1. &ho,. The, & Exp Prvchm Prmted I” tirear Bntam
Vol
21. No. 2. pp 13.%139. 1990
TEACHING
REFUSAL SKILLS TO SEXUALLY ADOLESCENTS WILLIAM
University
of Nebraska
ACTIVE
J. WARZAK
Medical Center.
Meyer Children’s
Rehabilitation
Center
and TERRY
J. PAGE
New Medico Rehabilitation
Center
of Philadelphia
Refusal skills training was extended to sexually active handicapped female adolescents who lacked an effective refusal strategy. Role-plays for assessment and training were developed using the who. what. when and where of situations which resulted in unwanted intercourse. Refusal skills were trained following the format of rationale. modeling, rehearsal. feedback. and reinforcement. Baseline rates of most target behaviors were quite low. High frequencies of target behaviors were observed as each behavior became the focus of training. Generalization across staff and time was also observed. The skillfulness and effectiveness of the subjects’ refusal skills were judged to be improved as a function of training. One-year follow-up showed decreased sexual activity for each girl. Summary
their teenage years than post-adolescent mothers (Elster & Lamb, 1986). Children born to school-age mothers are at increased risk for a variety of medical and emotional problems relative to children born to nonadolescents (Spivack & Weitzman. 1987). Behavioral disorders and school conduct disorders are also more common for this group (Belmont, Stein, & Zybert, 1978; Finkelstein, Finkelstein, Christie, Roden, & Shelton. 1982; Gunter & LaBarba, 1980). These children are also at greater risk for teen pregnancy themselves than are the children of postadolescent mothers (Baldwin, 1980). There have been many and varied attempts to curtail adolescent pregnancy. The development of psychological and sociodemographic profiles of sexually active adolescents has failed to identify commonalities leading to an effective intervention to reduce school-age pregnancy (Schinke. Gilchrist. & Small, 1979).
Approximately 500,000 teenage girls give birth each year (Guttmacher Institute, 1981) with approximately ten per cent of these births occurring to school-age mothers who are 15 years old or less (Hamburg, 1986). The potential negative impact of pregnancy for these young women and their children is enormous. Many school-age parents do not marry and those who do experience higher rates of divorce and marital distress than their older nonschool-age peers (Baldwin & Cain, 1980). Future academic and vocational achievement is typically curtailed for both adolescent mothers and fathers (Card & Wise, 1978; Klerman, 1986; Zellman, 1982). Additionally, teenage mothers tend to be more socially isolated than nonadolescent mothers (Kellam, Adams, Brown & Ensminger, 1982). a factor that may increase the potential for future child abuse (Helfer, 1973). Indeed, adolescent mothers tend to exhibit more child abuse subsequent to Requests U.S.A.
for reprints
should
be sent to William
J. Warzak.
Ph.D.,
133
MRIKJNMC.
444 S. 44th Street.
Omaha.
NE 68131.
133
WILLIAM
J. WARZAK
Many prevention programs have emphasized providing adolescents with information about conception and contraception (Rogel. Zuehlke, Peterson. Tobin-Richards. & Shelton, 1980; Scharff, Silber, Tripp, McGee, Bowie, & Emerson. 1980), or provided values, clarification and informed decision making skills as the basis of adolescent preventive pregnancy programs (Howard, 1985a; Toohey & Valenzuela. 1982). These approaches have met with limited success, however, perhaps because information alone may have little impact on sexual behavior (Howard. 1985b; Kirby, 1984). Moreover. adolescent cognitive immaturity puts added limits on the ability of some adolescents to use such information effectively (Howard. 1985b; Lancaster & Hamburg. 1986). More recent attempts to curtail adolescent pregnancy have acknowledged the necessity of providing new behavioral competencies to adolescents in addition to simply providing them information about sexuality and sexual functioning (e.g.. Hamburg. 1986; Melton, 1988). Several of these strategies take a skills acquisition approach to teaching decision making, problem solving skills. and interpersonal communication skills (Blythe. Gilchrist, & Schinke, 1981; Franzini, Sideman, & Dexter. 1988; Gilchrist & Schinke. 1983; Libby & Carlson. 1973: Schinke. Gilchrist. & Small. 1979). Assertiveness training. including Jusr say ‘No’ strategies have also been advocated (Private Line. 1988) as some individuals have reported that they have difficulty saying no or have difficulty communicating decisions about their preferences regarding sexual activity to their partners (Campbell & Barnlund. 1977; Cvetkovich. Grote, Lieberman, & Miller, 1978; Howard. 1985b). However. an empirical basis by which to guide efforts to say no effectively has yet to be reported for this population (e.g., Howard, 1985a. b; Private Line, 1988). Additionally, previous studies have not obtained social validation measures pertaining to the general effectiveness or skillfulness of refusal skills procedures.
