Journal of Consulting and Clinical Psychology 1977, Vol. 45, No. 5, 724-729
Marital Adjustment and the Efficacy of Behavior Therapy with Children Thomas F. Oltmanns, Joan E. Broderick, and K. Daniel O'Leary State University of New York at Stony Brook Parents of 62 children referred to a behaviorally oriented child psychological clinic provided measures of marital adjustment and their children's behavior before and after treatment. Parents of 31 nonreferred children of the same age and socioeconomic status as the clinic sample provided the same self-report measures. Marital adjustment scores of clinic parents were significantly lower than those of the control sample, although there was considerable overlap between the distribution of scores. Further, there was a consistent negative correlation between marital adjustment and severity of children's behavior problems. However, pretreatment level of marital discord was not related to degree of positive behavior change observed at therapy termination or at a S-month follow-up. Difficulty in obtaining follow-up data from parents was correlated with a small degree of improvement in child behavior. Behavior therapists have been largely concerned with parents' roles as models, reinforcers, and punishers in the etiology and treatment of children's problems (Becker, 1971; O'Leary & Wilson, 1975; Patterson, 1974; Wahler, 1976). Family therapists acknowledge such determinants of children's problems, but they have placed much stronger emphasis on the importance of parents' marital adjustment than behavior therapists. For example, Satir (1964) noted that parents' dissatisfaction with their own relationships may directly precipitate and maintain behavior problems in their children. Indeed, there is growing support for this notion. A number of studies have demonstrated greater communication problems (e.g., Gassner & Murray, 1969; Leighton, Stollak, & Ferguson, 1971) and less satisfaction with marriage (e.g., Love & Kaswan, 1974) in parents of referred than in parents of nonreferred children. Within a clinic sample, Johnson and Lobitz (1974) found a moderate correlation between marital adjustment and rate of deviant We are grateful to the graduate students and faculty of the clinical program who served as therapists and supervisors. We also thank Roger Schvaneveldt and Joel Redfield for assistance in data analysis. Requests for reprints should be sent to K. Daniel O'Leary, Department of Psychology, State University of New York, Stony Brook, New York 11794.
child behavior. More importantly, early family discord predicts later delinquent behavior (Rutter, 1971; Tait & Hodges, 1962), suggesting that marital problems may, in some cases, determine a child's behavior problems. In sum, not only are parents' marital problems related to child deviance, but the alleviation of marriage problems may prevent deviance. These data, as well as our own clinical impressions (Kent & O'Leary, 1976) and those of Patterson (Patterson, Cobb, & Ray, 1973), indicate that efficacy of behavioral treatments might be enhanced by more attention to the parents' marital relationship. However, there has been no attempt to determine whether marital adjustment affects a behavior therapist's ability to effect change in either specific deviant behaviors or the child's overall adjustment. This question has important implications for the assessment of children's behavior problems and for the temporal ordering of planned interventions (i.e., directed at either the parents or the child). The present study was designed to investigate the relationship between parents' marital adjustment and therapeutic success in a child clinic setting. If marital adjustment is related to therapeutic success, then parents initially reporting the greatest disharmony should report the smallest changes in their children's behavior during treatment.
724
MARITAL ADJUSTMENT AND BEHAVIOR THERAPY WITH CHILDREN Method Subjects Our clinic sample included 62 children who were treated at the Psychological Center of the State University of New York at Stony Brook between September 1974 and May 1975. This group included 49 families with both parents living in the home (intact families), 38 male and 11 female children, and 13 families with only the mother living in the home, 1 female and 12 male children. Data from the mother-only group are not fully presented here, since the focus of this study was on the assessment of marital distress and change during treatment. The average age of the clinic children was 9.7 years. The parents of intact families were married an average of 13.3 years and had an average socioeconomic status rating of 4.7 on a 10-point scale (Duncan, 1961). The clinic is behaviorally oriented. Its clients, therapists, and procedures have been described elsewhere (O'Leary, Turkewitz, & Taffel, 1973). Specific presenting problems were quite varied, but most of the children would be labeled unsocialized aggressive reaction of childhood, overanxious reaction of childhood, or withdrawing reaction of childhood according to the APA Diagnostic and Statistical Manual (1968). A community control sample (N = 37) with a child between kindergarten and the ninth grade was selected randomly from local school census records. The 37 control families were chosen on the basis of having a child of the same grade and sex as a clinic child. This sample was used to ascertain whether the clinic sample reported significantly greater marital distress and greater child deviance than is found in the general community. The parents were contacted by unannounced home visits. Parents were offered $15 to participate. Our selection methodology for the nonclinic cases was chosen to maximize participation by the contacted families to avoid the bias introduced by using volunteer families. The average control child was 9.5 years old. The control parents had been married an average of 15.1 years and had a socioeconomic status rating of 5.3.
