Media-assisted parent training: Alternative models

BEHAVIOR THERAPY 10, 103--110 (1979)

Media-Assisted Parent Training: Alternative Models STAN L . O ' D E L L , N E I L D . M A H O N E Y , W A N D A G . HORTON, AND P A U L E . T U R N E R

University of Mississippi The investigation assessed the relative effectiveness of five training models designed to teach the skills for administering time-out to children. Sixty parents were randomly assigned to one of six treatment groups: no-treatment control, training via a written manual, training via a film, training via a film plus a brief individual checkout, individual training via modeling and rehearsal, and brief individual training via modeling and rehearsal. Outcome was assessed through a parent-attitude questionnaire and an in vivo demonstration in which each parent role played with a child actor. No differences among models were found in parents'-attitude responses. Measures of parents' actual skills attained showed all models were significantly better than no treatment. A film plus brief individual checkout was superior to all other models, followed by a film alone. The models using a written manual or individual modeling and rehearsal were all significantly less effective than the film plus checkout and equally effective to one another. Results suggest that training films may enhance parents' acquisition of operant conditioning skills and increase therapists' efficiency.

Training parents in behavior modification is an increasingly popular strategy for meeting the demands for children's services (O'Dell, 1974). Many therapists who train parents in behavioral principles and skills rely on various mass-produced media materials as primary or secondary sources of training. Presumably, these therapists assume such materials enhance the efficiency of the training process (Patterson, Cobb, & Ray, 1972). However, little research is available regarding' this assumption. There is conflicting evidence concerning the extent to which various models assist the parent in training (Glogower & Sloop, 1976; O'DelI, Flynn, & Benlolo, 1977). At one extreme, materials may be used in a self-help format with little or no therapist guidance (Rosen, 1976). At the This study was partially supported by a grant from the Committee on Faculty Research, University of Mississippi. The authors would like to express their appreciation to the following persons for their assistance: Larry Annis, Samuel Hester, Bobby Holstead, Glenn Lowitz, Wayne Maxwell, Don Nidiffer, Jackie O'Dell, Jo Ann O'Quin, Arthur Rosenblatt, Beverly Stubblefield, Steve Ulissi, and Tim Wallace. Reprint requests should be sent to Stan L. O'Dell, Department of Psychology, University of Mississippi, University, MS 38677. 103 0005- 7894/79/010103-08501.00/0 Copyright © 1979by Associationfor Advancementof BehaviorTherapy All rightsof reproductionin any form reserved.

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other extreme, therapists may rely solely on providing direct modeling and rehearsal with the parent (O'Dell et al., 1977). Recent research has evaluated the effectiveness of commercially available materials (Butler, 1976) and compared the relative effectiveness of different training models (Nay, 1976). Nay found videotaped modeling coupled with role playing to be superior to either a written presentation or a lecture but not superior to videotaped modeling alone. The present study provides a further analysis of the relative effectiveness and efficiency of various models in providing parents with a basic management skill--time-out (TO). The models compared involve two types of media presentations, individual modeling and rehearsal with the therapist, and combinations of media and individual training.

METHOD

Subjects Subjects consisted of 60 parents each of whom had a child between the ages of 1 and 12 years. They were recruited through letters to target groups having children in area preschools, radio advertisement, and a newspaper article. The recruitment solicited their cooperation in developing some child-management materials and did not offer treatment services. Special efforts were made to recruit blacks and lower socioeconomic parents. All parents received $5 for their participation. Participants included 9 males and 51 females of whom 41 were white and 19 were black. The average age was 30 years and the median income level was $12,000 per year. Three had less than an eighth-grade education, 21 had 9 to 12 years of education, 25 had 13 to 16 years, and 11 were college graduates. The mean IQ level was 103 (SD, 18.9). An ANOVA across groups performed on the IQ measure showed no significant differences among the groups.