and TERRY
J. PAGE
In the present study. refusal skills were taught to two sexually active handicapped female adolescents who had expressed an interest in learning an effective refusal strategy for use when they wished to avoid unwanted sexual intimacy. Refusal skills technology was extended beyond Just .~a>!HO by (a) socially validating the general effectiveness and skillfulness of each girl’s refusal skills as a function of training in individual components. and (b) extending refusal skills training to special populations. among whom skills deficits may be more prevalent and the need for refusal skills the greatest.
Method Participants The participants were two adolescent females. Amy was a 16-year-old deaf girl who lived in a residential school setting for deaf youngsters. She had been repeatedly suspended from school because of sexual intimacy with male residents. At the time of treatment Amy was hospitalized on a psychiatric unit which specialized in treating sexual disorders. Karen was a 14-year-old developmentally delayed girl who resided in a residential treatment center for developmentally delayed adolescents. Karen was hospitalized following an automobile accident. During the course of her rehabilitation it was learned that she had a history of precocious sexual behavior. Both girls reported difficulty effectively refusing unwanted sexual advances and each expressed interest in learning skills that might help them avoid unwanted sexual intimacy. AssessmerIt Each girl described situations that resulted in unwanted intercourse. The who. what, when and where of these situations was used to develop role-play vignettes for each girl. Their performance during role-play was used to
Refusal
identify the particular deficits in refusal assertion which were to be addressed during training. Two scenes were used for pre/post assessment and three scenes were used for daily training. Two-person two-prompt structured roleplays (cf. Kelly, 1982) were used. Each roleplay began with a reading of the problem situation followed by a prompt delivered by a confederate, suggesting that the patient and the confederate engage in sexual behavior. All role plays were video taped. Dependent
Measures
Eye-contact. Any directed gaze by the participant to the face of the confederate was scored as an occurrence. Refusal. observable) occurrence.
An explicit and audible (or readily NO was required to score as an
Specification. A specific statement regarding the unacceptability of sexual behavior was required to score as an occurrence. Leaving the situation. Walking away from the confederate, following the confederate’s request for sexual intimacy, was required to score as an occurrence. Method of recording. Refusal, Specification, and Leaving the situation were scored on an occurrence/nonoccurrence basis for each scene. A 10” partial interval recording procedure was used to record the presence/absence of Eye-contact. Eye-contact was then scored on an occurrence/nonoccurrence basis, with a criterion of 50% of intervals scored, per role play, required to be scored as an occurrence. General Procedure Each session began with role-play assessment, followed by a review of previously learned refusal skills components, training in
Skills
1.15
refusal skills and additional role play assessment. Refusal skills training followed the format of rationale. modeling. behavioral rehearsal, feedback, and reinforcement (cf. Eisler & Frederiksen. 1980; Kelley. 1982). A female interpreter fluent in American Sign Language (ASL) for the deaf served as confederate for Amy throughout training. Followup trials for both girls took place approximately two weeks following the completion of refusal skills training. Novel role-plays and different confederates were used during this assessment. A male ASL interpreter served as confederate for Amy during these latter trials. Social Validity Ten female psychology graduate students rated videotaped role-plays randomly selected from those obtained at the conclusion of training each refusal skills component. A total of eight randomly ordered role plays (i.e., two from baseline, and two each following training of the three target behaviors taught each girl) were rated. Each vignette was rated using ninepoint (low to high) Likert Scales for refusal effectiveness and refusal skill. The ratings for baseline role-plays and those following training in each refusal skills component (i.e., eyecontact. saying no, etc.) were used in a repeated measures ANOVA to evaluate social perception of client refusal skills and effectiveness.