Measures Marital adjustment was indexed by parents' selfreport on the Short Marital Adjustment Test (SMAT). The SMAT has been shown to distinguish harmonious and disturbed marriages (Locke & Wallace, 1959), and a longer form has proven remarkably stable over a 2J-year period (Kimmel & van der Veen, 1974). Children's general level of deviant behavior was assessed by parental report on the Behavior Problem Checklist (BPC) described by Quay (1972). The checklist contains 55 items that are rated on a 3-point scale. Scores cluster into four factors: Conduct Disorder, Personality Disorder, Inadequacy-Immaturity, and Subcultural Deviance. Speer (1971) established the validity of these factors in distinguishing between children referred for psychological treatment, their siblings, and nonreferred peers. Children's specific behavior problems
725
were assessed by ratings of individual target behaviors deemed important by both parent and therapist. Such measures are sensitive to change (Kent & O'Leary, 1976), and they significantly relate to direct observation of such behaviors (Kent & Foster, 1977, chap. 9).
Procedure Clinic parents were asked to complete independently the SMAT and BPC before their initial clinic appointments. This information was not made available to the family's therapist. Control families were contacted in the fall of 1975. Both parents completed the SMAT and the BPC for the child who was selected from the census records. At treatment termination, each therapist was asked to rate the outcome of each target behavior separately on a V-point scale (from "much worse" to "much improved") and to indicate the percent of time spent dealing with the children's specific problems and the parents' marital adjustment.
Follow-up Procedure Follow-up questionnaires were obtained from each parent individually at approximately 5 months after the termination of therapy. These forms included a BPC, SMAT, and a listing of the target behaviors indicated by the therapist that the parents were to rate using the 7-point scale previously described. After all follow-up forms had been obtained (or the parents had openly refused to cooperate), two authors independently rated each family with regard to the difficulty of obtaining this information. A 5-point "hassle" rating was used with the following anchor points: Forms were mailed and promptly returned (1); call was made reminding parents to return forms (2); call was made and a second set of forms had to be sent or two calls had to be made about the first set (3); second call was needed after a second set of forms was mailed or the husband refused to cooperate after the wife had returned her evaluation (4); and three or more calls had to be made, three or more sets of forms had to be mailed, registered letters had to be sent, or both parents refused to cooperate (5).
Results In 2 of the 37 control families, the parents were divorced and the mother was living alone with the children. These mothers were eliminated because our primary interest was in obtaining a control sample of SMAT scores from intact marriages. Of the remaining 35 families, only 4 refused to participate, leaving 31 families, or 89%, of the intact contacted sample. In the clinic sample, 7 (14%) of the intact families terminated therapy before the comple-
726
T. OLTMANNS, J. BRODERICK, AND K. O'LEARY
Table 1 Mean Marital Adjustment Scores and Ratings of Children's Behavioral Adjustment by Parents in both Clinic Groups and the Control Sample Clinic families Both parents
Control families
Measure
Mother only
Mother
Father
Mother
Father
SMAT BPC Conduct Disorder Personality Disorder Inadequacy-Immaturity Subcultural Deviance
—
103.1 (26.5)
107.8 (21.2)
122.0 (21.5)
122.0 (22.4)
17.5 11.6 4.3 1.9
13.1 9.1 3.9 .9
12.1 8.0 3.5 .7
3.9 4.8 1.5 .1
4.6 4.0 1.9 .2
Note. Numbers in parentheses are standard deviations.
tion of five sessions.1 In contrast, 6 of the 13 mother-only families (46%) terminated before completing five sessions. Pretreatment Comparisons Average SMAT scores are presented in Table 1. Data were analyzed using a 2 (clinicnonclinic) X 2 (sex of parent) unweightedmeans analysis of variance. SMAT scores of intact clinic parents were significantly lower than the control sample, F(l, 78) = 10.65, p < .01. Correlations between SMAT scores and socioeconomic status were insignificant. Correlations between SMAT scores and years married were also insignificant. After obtaining significant effects in the analyses of variance on pretherapy BPC scores in comparisons of the three groups (intactclinic, mother-only-clinic, and community sample), individual comparisons were made using Scheffe's multiple comparison method. For the Conduct, Personality, and Immaturity factors, the intact clinic and the mother-only clinic groups were each significantly different on these factors (p < .05). On the fourth factor, Subcultural Deviance, the mother-only clinic group and the two clinic groups combined were significantly different from the community sample (p < .05). However, the intact clinic group did not differ from the community group, and the two clinic groups did not differ from each other. Correlations were computed between parents' SMAT scores and BPC ratings of their
children's behavior for the clinic sample (intact families). There was a significant negative relationship between the parents' marital satisfaction and their children's behavioral deviance (see Table 2). Similar correlations for the control sample were not significant. Treatment Outcome Average length of treatment was 12.3 sessions, and an average of 90% of therapy time was spent on the children's behavior alone. To determine an average improvement rating for individual children, each child was designated as either improved or unimproved by averaging the ratings (1-7 scale) made for all of the child's target behaviors. Average scores of 4.5 and above were considered improved, and 4.4 and below were designated as unimproved. By these standards, 40 out of 46 children (87%) were rated as improved by their therapists. The mothers rated 44 out of 48 children (92%) as improved, and 29 out of 35 children (83%) were considered as improved by their fathers. Some outcome information was obtained for each of the 49 children who completed at least five treatment sessions. Therapists' ratings of target behaviors were available for 39 of the 42 clinic cases. In one family, both parents re1
This arbitrary limit was established for the inclusion of families in the outcome data, since our primary interest was in the effect of treatment as influenced by marital adjustment, and we felt that this must allow for a minimum length of contact.
