideration the physical condition and learning history of the client. Implementation of the techniques by the caregiver at home have shown promise for aiding in the solution of the dilemmas faced by caregivers of the frail elderly (Green, Linsk, & Pinkston, 1986; Linsk, Pinkston, & Green, 1982; Pinkston & Linsk, 1984a; 1984b). This research was designed to examine the effectiveness of operant procedures applied to a wide variety of problems of seriously impaired elderly individuals living at home, and to evaluate the effectiveness of behavioral parent training procedures for teaching their caregivers to use operant procedures (Linsk, Pinkston & Green, 1982; Pinkston & Linsk, 1984a, 1984b). The questions that follow then, are" a) Can family caregivers of the elderly be taught to implement behavioral methods? b) Are behavioral techniques, specifically stimulus control and reinforcement, useful for alleviating behavioral problems serious enough to place continued home care in jeopardy? c) Does learning behavioral methods alter caregiver perception of burden? d) Do caregivers report improvement in their perceptions of caregiving competency? e) How can single case methods be incorporated in planning and implementing interventions as well as evaluating results?
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METHOD Clients Client criteria were defined in such a way that a broad range of diagnoses and problems were included in the sample. The following specific referral criteria were distributed to agencies and hospitals in the Chicago area. Clients a) were at least 60 years of age; b) had been diagnosed as having impaired physical or psychological functioning (e.g., brain dysfunction including chronic and acute brain syndromes, reactive mental disorders, depression that would otherwise have prevented community functioning, schizophrenia, senile psychosis, paraphrenia, arteriosclerotic brain disease, acute confusional states or physical impairments such as cardiovascular accidents, arthritis, fractures, or spinal cord injuries); c) were believed by the referral source to be exhibiting excess disability, i.e., more disability than was justified by physical and mental conditions (Kahn, 1965); d) had a family member or significant other willing to participate in behavioral change efforts; e) displayed behavioral excesses or deficits in rates of appropriate or inappropriate behavior, family interaction dysfunction, interpersonal problems, communication difficulties, social isolation, or inability to engage in activities of daily living; and f) used few community activities or services.
Caregivers Even more importantly, the following criteria were used to determine the caregivers' ability and willingness to participate in the change effort: a) available with adequate time for involvement with the program; b) adequately motivated, that is, adversely affected by the present behavior of the client; c) adequate access to the client to control behavioral consequences; d) adequate skill level or ability to learn skills; e) adequate mental and physical health.
Therapists The therapists included second-year social work interns (4) or social workers with M.A.'s in social work (7) from the School of Social Service Administration at the University of Chicago. All of the therapists had completed at least one basic course in behavioral procedures. They were supervised in weekly meetings by the three authors of this paper. All sessions were audiotaped and used for supervision when difficulties in implementing the program occurred. Training was provided by using materials later formulated into a practice guide book, Care of the elderly: A family approach (Pinkston & Linsk, 1984b). After a review of interviewing techniques, behavioral procedures, and a basic introduction to facts about aging, training was conducted during weekly clinic supervision sessions.
Procedures Subject Recruitment The Elderly Support Project (ESP) was introduced to the client by the refer-
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ring agency staff. A checklist of information about the program was provided to the referral source to standardize how the program was introduced to clients. During the first meeting in the client's home, the ESP therapist described the program along with the confidential nature of the research and obtained permission from both the elderly client and the caregiver regardless of the mental status of the client. If there was reluctance on the part of the impaired client to sign anything, this was usually solved by an additional home visit to become better acquainted with the therapist. If either the client or the caregiver refused to give signed informed consent, they were not engaged. This conservative approach was used to avoid violating the rights of the elderly person who had not been declared incompetent through due legal process. (If this were not a research project, the authors would see no ethical reasons for not engaging the caregiver as the sole client to aid him or her with caregiving responsibilities.)