Training Media Since the purpose of the study was to compare the effectiveness of various types of media upon parents' acquisition and use of TO skills, it was necessary to develop materials which differed in the presentation medium but which were parallel in content. The first step was to develop a behavioral analysis of TO. This analysis yielded 16 rules for using TO, for handling problems which were likely to occur, and for selecting a boring place. These 16 rules, described below, provided the content from which all media materials were developed and served as the basis for individual training via modeling and rehearsal. Using the 16 rules, one set of faculty and graduate students independently developed a written manual for teaching the TO skills. The 1500word manual was modeled after Becker and Becker's (1971) Successful Parenthood, Patterson's (1973)Families, and Blackham and Silberman's (1971) Modification of Child Behavior. Vocabulady was kept below an eighth-grade level, and content was presented in a series of step-by-step rules and procedures with examples of each.

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Another set of faculty and graduate students independently developed a 20-min sound color movie teaching the same TO skills. The movie was modeled after Hanson's (1969) film, Time Out: A Way to Help Children Behave Better, and Patterson and Forgatch's (1976) audio tape, Time Out. The movie consisted of edited scenes in which parents modeled the use of TO and how to respond to typical problems. Time-out was modeled in several families and in different settings to provide repetition and diversity. A narrator presented the scenes and stop-action was used for emphasis. The third medium of training consisted of individual modeling and behavioral rehearsal with the parent. Six third-year clinical graduate students in a behaviorally oriented program were given copies of the 16 rules and asked to develop modeling and rehearsal procedures for the training of parents in TO. Assessment The parents' intelligence levels were assessed through administration of the Vocabulary, Similarities, Picture Completion, and Block Design subtests of the WAIS. Full-scale and verbal IQ levels were prorated from these values. While using a brief version of the WAIS is undesirable for individual clinical work, such a procedure should be accepted for groupcomparative purposes. Parents' attitudes toward training were assessed through three 5-point Likert-scale items. The questions asked them to rate their overall impression of the training, how well they felt they understood the content, and how likely they would be to use the technique. The parents' skill in using TO was assessed through direct observation of their use of TO with a child during a structured role-playing procedure. This assessment was independently developed by two graduate students and was based on the same TO principles used to develop the media materials. The setting for role playing was a room in the psychology clinic designed to resemble the den in a home. The furnishings included carpet, four chairs, one recliner, two tables, a 4 by 5-ft partition, a kitchen timer, a radio (playing), a lamp, a plant, and ash trays. Toys, magazines, and comic books were in the immediate proximity of each chair. Four boys, ages 9 to ll, were each trained via a prewritten script to produce a specific chain of realistic problem behaviors which cued the parent to engage in the TO skills they had learned. At the beginning of the assessment, the parent was taken to the prepared room. They were read directions explaining that they were about to participate in a 15-min problem situation in which they should see the boy as their own son and use TO for his problem behavior--climbing on furniture. The following sequence of events would occur if the parent implemented TO "perfectly." After a brief period the boy would step up on the coffee table to get a comic book. The parent was to immediately emit a verbal cue such as "stop," calmly describe the undesirable behavior, and suggest an acceptable, desirable way for him to get his comic in the future. Then the

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parent was to select the most boring place in the room, a chair behind the partition, and lead the child there to TO. She/he was to remove the comic book from his hand, remove toys and magazines from the immediate vicinity, turn off the radio, set the timer for approximately 5 rain, tell him how much time he had to stay and say that he could come out when the bell sounded. When time was up the boy got up and returned to another chair. Then the boy again engaged in the problem behavior to which the parent was to respond with the same sequence. However, this time the boy tried to elicit an argument which the parent was to ignore and insist he go to TO. Also, the boy came out of TO early on this trial. The parent was to return him an additional time and repeat the rule about coming out early. On the third trial the boy refused to go to TO and the session was ended as soon as it could be seen if the parent reacted properly by not forcing the child into TO but instead withdrawing a privilege for refusing to go. The parents' skills were assessed from behind one-way mirrors by trained observers who were unaware of the type of training the parent had received. They could also communicate with the boy via a bug-in-the-ear if he forgot a step or was unsure how to respond. They checked off the occurrence or nonoccurrence of 33 sequential parent behaviors during the session. The sequence described above required the parent to exhibit the 16 TO behaviors on two or three trials. Of the 33 behaviors, 25 were considered relatively more important and were weighted by a factor of 2 in the scoring system. Nine of the behaviors were considered less important and were weighted by a factor of I (i.e., "Using a warning signal such as 'no' or 'stop' before using TO."). Thus, a parent's score could range from 0 to 65. Reliability was assessed by calculating the percentage of the 33 sequential behaviors which two observers checked identically for an individual parent. The mean percentage agreement for eight practice subjects before the study began was 94%. Reliability checks made during approximately half of the experimental sessions yielded a mean of 92% agreement between pairs of observers.