MARITAL ADJUSTMENT AND BEHAVIOR THERAPY WITH CHILDREN
fused to return the forms, but the mother's ratings of target behaviors were obtained by phone. For three additional families, one parent refused to cooperate or was otherwise unavailable for comment (two fathers and one mother), but the other parent completed the entire evaluation form. Finally, two families refused to complete the SMAT at follow-up, but they did return the BPC and target ratings. To determine the potential effect of not persistently pursuing follow-up data, we examined the relationship between difficulty in obtaining follow-up data and ratings of target behavior improvement. The interrater reliability of our hassle ratings was highly significant (r = .98). The five hassle ratings were collapsed into three categories (1 and 2, n = 19; 3 and 4, n = 17; and 5, n = 13) to obtain adequate expected cell frequencies in chi-square analyses. Similarly, mean target behavior ratings made by parents and therapists were grouped into a significant improvement category (6 and 7, n = 34) and a category reflecting no improvement to only slight improvement (1-5, n = 15). Children of parents who were most delinquent in returning the forms were more frequently rated as showing low improvement by their therapists at close of treatment, X 2 (2) = 6.99, p < .05, and by the combination of their parents' ratings at follow-up, X 2 (2) = 8.22, p < .05. Comparisons of pretreatment and posttreatment BPC weighted scores were made using a separate repeated measures analysis of variance for each factor. The mothers and fathers rated their children as significantly (p < .05) improved on all BPC factors at termination, except that the fathers did not report significant improvement on Subcultural Deviance. The SMAT scores of the intact clinic families declined very slightly after treatment. The mothers' scores dropped from 103.1 to 100.2, and the fathers' scores dropped from 107.8 to 105.4. These changes were not significant. Relationship Between Marital Adjustment and We were unable to compute meaningful correlations between the parents' pretreatment SMAT scores and the ratings of target behaviors at termination because of the restricted
727
Table 2 Correlations between Marital Adjustment and Ratings of Children's Deviance Clinic sample Measure of child's
behavior
Mothers
BPC Conduct Disorder Personality Disorder Inadequacy-Immaturity Subcultural Deviance
-.37** -.31* -.36** -.33*
Fathers
_.40«* -.24 -.34* -.43***
*p < .05. ** p < .02. *** p < .01.
range of the latter measure. Alternatively, the clinic sample was divided into quartiles based on the average SMAT scores of the parents. All of the quartiles reported very similar moderate rates of improvement, F(2, 57) = .35. In addition to these comparisons, the children's BPC change scores on each subscale were correlated with the intake SMAT scores of their parents. 'Given the unequal initial levels of child deviance reported by parents with varying intake SMAT scores, the initial BPC subscale scores were partialed out from the BPC change scores (part correlation, McNemar, 1975). The results of this analysis indicated no significant relationship between SMAT scores and BPC change scores on any of the subscales for either mothers' or fathers' ratings. Discussion Parents of clinic children generally reported less satisfaction with their marriages than did the parents of our community sample. This finding is consistent with earlier reports of parents who had referred their children to psychological clinics (e.g., Love & Kaswan, 1974) and suggests that some parents seeking behavioral treatment for their children are also troubled by marital problems. These problems, however,1 may not be presented to the therapist as immediate areas of concern. It is thus the therapist's responsibility to assess the parents' relationship and to determine whether it is an important factor in maintaining the child's deviant behavior.
728
T. OLTMANNS, J. BRODERICK, AND K. O'LEARY
Although a portion of our clinic parents were experiencing marital difficulties, it is particularly important to note that there was significant overlap between the distributions of SMAT scores in the two samples. A few family therapists have speculated that behavior problems in children are always associated with marital discord. For example, Framo (1975) asserted that "whenever you have a disturbed child, you have a disturbed marriage" (p. 22). This relationship was definitely not observed in our sample. Given the rather modest, albeit consistent, associations reported between marital conflict and children's behavior, overly ambitious speculation such as Frame's is likely to unnecessarily alienate those parents whose marriages are not disturbed when they seek treatment for their children. Even though therapists should be aware of the possibility of marital discord, they need not attend rigidly to it. The overall treatment success we observed was quite comparable to that reported by O'Leary et al. (1973). The average mothers' improvement rating in that study was 90%, as compared to the present rate of 92%. Since our study was not intended to assess the efficacy of behavior therapy per se, we did not use the necessary controls to assert that our procedures were more effective than other alternatives or indeed than no treatment at all. Nevertheless, the observed rates of improvement are substantially higher than those reported by Levitt (1963) in a survey of therapeutic success in various child clinic settings and in groups that did not receive treatment. The efficacy of many of the treatment procedures used in the setting of the present study has been documented in controlled evaluations (Gelfand, in press; Kent & O'Leary, 1976; Patterson, 1974). Further, improvement in general factors of adjustment (BPC subscales) associated with specific improvement in identified problems suggests that the success of behavior therapy is probably not limited to change in specific target behaviors. The observed relationship between our ratings of difficulty in obtaining follow-up data and reports of therapeutic success by both parents and therapists indicates that our improvement estimates would have been even higher if we had been less diligent in our pursuit of