Intervention Although relationship building was not systematically studied, it was the usual procedure to develop the relationships with clients and caregivers by using reinforcement procedures during the engagement and assessment period. Specifically, the therapist praised the attempts that the clients and caregivers were making to solve their problems. Generally positive statements regarding the home and sympathetic statements regarding their dilemma were made. Because of the high response requirements on the caregivers in most cases, it was assumed that some anger might be present and that it was a valid response to their difficulty. During the questionnaire interview part of the assessment, therapists were taught to discontinue the interview if the client or caregiver became fatigued or anxious. Praise and supportive statements were continued across all experimental conditions. The intervention was implemented through a seven-step program summarized below (For a more detailed description of the intervention methods, see Pinkston and Linsk, 1984b): Step L Referral. Referrals came from social agencies, hospital social workers, and medical staff. The project staff and referring personnel assessed the client's eligibility for the project as measured against the established criteria. Step 2. Assessment. The therapist used a home interview to evaluate caregivers' and clients' abilities and problems and to determine desired outcomes. The interview questions focused on the older person's strengths and deficits, current behaviors, dally activities, and goals for change. Typical goals were increased social behaviors, correct toileting behavior, medication monitoring, and independent self-care. The therapists used a caregiver checklist (see sample in Pinkston & Linsk, 1984b) to determine the degree to which the caregiver was able and willing to participate in the program and to develop an appropriate focus for the initial part of the intervention. The older person's physical and mental capabilities, demographic characteristics, health, medication, attitudes, and activities were evaluated using standardized questionnaires and checklists.
Step 3. Definition o f Excesses and Deficits and Recording of Baseline Data.
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This step was designed to teach older clients and caregivers to redefine problems more objectively in terms of behavioral excesses and deficits in formulating desired outcomes. This definition provided a more specific problem focus and frequently focused on the increase in positive behaviors. The therapist devised simple measures to record baseline data on the rate of occurrence of client behaviors. Each family member who was to record data first practiced with, and received corrective feedback from the therapist. Within a week another staff member visited the home to conduct a reliability observation with the caregiver. Data were then used to evaluate behavioral difficulties and to provide the basis for the design of interventions. These data enabled the therapist to assess variables likely to be functional in the client's interactions with people and environmental events. Step 4. Behavioral Education o f Support Persons. To prepare the caregivers for intervention, the therapist taught them to use behavioral procedures. This instruction included applications of operant principles and procedures through modeling, role-play, corrective feedback, written procedures, and discussion of data. These training methods were continued throughout the intervention phases. Behavioral language was kept to a minimum level; instead, more naturalistic language was used. Step 5. Development of Intervention. Following the recording and graphing of baseline data, the therapist along with the client and caregivers developed an intervention plan from their joint analysis of the data. The intervention incorporated the differential consequences and cues needed to foster positive behaviors and, to the greatest extent possible, fit naturally into the home context. These interventions included reinforcement, stimulus control, and community linkages. Contracts were then drawn up using specific reinforcement and stimulus control procedures such as praise contingent on the occurrence of desired behavior, prompts, scheduled activities, and differential attending. Step 6. Maintenance. The maintenance plans included behaviors most likely to be valued and actually reinforced in the client's environment. The deterioration of behavioral improvement was avoided by using clear antecedent cues and fading. A planned decrease of the therapist's involvement as the reinforcing agent and the simultaneous increase of the natural caregiver in that role (fading) helped to avoid abruptly changing consequences. Step Z Termination and Follow-Up. Termination guidelines for completed cases included: a) stable levels of behaviors appropriate to the goals of treatment; b) the transfer of all monitoring and intervention responsibilities to the caregiver, c) the gradual decrease in frequency (fading) of the therapist's visits from weekly to monthly sessions; and d) termintion of practitioner's visits after 2 months of successful goal achievement and monitoring.