Training Models Parents participated in one of the following six types of training experiences: 1. No-treatment control (NT). Parents in this group received no training before attempting to use TO. 2. Written manual. Parents in this group were given the written manual and allowed 20 min to study the information. When asked, none reported having difficulty reading the manual in the time allowed. 3. Film. Parents in this group viewed the 20-min TO training film. 4. Film plus brief individual rehearsal and check out. Parents in this group viewed the film and then received 7 min of individual checkout which allowed the trainer to check their understanding of the material and provide a brief rehearsal of the technique.

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5. Individual modeling and rehearsal. Parents in this group were individually trained during a 20-min session in which the trainer modeled the behaviors to be learned and role played the part of the child, so the parent could practice and receive feedback. 6. Brief individual modeling and rehearsal. Parents in this group received 7 min of abbreviated training using modeling and rehearsal. This training provided a control comparison for the 7 extra min of individual training received by parents in Group 4. Procedure Groups of from 8 to 12 parents participated on six evenings. Parents in each evening's group were randomly assigned to a treatment with the stipulation that there be 10 per treatment group in the final sample. Following introductory remarks by the experimenter which explained the project and the evening's agenda, parents simultaneously underwent the 20-min training in separate rooms. As only two trainers were available, those receiving the 7-min training or checkout had to be trained after the 20-min sessions ended. Immediately following the training, the parent filled out the attitude questions. Parents then began individual participation in the role-playing assessment. While parents were waiting to participate, they filled out demographic information forms and were individually tested on the WAIS. The entire session took approximately 2 hr. Parents were fully informed of all aspects of the experiment before participation and were informed that a TO program used without a reinforcement program was usually undesirable. They were also told the experimenters were not necessarily encouraging them to use TO and that they should carefully evaluate it for their unique situation before using it as a discipline technique. They were also told that when actual future training groups were offered, they would be invited to attend at no charge. RESULTS The results of an ANOVA on the attitude questions showed the reported attitudes toward all types of training were equally positive and suggested a ceiling effect. Table 1 presents the means and standard deviations of parents' TO scores for each treatment. A two-factor ANOVA was run with the TO scores. The first factor consisted of the five TABLE 1 MEANS AND STANDARD DEVIATIONS OF GROUP TO SCORES Group

M SD

NT

Written

Film

Film plus checkout

Individual

Brief individual

10.6 4.9

35.0 17.9

47.4 10.1

52.7 9.3

39.2 6.5

38.6 11.5

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treatment groups. The second factor was based on the parents' prorated verbal IQ scores and was divided into two levels using a median split. The main effects of the Groups were significant, F (4, 40) = 4.4, p < .01, as well as Verbal Scale IQ scores, F (1, 40) = 5.6, p < .05. The interaction effects of TO scores by IQ was nonsignificant, F (4, 40) = 1.1, p > .05. Duncan's multiple range test was used to determine the relative effectiveness of the five types of training. Table 2 presents a matrix of the difference in means for all pairs of treatment groups. The results suggest that the best training was film plus individual checkout. This treatment was significantly better than all others except film alone.

DISCUSSION There are several limitations of the interpretation and generalization of the results. It is quite possible, perhaps probable, that there are interaction effects between the type of training, the content of the material, the types of parents, and/or the timing and type of outcome measures. Such effects are not assessed by the present study. The present study looked at only one aspect of these dimensions and used only a short-term clinic assessment of parents' skills. The most important implication of the study seems to be that it does not appear possible to fully assess the effectiveness of parent-training techniques without consideration of the medium through which the information was presented. The type of media may significantly effect the effectiveness and cost-efficiency of the training. Written materials provide perhaps the least expensive training model and can be studied repeatedly at home. However, when training time was held constant, written materials proved to be a relatively less effective medium as is reflected by this group's variability (see Standard deviations, Table 1). The addition of individual checkout following written training was not assessed but could prove to be an effective and cost-efficient model. Individual training is costly but has advantages of visual demonstration, TABLE 2 MEAN TO SCORE DIFFERENCES AMONG PAIRS OF GROUPS