follow-up data. This pattern lends further empirical support to skeptics who have urged caution in interpreting therapeutic success rates that are based on only a portion of the families seen in treatment (Kent, 1976). References American Psychiatric Association. Diagnostic, and statistical manual of mental disorders (3rd ed.). Washington, D. C.: Author, 1968. Becker, W. C. Parents are teacliers. Champaign, 111.: Research Press, 1971. Duncan, O. D. A socioeconomic index for all occupations. In A. J. Reiss (Ed.), Occupations and social status. New York: Free Press of Glencoe, 1961. Framo, J. L. Personal reflections of a family therapist. Journal of Marriage and Family Counseling, 1975, 1, 15-28. Gassner, S., & Murray, E. J. Dominance and conflict in the interactions between parents of normal and neurotic children. Journal of Abnormal Psychology, 1969, 74, 33-41. Gelfand, D. M. Behavioral treatment of avoidance, social withdrawal, and negative emotional states. In B. B. Wolman, J. Egan, & A. 0. Ross (Eds.), Handbook of treatment of mental disorders in childhood and adolescence. Englewood Cliffs, N.J.: PrenticeHall, in press. Johnson, S. M., & Lobitz, C. K. The personal and marital adjustment of parents as related to observed child deviance and parenting behavior. Journal of Abnormal Child Psychology, 1974, 2, 193-207. Kent, R. N. A methodological critique of "Interventions for boys with conduct problems." Journal of Consulting and Clinical Psychology, 1976, 44, 297299. Kent, R. N., & Foster, S. L. Direct observation procedures: Methodological issues in naturalistic settings. In A. Ciminero, K. Calhoun, & H. E. Adams (Eds.), Handbook for behavioral assessment. New York: Wiley, 1977. Kent, R. N., & O'Leary, K. D. A controlled evaluation of behavior modification with conduct problem children. Journal of Consulting and Clinical Psychology, 1976, 44, 586-596. Kimmel, D. C., & van der Veen, F. Factors of marital adjustment in Locke's marital adjustment test. Journal of Marriage and the Family, 1974, 36, 57-63. Leighton, L. A., Stollak, G. E., & Ferguson, L. R. Patterns of communication in normal and clinic families. Journal of Consulting and Clinical Psychology, 1971, 36, 252-256. Levitt, E. E. Psychotherapy with children: A further evaluation. Behaviour Research and Therapy, 1963, 1, 45-51. Locke, H. J., & Wallace, K. M. Short marital-adjustment and prediction tests: Their reliability and validity. Marriage and Family Living, 1959, 21, 251-255. Love, L. R., & Kaswan, J. W. Troubled children: Their families, schools, and their treatments. New York: Wiley, 1974.
MARITAL ADJUSTMENT AND BEHAVIOR THERAPY WITH CHILDREN McNemar, Q, Psychological statistics (4th ed.). New York: Wiley, 19V5. O'Leary, K. D., Turkewitz, H., & Taffel, S. J. Parent and therapist evaluation of behavior therapy in a child psychological clinic. Journal of Consulting and Clinical Psychology, 1973, 41, 279-283. O'Leary, K. D., & Wilson, G. T. Behavior therapy: Application and outcome. Englewood Cliffs, N.J.: Prentice-Hall, 1975. Patterson, G. R. Intervention for boys with conduct problems: Multiple settings, treatments, and criteria. Journal of Consulting and Clinical Psychology, 1974, 42, 471-481. 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, 111.: Charles C Thomas, 1973. Quay, H. C. Patterns of aggression, withdrawal, and immaturity. In H. C. Quay & J. S. Werry (Eds.), Psychopatlwlogical disorders of children. New York: Wiley, 1972.
Ruttcr, M. Parent-child separation: Psychological effects on the children. Journal of Child Psychology and Psychiatry, 1971, 12, 233-260. Satir, V. Conjoint family therapy: A guide to theory and technique. Palo Alto, Calif.: Science and Behavior Books, 1964. Speer, D. C. Behavior problem checklist (PetersonQuay) : Baseline data from parents of child guidance and nonclinic children. Journal of Consulting and Clinical Psychology, 1971, 36, 221-228. Tait, C. D., & Hodges, E. F. Delinquents, their families and the community. Springfield, 111.: Charles C Thomas, 1962. Wahler, R. G. Deviant child behavior within the family: Developmental speculation and behavior change strategies. In H. Lcitenberg (Ed.), Handbook of behavior modification and therapy. Englewood Cliffs, N.J.: Prentice-Hall, 1976. Received February 9, 1976
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2. Agrees not to submit the full report to another journal of general circulation. Specifications. The Brief Report should give a clear, condensed summary of the procedure of the study and as full an account of the results as space permits. To ensure that a brief report does not exceed two printed pages, follow these instructions for typing: (a) Set typewriter to a 48space line, (b) Type text, (c) Count all lines except abstract, title, and by-line, including acknowledgments. If you have exceeded 185 lines, shorten the material, (d) If your brief report barely exceeds 75 lines (one printed page), try to edit to 75 lines exactly. Reports slightly exceeding one page will be edited for length in order to use space economically. In Brief Reports, headings, tables, and references arc avoided, or, if essential, must be counted in the 75 lines. This journal no longer requires an extended report, but if one is available, it must be available without charge to readers who request a copy. Each such Brief Report must also be accompanied by the following footnote: Requests for reprints and for an extended report of this study should be sent to John Doc (give the author's full name and address). The footnote should be typed on a separate sheet and not counted in the 75-line quota.