RESEARCH AND EVALUATION METHODS Research Designs Single-case designs (Baer, Wolf, & Risley, 1968; Hersen & Barlow, 1976) were used in each case to evaluate the effects of intervention on behavioral targets. These designs made it possible to analyze each individual's treatment
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plan by comparing baseline observation data with intervention data. Clinical multiple-baseline (Pinkston et al., 1982), multiple baseline, and AB (baseline, treatment) designs were used most frequently to evaluate interventions. Where behavior problems were not too serious or disruptive, and to demonstrate to caregivers the power of their intervention, reversal designs were used to evaluate the intervention.
Instruments Observational data recording methods involved a combination of direct observations of frequency and/or duration by clients, families, and research staff. The primary observers were usually family members with reliability observations recorded by staff members other than the therapist. These observations were recorded in two forms: time-sampling techniques (Baer et al., 1968; Polster & Lynch, 1981) and checklists (Pinkston et al., 1982; Pinkston & Linsk, 1984b). In the time-sampling technique the observer watched the elderly person and recorded the occurrence of behaviors at a specified time. The observer used checklists to record the occurrence or nonoccurrence of specific behaviors or behavioral interactions with others within a specified time, from, for instance, time spent out of bed between 7 am and 7 pm, number of social initiations that occurred within a specified time, activities such as bathing, engaging in household chores, or going out for a newspaper. The client's specific problem determined the definition of the observation codes. In order to encourage reliable recording, the practitioner wrote these codes in clear, objective terms using the client's language as much as possible. Instruments used to assess demographic characteristics included the Mental Status Questionnaire, (Kahn, Goldfarb, Pollock, & Peck, 1960); the Family Burden Scale (Zarit, Reever, & Bachman-Peterson, 1980); and the Older Americans Resource and Services Program (OARS) multidimensional assessment (Pfeiffer, 1976). These instruments were administered pre- and postintervention.
RESULTS AND CONCLUSIONS Elderly Clients and Caregivers Clients. The average age of the clients was 73 years, with 45°70 male and 5507o female and 6607o white and 3407o black. The marital status of the clients was 5807o married and 3607o widowed; the rest were divorced or single. Their mean income was $13,020; 56070 were living in their own homes. The seriousness of the 66 clients' impairments was established clearly by the following data from the OARS pretest. On scales ranging from 6 (positive) to 1 (negative), the following average data were obtained. Physical health was rated a mean of 5.57, mental health a mean of 4.12, and activities of daily living a mean of 4.77. Social resources earned a mean of 3.00, and economic resources a mean of 2.36. As compared with previous data on institutionalized samples (Kane & Kane, 1981), clients yielded a similar profile except they were more physically impaired than were nursing home comparison samples. Mental Status scores ranged from 0 to 100 (below 80 shows mental impair-
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ment) with means of 63 at pretest and 71 at posttest, a significant but expected change over time, (one-tailed tp < .03). An analysis of early client data showed that improved performance on the Mental Status Questionnaire occurred only for those who showed serious impairment at the onset. Caregivers. The mean age of the caregivers was 64 years; 75 % of them were female, 45% were spouses; 28% were adult children of the clients, and the remaining relationships were distributed evenly across siblings, friends, or other relatives. In keeping with the theory and philosophy of the behavioral clinical approach, 86% of the 96 behaviors treated were designed to increase desirable behaviors with only 14% of problems defined as decreasing negative behaviors. The behaviors defined as negative were extreme in nature and demanded intervention in order for the clients to improve along other dimensions. Exemplars of single-case graphs are presented in Figures 1-4 and are representative of how single case designs were used to monitor and evaluate interventions. Figures 1-3 illustrate the analysis and intervention with multiple problems of Client 1, a 66-year-old male diagnosed as clinically depressed and agitated with intermittent contact with reality. He was cared for by his spouse who complained of poor personal care, aggressive behavior, and social withdrawal. The first intervention addressed his personal care in three phases (Figure 1). In phase 1, his wife was asked to bring him a warm wet washcloth while he was still in bed, and to talk with him in a soothing manner when she washed and dried his hands and face. In phase 2, the client began to bathe weekly and, in phase 3, on request he washed his hands and face in the bathroom and usually bathed at least once a week. During follow-up calls for 1 year, his wife reported being able to maintain these behaviors with occasional outside hired help for haircuts and bathing.