Group Group Written Film Film plus checkout Individual *p < .05 **p < .01

Film 12.4"

Film plus checkout 17.7"* 5.3

Individual 4.2 8.2 13.5"*

Brief individual 3.6 8.8 14. !** .7

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and the opportunity for the parent to practice skills and receive feedback. At the inception of the study, the individual modeling and rehearsal was assumed to be the most effective model. The reason that the 20-min individual training failed to be more effective than either the written training or 7-min individual training remains unclear. One reason that the 7-min training was as effective as the 20-min training could have been that each trainer always completed a 20-min training session with one parent before undertaking a 7-min session with another parent. Also, some trainers reported talking much faster in the brief training. Filmed materials are often initially costly to develop. However, they have the advantages of mass dissemination, low individual training cost when used with groups, and they can be shown by untrained personnel. The film treatment seemed to be able to train a wider range of parents more consistently and satisfactorily. Film has advantages over written materials such as visual demonstration of skills and the fact that, generally, information can be communicated more rapidly via visual media. Its advantages over live modeling include its ability to have several different persons demonstrate skills in a variety of realistic settings, editing techniques can greatly reduce nonproductive time, and film is completely replicable. However, there may be ethical issues to consider when parents are trained without individual feedback, as some parents do misunderstand and misuse the technique. The most effective model was the combination of filmed training plus a 7-min individual checkout from the trainer. This took little therapist time and resulted in half of the parents in this group achieving nearly perfect scores. This compromise between mass-disseminated treatment and individual training seems to be a relatively effective and cost-efficient model. Parent trainers may find their time spent more efficiently if they provide the parent with an individual checkout following media training such as film, rather than a longer period of direct individual training without media assistance. This may also be true for other types of therapy situations, such as training clients in relaxation, assertive training, or social reinforcement. REFERENCES Becker, W. C. Parents are teachers. Champaign, IL: Research Press, 1971. Becker, W. C., & Becker, J. W. Successful parenthood. Chicago: Follett, 1974. Blackham, G. J., & Silberman, A. Modification o f child behavior. Belmont, CA: Wadsworth, 1971. Butler, J. F. The toilet training success of parents after reading Toilet training in less than a day. Behavior Therapy, 1976, 7, 185-191. Glogower, F., & Sloop, E. W. Two strategies of group training of parents as effective behavior modifiers. Behavior Therapy, 1976, 7, 177-184. Hanson, R. (Producer). Time out: A way to help children behave better. Detroit, MI: lnformatics, 1969. (Film) Kirk, R. E. Experimental design: Procedures for the behavioral sciences. Belmont, CA: Brooks/Cole, 1968. Nay, R. W. A systematic comparison of instructional techniques for parents. Behavior Therapy, 1976, 6, 14-21.

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O'Dell, S. L. Training parents in behavior modification: A review. Psychological Bulletin, 1974, 81, 418-433. O'DelI, S. L., Flynn, J. M., & Benlolo, L. T. A comparison of parent training techniques in child behavior modification. Journal of Behavior Therapy and Experimental Psychiatry, 1977. Patterson, G. R. Families. Champaign, IL: Research Press, 1973. Patterson, G. R., Cobb, J. A., & Ray, R. S. A social engineering technology for retraining the families of aggressive boys. In H. E. Adams & I. P. Unikel (Eds.), Issues and trends in behavior therapy. Springfield, IL: Charles C Thomas, 1972. Patterson, G. R., & Forgatch, M. (Producers). F , mily living series~Time out. Champaign, IL: Research Press, 1975. (Audiotape) Rosen, G. M. The development and use of non-prescription behavior therapies. American Psychologist, 1976, 1, 139-141. RECEIVED; July 20, 1977; REVISED"November 15, 1977 FINAL ACCEPTANCE:December 6, 1977