Marital Adjustment and the Efficacy of Behavior Therapy with Children Thomas F. Oltmanns, Joan E. Broderick, and K. Daniel O'Leary State University of New York at Stony Brook Parents of 62 children referred to a behaviorally oriented child psychological clinic provided measures of marital adjustment and their children's behavior before and after treatment. Parents of 31 nonreferred children of the same age and socioeconomic status as the clinic sample provided the same self-report measures. Marital adjustment scores of clinic parents were significantly lower than those of the control sample, although there was considerable overlap between the distribution of scores. Further, there was a consistent negative correlation between marital adjustment and severity of children's behavior problems. However, pretreatment level of marital discord was not related to degree of positive behavior change observed at therapy termination or at a S-month follow-up. Difficulty in obtaining follow-up data from parents was correlated with a small degree of improvement in child behavior. Behavior therapists have been largely concerned with parents' roles as models, reinforcers, and punishers in the etiology and treatment of children's problems (Becker, 1971; O'Leary & Wilson, 1975; Patterson, 1974; Wahler, 1976). Family therapists acknowledge such determinants of children's problems, but they have placed much stronger emphasis on the importance of parents' marital adjustment than behavior therapists. For example, Satir (1964) noted that parents' dissatisfaction with their own relationships may directly precipitate and maintain behavior problems in their children. Indeed, there is growing support for this notion. A number of studies have demonstrated greater communication problems (e.g., Gassner & Murray, 1969; Leighton, Stollak, & Ferguson, 1971) and less satisfaction with marriage (e.g., Love & Kaswan, 1974) in parents of referred than in parents of nonreferred children. Within a clinic sample, Johnson and Lobitz (1974) found a moderate correlation between marital adjustment and rate of deviant We are grateful to the graduate students and faculty of the clinical program who served as therapists and supervisors. We also thank Roger Schvaneveldt and Joel Redfield for assistance in data analysis. Requests for reprints should be sent to K. Daniel O'Leary, Department of Psychology, State University of New York, Stony Brook, New York 11794.
child behavior. More importantly, early family discord predicts later delinquent behavior (Rutter, 1971; Tait & Hodges, 1962), suggesting that marital problems may, in some cases, determine a child's behavior problems. In sum, not only are parents' marital problems related to child deviance, but the alleviation of marriage problems may prevent deviance. These data, as well as our own clinical impressions (Kent & O'Leary, 1976) and those of Patterson (Patterson, Cobb, & Ray, 1973), indicate that efficacy of behavioral treatments might be enhanced by more attention to the parents' marital relationship. However, there has been no attempt to determine whether marital adjustment affects a behavior therapist's ability to effect change in either specific deviant behaviors or the child's overall adjustment. This question has important implications for the assessment of children's behavior problems and for the temporal ordering of planned interventions (i.e., directed at either the parents or the child). The present study was designed to investigate the relationship between parents' marital adjustment and therapeutic success in a child clinic setting. If marital adjustment is related to therapeutic success, then parents initially reporting the greatest disharmony should report the smallest changes in their children's behavior during treatment.
724
MARITAL ADJUSTMENT AND BEHAVIOR THERAPY WITH CHILDREN Method Subjects Our clinic sample included 62 children who were treated at the Psychological Center of the State University of New York at Stony Brook between September 1974 and May 1975. This group included 49 families with both parents living in the home (intact families), 38 male and 11 female children, and 13 families with only the mother living in the home, 1 female and 12 male children. Data from the mother-only group are not fully presented here, since the focus of this study was on the assessment of marital distress and change during treatment. The average age of the clinic children was 9.7 years. The parents of intact families were married an average of 13.3 years and had an average socioeconomic status rating of 4.7 on a 10-point scale (Duncan, 1961). The clinic is behaviorally oriented. Its clients, therapists, and procedures have been described elsewhere (O'Leary, Turkewitz, & Taffel, 1973). Specific presenting problems were quite varied, but most of the children would be labeled unsocialized aggressive reaction of childhood, overanxious reaction of childhood, or withdrawing reaction of childhood according to the APA Diagnostic and Statistical Manual (1968). A community control sample (N = 37) with a child between kindergarten and the ninth grade was selected randomly from local school census records. The 37 control families were chosen on the basis of having a child of the same grade and sex as a clinic child. This sample was used to ascertain whether the clinic sample reported significantly greater marital distress and greater child deviance than is found in the general community. The parents were contacted by unannounced home visits. Parents were offered $15 to participate. Our selection methodology for the nonclinic cases was chosen to maximize participation by the contacted families to avoid the bias introduced by using volunteer families. The average control child was 9.5 years old. The control parents had been married an average of 15.1 years and had a socioeconomic status rating of 5.3.