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forcement procedure but to store needed objects elsewhere and to reduce their visits to his room to an average of 3 times per day. As depicted in Figures 2 and 3 this resulted in an increase in positive social behavior and a reduction in aggression. Client 2 was 84 years old and living with his wife who was his primary caretaker. He was referred to the Elderly Support Project because of depression and inactivity. Following baseline, the worker set a goal with the client and his wife to take one walk together around the block; during the second week the goal was altered to two short walks halfway around the block together. After returning home from their walk the client was given a glass of juice. During the fourth week of intervention, the number of walks was increased to three, and it was agreed the client could walk inside the apartment building in bad weather. In response to the client's complaints, his wife agreed to massage her husband's lower legs after they returned from walking (weeks 8 thru 11). An adjunct gain that was not measured was the increased opportunity for social contact between the couple. The data indicate a mean weekly frequency of 2 walks during baseline and about 4 walks during maintenance (Figure 4). Although gains observed in each individual behavior analysis are not particularly large, the changes across multiple clients support some causal inference and provide an excellent practitioner-researcher model for evaluating practice. Over all, clients' behavioral improvement occurred in 76070of the behaviors treated although compared to behavioral improvement with younger clients these improvements were sometimes small. Small improvements, however, tended to be valued more by the caregivers of the elderly than by parental change agents of children. In fact, some caregivers were comforted by graphs
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showing the maintenance of existing levels of positive behavior even when no improvement was shown. Four questions provided the basis for the analysis of the impact of the intervention on caregivers: (1) What were the initial consequences of caregiving? (2) Were consequences altered by the program? (3) What were the caregivers' abilities to alter consequences for the impaired elderly clients? (4) Did the ESP interventions alter caregivers' feelings of burden? Beginning with the initial consequence of caregiving, we found that 61% of our caregivers provided personal care or assistance to the elderly person, with 78 % providing medication, 80% help with managing finances, 65 % help with housekeeping, 83°70 help with meal preparation, 45% help with transportation, and 70% providing help with shopping. These percentages indicated that caregivers supplied a substantial amount of assistance; therefore, taking on additional responsibilities became one of the initial consequences of caregiving. Those tasks reported to be most burdensome were new tasks that caregivers had not performed in the past; for example, a wife who had not managed the budget or money found herself entirely responsible for finances, or a husband suddenly had to take responsibility for cooking, personal care, and housekeeping. Even the degree of task difficulty was not as taxing as were demands for changes in accustomed roles. In addition to asking about the kinds of services promised we asked caregivers to rate their own mental and physical health both of which earned means of "fair" ("3" on a five-point scale where 5 = excellent and 1 -- very poor). There were no significant changes either in physical or mental health scores from pre- to posttest, nor in the kinds of help which caregivers provided. An additional set of questions using a scale from 0 (completely dissatisfied) to l0 (completely satisfied), asked if the ESP interventions altered the caregivers' feelings of competence. At pre- and posttest caregivers were asked how satisfied they were with how they currently managed undesirable or problem behavior. On satisfaction with current ability to learn to change their relative's behaviors, caregivers rose from a rating of 4.4 at pretest to 6.6 at posttest, p < .001. Our final question of caregivers addressed alteration in their feelings of burden by comparing their pre- and posttest scores on the Zarit Burden Scale. There were no significant differences on the overall scores. Caregivers did report being less embarrassed by relative's behavior, on a scale of 1-5 (5 indicating extremely embarrassed) with responses changing from 1.8 at pretest to 1.5 at posttest, a significant improvement, p < .03. There was also some improvement on how much caregivers perceived the elderly person as having negative effects on their own relationships with family members and friends. On the same 1-5 scale, average interference dropped from 2.3 before to 1.6 after intervention, p < .01. Likewise, caregivers reported feeling less strain interacting with their elderly relative, a pre- to posttest drop of only 0.6 points but still significant, p < .03 level. While the foregoing results indicate some improvement, it is interesting that caregivers perceived their elderly relative as more dependent after the intervention with score changes from 4 to 4.4, p < .03. A primary factor influencing the caregivers' ability to alter consequences