Measures Marital adjustment was indexed by parents' selfreport on the Short Marital Adjustment Test (SMAT). The SMAT has been shown to distinguish harmonious and disturbed marriages (Locke & Wallace, 1959), and a longer form has proven remarkably stable over a 2J-year period (Kimmel & van der Veen, 1974). Children's general level of deviant behavior was assessed by parental report on the Behavior Problem Checklist (BPC) described by Quay (1972). The checklist contains 55 items that are rated on a 3-point scale. Scores cluster into four factors: Conduct Disorder, Personality Disorder, Inadequacy-Immaturity, and Subcultural Deviance. Speer (1971) established the validity of these factors in distinguishing between children referred for psychological treatment, their siblings, and nonreferred peers. Children's specific behavior problems
725
were assessed by ratings of individual target behaviors deemed important by both parent and therapist. Such measures are sensitive to change (Kent & O'Leary, 1976), and they significantly relate to direct observation of such behaviors (Kent & Foster, 1977, chap. 9).
Procedure Clinic parents were asked to complete independently the SMAT and BPC before their initial clinic appointments. This information was not made available to the family's therapist. Control families were contacted in the fall of 1975. Both parents completed the SMAT and the BPC for the child who was selected from the census records. At treatment termination, each therapist was asked to rate the outcome of each target behavior separately on a V-point scale (from "much worse" to "much improved") and to indicate the percent of time spent dealing with the children's specific problems and the parents' marital adjustment.
Follow-up Procedure Follow-up questionnaires were obtained from each parent individually at approximately 5 months after the termination of therapy. These forms included a BPC, SMAT, and a listing of the target behaviors indicated by the therapist that the parents were to rate using the 7-point scale previously described. After all follow-up forms had been obtained (or the parents had openly refused to cooperate), two authors independently rated each family with regard to the difficulty of obtaining this information. A 5-point "hassle" rating was used with the following anchor points: Forms were mailed and promptly returned (1); call was made reminding parents to return forms (2); call was made and a second set of forms had to be sent or two calls had to be made about the first set (3); second call was needed after a second set of forms was mailed or the husband refused to cooperate after the wife had returned her evaluation (4); and three or more calls had to be made, three or more sets of forms had to be mailed, registered letters had to be sent, or both parents refused to cooperate (5).
Results In 2 of the 37 control families, the parents were divorced and the mother was living alone with the children. These mothers were eliminated because our primary interest was in obtaining a control sample of SMAT scores from intact marriages. Of the remaining 35 families, only 4 refused to participate, leaving 31 families, or 89%, of the intact contacted sample. In the clinic sample, 7 (14%) of the intact families terminated therapy before the comple-
726
T. OLTMANNS, J. BRODERICK, AND K. O'LEARY
Table 1 Mean Marital Adjustment Scores and Ratings of Children's Behavioral Adjustment by Parents in both Clinic Groups and the Control Sample Clinic families Both parents
Control families
Measure
Mother only
Mother
Father
Mother
Father
SMAT BPC Conduct Disorder Personality Disorder Inadequacy-Immaturity Subcultural Deviance
—
103.1 (26.5)
107.8 (21.2)
122.0 (21.5)
122.0 (22.4)
17.5 11.6 4.3 1.9
13.1 9.1 3.9 .9
12.1 8.0 3.5 .7
3.9 4.8 1.5 .1
4.6 4.0 1.9 .2
Note. Numbers in parentheses are standard deviations.
tion of five sessions.1 In contrast, 6 of the 13 mother-only families (46%) terminated before completing five sessions. Pretreatment Comparisons Average SMAT scores are presented in Table 1. Data were analyzed using a 2 (clinicnonclinic) X 2 (sex of parent) unweightedmeans analysis of variance. SMAT scores of intact clinic parents were significantly lower than the control sample, F(l, 78) = 10.65, p < .01. Correlations between SMAT scores and socioeconomic status were insignificant. Correlations between SMAT scores and years married were also insignificant. After obtaining significant effects in the analyses of variance on pretherapy BPC scores in comparisons of the three groups (intactclinic, mother-only-clinic, and community sample), individual comparisons were made using Scheffe's multiple comparison method. For the Conduct, Personality, and Immaturity factors, the intact clinic and the mother-only clinic groups were each significantly different on these factors (p < .05). On the fourth factor, Subcultural Deviance, the mother-only clinic group and the two clinic groups combined were significantly different from the community sample (p < .05). However, the intact clinic group did not differ from the community group, and the two clinic groups did not differ from each other. Correlations were computed between parents' SMAT scores and BPC ratings of their
children's behavior for the clinic sample (intact families). There was a significant negative relationship between the parents' marital satisfaction and their children's behavioral deviance (see Table 2). Similar correlations for the control sample were not significant. Treatment Outcome Average length of treatment was 12.3 sessions, and an average of 90% of therapy time was spent on the children's behavior alone. To determine an average improvement rating for individual children, each child was designated as either improved or unimproved by averaging the ratings (1-7 scale) made for all of the child's target behaviors. Average scores of 4.5 and above were considered improved, and 4.4 and below were designated as unimproved. By these standards, 40 out of 46 children (87%) were rated as improved by their therapists. The mothers rated 44 out of 48 children (92%) as improved, and 29 out of 35 children (83%) were considered as improved by their fathers. Some outcome information was obtained for each of the 49 children who completed at least five treatment sessions. Therapists' ratings of target behaviors were available for 39 of the 42 clinic cases. In one family, both parents re1
This arbitrary limit was established for the inclusion of families in the outcome data, since our primary interest was in the effect of treatment as influenced by marital adjustment, and we felt that this must allow for a minimum length of contact.
MARITAL ADJUSTMENT AND BEHAVIOR THERAPY WITH CHILDREN
fused to return the forms, but the mother's ratings of target behaviors were obtained by phone. For three additional families, one parent refused to cooperate or was otherwise unavailable for comment (two fathers and one mother), but the other parent completed the entire evaluation form. Finally, two families refused to complete the SMAT at follow-up, but they did return the BPC and target ratings. To determine the potential effect of not persistently pursuing follow-up data, we examined the relationship between difficulty in obtaining follow-up data and ratings of target behavior improvement. The interrater reliability of our hassle ratings was highly significant (r = .98). The five hassle ratings were collapsed into three categories (1 and 2, n = 19; 3 and 4, n = 17; and 5, n = 13) to obtain adequate expected cell frequencies in chi-square analyses. Similarly, mean target behavior ratings made by parents and therapists were grouped into a significant improvement category (6 and 7, n = 34) and a category reflecting no improvement to only slight improvement (1-5, n = 15). Children of parents who were most delinquent in returning the forms were more frequently rated as showing low improvement by their therapists at close of treatment, X 2 (2) = 6.99, p < .05, and by the combination of their parents' ratings at follow-up, X 2 (2) = 8.22, p < .05. Comparisons of pretreatment and posttreatment BPC weighted scores were made using a separate repeated measures analysis of variance for each factor. The mothers and fathers rated their children as significantly (p < .05) improved on all BPC factors at termination, except that the fathers did not report significant improvement on Subcultural Deviance. The SMAT scores of the intact clinic families declined very slightly after treatment. The mothers' scores dropped from 103.1 to 100.2, and the fathers' scores dropped from 107.8 to 105.4. These changes were not significant. Relationship Between Marital Adjustment and We were unable to compute meaningful correlations between the parents' pretreatment SMAT scores and the ratings of target behaviors at termination because of the restricted
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Table 2 Correlations between Marital Adjustment and Ratings of Children's Deviance Clinic sample Measure of child's
behavior
Mothers
BPC Conduct Disorder Personality Disorder Inadequacy-Immaturity Subcultural Deviance
-.37** -.31* -.36** -.33*
Fathers
_.40«* -.24 -.34* -.43***
*p < .05. ** p < .02. *** p < .01.
range of the latter measure. Alternatively, the clinic sample was divided into quartiles based on the average SMAT scores of the parents. All of the quartiles reported very similar moderate rates of improvement, F(2, 57) = .35. In addition to these comparisons, the children's BPC change scores on each subscale were correlated with the intake SMAT scores of their parents. 'Given the unequal initial levels of child deviance reported by parents with varying intake SMAT scores, the initial BPC subscale scores were partialed out from the BPC change scores (part correlation, McNemar, 1975). The results of this analysis indicated no significant relationship between SMAT scores and BPC change scores on any of the subscales for either mothers' or fathers' ratings. Discussion Parents of clinic children generally reported less satisfaction with their marriages than did the parents of our community sample. This finding is consistent with earlier reports of parents who had referred their children to psychological clinics (e.g., Love & Kaswan, 1974) and suggests that some parents seeking behavioral treatment for their children are also troubled by marital problems. These problems, however,1 may not be presented to the therapist as immediate areas of concern. It is thus the therapist's responsibility to assess the parents' relationship and to determine whether it is an important factor in maintaining the child's deviant behavior.