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was availability to spend time with the client. This was considered within the context of competing demands. No competing demands were reported by 50°70 of our caregivers, 21°70 were engaged in part-time activities outside the home; 25°70 were employed part-time, plus having additional activities; and 4°7o reported extensive activities outside the home. Pains were taken to insure that adequate time was available to carry out procedures before the behavioral intervention was scheduled. An important factor determining caregivers' willingness to use their ability to alter behavioral consequences was how they viewed the elderly person's behavior. Most caregivers, 70070, were rated as having a realistic view of the elderly person's behavior; 1507o, however, did not understand the behavior nor how it was related to the elderly person's impairment; 10°70 thought the elder was being punitive to them; and 5 °7othought the elderly person was helpless and couldn't improve. In cases where change was not obtained, failure usually was due to poor health of the caregiver, nonreversible physical condition of the client and/or an inability to engage the caregiver to record data or implement the program. The number of program failures was small but, clearly, a therapist should assess a number of variables carefully before attempting an intervention. In general, the most effective caregivers were those who had 1) a realistic view of the elderly person's behavior, 2) a historically reciprocal relationship, 3) time available to spend with the elderly person, and 4) continued at least some positive activities both in and outside the home.
DISCUSSION Findings from this research contribute to a growing literature that suggests that operant procedures are valuable tools in the treatment of impairments associated with old age. Procedures based on reinforcement theory were used to create opportunities for elders to receive positive consequences for their behavior and to establish more prosthetic environments that are effective in regaining and supporting improved levels of functional behavior. Although difficult to demonstrate experimentally, it appeared to us that the procedures also helped to maintain existing levels of adaptive behavior in our clients. A central question addressed in this respect project was whether or not family members, often elderly themselves, are able to acquire the skills necessary to implement interventions with their relatives. Project staff worked with both caregivers and clients initially, but quickly faded from the treatment as the caregivers became proficient in conducting the intervention. As has been found with other impairments, some reinforcement procedures must continue in force even after the behavioral goal has been attained. In such cases, practitioners must carefully fade themselves from the program while maintaining systematic availability to the caregivers. Since maintenance of treatment goals is essential to treatment effectiveness, efforts aimed at fading are especially important. We felt strongly that another element central to the success of the project was the extensiveness of the assessment conducted prior to the implementation of behavior change procedures. Caution must be exercised when designing
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interventions for this frail group of elders to conduct a proper assessment of the caregivers' total situation and to insure that adequate resources, both physical and material, are available for a positive outcome. A trial and error approach must be avoided in order to minimize the risk of adding stress to the caregivers and decreasing the probability that they will seek help in the future. Care of seriously impaired individuals brings with it profound alterations in consequences for the caregiver. These consequences not only include an increase in response demands on the caregiver. These consequences not only include an increase in response demands on the caregiver, but also a loss of opportunity to engage in reinforcing and pleasurable activities. Many caregivers find themselves unable to even think of things they would enjoy doing. It is, of course, reasonable to place emphasis on pleasurable activities and respites to offset the taxing demands of caregiving. But, it is also important to study the naturalistic reinforcers that currently maintain caregiving behaviors, and to identify reinforcing consequences that caregivers desire from their friends, families, and society. A second question addressed in