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T. OLTMANNS, J. BRODERICK, AND K. O'LEARY
Although a portion of our clinic parents were experiencing marital difficulties, it is particularly important to note that there was significant overlap between the distributions of SMAT scores in the two samples. A few family therapists have speculated that behavior problems in children are always associated with marital discord. For example, Framo (1975) asserted that "whenever you have a disturbed child, you have a disturbed marriage" (p. 22). This relationship was definitely not observed in our sample. Given the rather modest, albeit consistent, associations reported between marital conflict and children's behavior, overly ambitious speculation such as Frame's is likely to unnecessarily alienate those parents whose marriages are not disturbed when they seek treatment for their children. Even though therapists should be aware of the possibility of marital discord, they need not attend rigidly to it. The overall treatment success we observed was quite comparable to that reported by O'Leary et al. (1973). The average mothers' improvement rating in that study was 90%, as compared to the present rate of 92%. Since our study was not intended to assess the efficacy of behavior therapy per se, we did not use the necessary controls to assert that our procedures were more effective than other alternatives or indeed than no treatment at all. Nevertheless, the observed rates of improvement are substantially higher than those reported by Levitt (1963) in a survey of therapeutic success in various child clinic settings and in groups that did not receive treatment. The efficacy of many of the treatment procedures used in the setting of the present study has been documented in controlled evaluations (Gelfand, in press; Kent & O'Leary, 1976; Patterson, 1974). Further, improvement in general factors of adjustment (BPC subscales) associated with specific improvement in identified problems suggests that the success of behavior therapy is probably not limited to change in specific target behaviors. The observed relationship between our ratings of difficulty in obtaining follow-up data and reports of therapeutic success by both parents and therapists indicates that our improvement estimates would have been even higher if we had been less diligent in our pursuit of
follow-up data. This pattern lends further empirical support to skeptics who have urged caution in interpreting therapeutic success rates that are based on only a portion of the families seen in treatment (Kent, 1976). References American Psychiatric Association. Diagnostic, and statistical manual of mental disorders (3rd ed.). Washington, D. C.: Author, 1968. Becker, W. C. Parents are teacliers. Champaign, 111.: Research Press, 1971. Duncan, O. D. A socioeconomic index for all occupations. In A. J. Reiss (Ed.), Occupations and social status. New York: Free Press of Glencoe, 1961. Framo, J. L. Personal reflections of a family therapist. Journal of Marriage and Family Counseling, 1975, 1, 15-28. Gassner, S., & Murray, E. J. Dominance and conflict in the interactions between parents of normal and neurotic children. Journal of Abnormal Psychology, 1969, 74, 33-41. Gelfand, D. M. Behavioral treatment of avoidance, social withdrawal, and negative emotional states. In B. B. Wolman, J. Egan, & A. 0. Ross (Eds.), Handbook of treatment of mental disorders in childhood and adolescence. Englewood Cliffs, N.J.: PrenticeHall, in press. Johnson, S. M., & Lobitz, C. K. The personal and marital adjustment of parents as related to observed child deviance and parenting behavior. Journal of Abnormal Child Psychology, 1974, 2, 193-207. Kent, R. N. A methodological critique of "Interventions for boys with conduct problems." Journal of Consulting and Clinical Psychology, 1976, 44, 297299. Kent, R. N., & Foster, S. L. Direct observation procedures: Methodological issues in naturalistic settings. In A. Ciminero, K. Calhoun, & H. E. Adams (Eds.), Handbook for behavioral assessment. New York: Wiley, 1977. Kent, R. N., & O'Leary, K. D. A controlled evaluation of behavior modification with conduct problem children. Journal of Consulting and Clinical Psychology, 1976, 44, 586-596. Kimmel, D. C., & van der Veen, F. Factors of marital adjustment in Locke's marital adjustment test. Journal of Marriage and the Family, 1974, 36, 57-63. Leighton, L. A., Stollak, G. E., & Ferguson, L. R. Patterns of communication in normal and clinic families. Journal of Consulting and Clinical Psychology, 1971, 36, 252-256. Levitt, E. E. Psychotherapy with children: A further evaluation. Behaviour Research and Therapy, 1963, 1, 45-51. Locke, H. J., & Wallace, K. M. Short marital-adjustment and prediction tests: Their reliability and validity. Marriage and Family Living, 1959, 21, 251-255. Love, L. R., & Kaswan, J. W. Troubled children: Their families, schools, and their treatments. New York: Wiley, 1974.
MARITAL ADJUSTMENT AND BEHAVIOR THERAPY WITH CHILDREN McNemar, Q, Psychological statistics (4th ed.). New York: Wiley, 19V5. O'Leary, K. D., Turkewitz, H., & Taffel, S. J. Parent and therapist evaluation of behavior therapy in a child psychological clinic. Journal of Consulting and Clinical Psychology, 1973, 41, 279-283. O'Leary, K. D., & Wilson, G. T. Behavior therapy: Application and outcome. Englewood Cliffs, N.J.: Prentice-Hall, 1975. Patterson, G. R. Intervention for boys with conduct problems: Multiple settings, treatments, and criteria. Journal of Consulting and Clinical Psychology, 1974, 42, 471-481. 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, 111.: Charles C Thomas, 1973. Quay, H. C. Patterns of aggression, withdrawal, and immaturity. In H. C. Quay & J. S. Werry (Eds.), Psychopatlwlogical disorders of children. New York: Wiley, 1972.
Ruttcr, M. Parent-child separation: Psychological effects on the children. Journal of Child Psychology and Psychiatry, 1971, 12, 233-260. Satir, V. Conjoint family therapy: A guide to theory and technique. Palo Alto, Calif.: Science and Behavior Books, 1964. Speer, D. C. Behavior problem checklist (PetersonQuay) : Baseline data from parents of child guidance and nonclinic children. Journal of Consulting and Clinical Psychology, 1971, 36, 221-228. Tait, C. D., & Hodges, E. F. Delinquents, their families and the community. Springfield, 111.: Charles C Thomas, 1962. Wahler, R. G. Deviant child behavior within the family: Developmental speculation and behavior change strategies. In H. Lcitenberg (Ed.), Handbook of behavior modification and therapy. Englewood Cliffs, N.J.: Prentice-Hall, 1976. Received February 9, 1976
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