this project was whether behavioral techniques, specifically stimulus control and reinforcement, are useful in alleviating behavioral problems serious enough to place continued home care in jeopardy. Although the maintenance phase in our research is not complete, it seems clear that the interventions were effective in allowing caregivers to maintain efforts in providing care for their elderly relatives. We believe that results will sustain the promise of early intervention with depressed and demented clients. We were also interested in whether or not learning intervention skills would alter caregivers' perceptions of burden and competence. The answer in this domain was complex. Following training, caregivers reported increased competence and stated that they felt better able to cope with their problems. Overall scores on our measure of burden did not change, however; in fact, caregivers saw their relatives as more dependent on them after the intervention. Perhaps focus on the influence of the caregiver's behavior on the client contributed to this change. Alternatively, once caregivers felt more competent to manage and change behavior, they may have become more willing to admit the elderly person's dependendence on them. Clearly, more research is needed in this area. Finally, we studied the utility of single-case methods in the planning and implementation of interventions. Not only were these methods useful in the analysis of results, they were particularly helpful in assessing the problems and programming maintenance. As in behavioral parent training programs, the graphs were used to show caregivers the progress being made, and to demonstrate the functional relationships that behavior change efforts had on their relative's behavior. The recording of behavioral data and their figural depiction appeared to have great clinical value. The caregivers enjoyed this aspect of the project more often than not, and the graphs clearly aided in the development of interventions. In conclusion, results of this research suggest that operant procedures can be used to effectively modify the problems displayed by seriously impaired elderly persons. In our project, caregivers of elderly individuals suffering from a wide range of conditions, including dementia and depression, learned be-
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havioral technologies that allowed them to alleviate targeted problems and increase their own feelings of competence. We feel strongly that interventions with the frail elderly should involve and support the caregivers who frequently serve as their primary link to the least restrictive living environments. Our future research efforts will be directed at caregiver maintenance using operant theory to analyze the positive and negative consequences of caregiving and the value of providing increased rewards for caregivers combined with daycare or other forms of respite.
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Pinkston, E. M., Levitt, J. L., Green, G. R., Linsk, N. L. & Rzepnicki, T. L. (1982). Effective social work practice" Advanced techniques for behavioral intervention with individuals, families, and institutional staff. San Francisco: Jossey-Bass Publishers. Pinkston, E. M., & Linsk, N. L. (1984a). Behavior family intervention with the impaired elderly. The Gerontologist, 6, 576-583. Pinkston, E. M., & Linsk, N. L. (1984b). Care of the elderly." A family approach. New York: Pergamon Press. Polster, R. A. & Lynch, M. A. (1981). Single-subject design. In R. M. Grinnel, Jr. (Ed.), Social work research and evaluation, ltasca, IL: E E. Peacock Publishers. Shanas, E. (1960). Family responsibility and the health of older people. Journal of Gerontology, 15, 408-411. Shanas, E. (1978). Social myth as hypothesis: The case of family relatives of older people. The Gerontologist, 19, 3-9. Shanas, E. (1980). Older people and their families: The new pioneers. Journal o f Marriage and the Family, 42, 9-15. Sussman, M. B. (1965). Relationships of adult children with their parents in the United States. In E. Shanas & G. Streib (Eds.), Social structure and the family: Generational relations. Englewood Cliffs, N J: Prentice Hall. Treas, J. (1977). Family support systems for the aged: Some social and demographic considerations. The Gerontologist, 17, 486-491. U.S. Bureau of Census (1983). America in transition: An aging society. Current population reports. (Series P-23, No. 128). Washington, DC: U.S. Government Printing Office. Zarit, S. H., Orr, N. K., & Zarit, J. M. (1985). The hidden victims of AIzheimer's disease: Families under stress. New York: New York University Press. Zarit, S. H., Reever, K. E., & Bachman-Peterson, J. (1980). The burden interview. The Gerontologist, 20, 649-655. Zarit, S. H., Todd, P. A., & Zarit, J. M. (1986). Subjective burden of husbands and wives as caregivers: A longitudinal study. The Gerontologist, 26, 260-266. RECEIVEDI November 6, 1987 FINAL ACCEPTANCE,"December 10, 1987