Results Reliability Seventy percent of all role plays were scored by two observers for purposes of reliability. Cohen’s Kappa (K) was computed across both subjects. K for eye-contact was 0.84, for refusal was 0.85, for leaving the situation was 1.0, and for specifying objectionable behavior was 0.90. Mean Kappa across all variables was 0.90.
136
WILLIAM
Treatment
J. WARZAIi
Effects
A multiple baseline design across target behaviors was used to evaluate the acquisition of refusal skills. Each girl’s data are presented separately as Figures 1 (Amy) and 2 (Karen). Amy exhibited high levels of eye-contact during baseline. perhaps as a function of her deafness and a need to attend to visual communication cues. She failed to exhibit any other components of refusal skills prior to treatment. Karen exhibited verbal refusal prior to treatment but without the additional components of eye-contact, specification of the objectionable behavior or leaving the scene upon repeated prompts to engage in sexual behavior. Subsequent to intervention each girl exhibited high frequencies of target behaviors as each behavior became the focus of training. Two-week follow-up yielded short-term maintenance of refusal skills with treatment staff not previously included in training. Long-term
Figure
1. Presence/absence
of refusal
skills components
and
TERRY
J
PAGE
telephone follow-up (one year). with residential staff serving as informants. indicated decreased sexual activity for each girl, as noted by patient incidence reports. A repeated measures analysis of social validation data confirmed each girl’s acquisition of refusal behavior within role-play contexts. For Amy. significant differences between baseline and post-treatment performance ratings were obtained for both refusal effectiveness (F = 243.7; df = 27.3; p = < .OOl) and skill (F = 103.02: df = 27.3; p = < ,001). Tukey’s test yielded critical differences on effectiveness ratings between baseline performance and the addition of the refusal component for Amy. Critical differences were also found for skillfulness measures obtained at baseline and after the addition of each of the other skill components (i.e.. refusal. specifies objection and leaves scene). A significant increment in skillful ratings was also obtained when comparing data between the addition of the second
as a function
of refusal
skills tramlnp
for Am!
Refusal
Figure
2. Presence/absence
of refusal
skills components
component to Amy’s program (i.e., refusal) and following the addition of specifying her objection and leaving the scene. A significant difference was obtained for Karen’s refusal skill rating (F = 22.06; df = 27,3; p = < .OOl) at baseline vs. the conclusion of treatment but not for her effectiveness (F = 7.19; df = 27,3; N.S.). Tukey’s test yielded critical differences at each level of intervention as additional components of refusal skills were added to her repertoire.
Discussion In the present case, refusal skills were extended to two sexually active handicapped adolescents to reduce the occurrence of unwanted sexual intercourse. Training to eliminate all occasions of sexual intercourse was not attempted. Rather, training was designed to teach patients to effectively refuse sexual advances when they deemed it necessary and
137
Skills
as a function
of refusal
skills training
for Karen.
desirable to do so. This more modest goal was chosen because it increased the likelihood of patient participation and the subsequent likelihood of reducing their sexual behavior. The reports of staff responsible for their care confirmed reduced rates of sexual activity for each girl suggesting that refusal skills training served to reduce the frequency with which they engaged in sexual intercourse. The skill and effectiveness ratings of the social validation raters are consistent with this interpretation. Although raters considered Karen’s refusal effective. but unskilled, prior to training, their ratings suggest that increases in skill and effectiveness result from the training of additional refusal components. Additional research is needed to verify the actual effectiveness of refusal skills packages and their impact on the occurrence of unwanted sexual behavior. Which refusal components are most critical for this context remains to be determined. In addition, refusal comprises only one variable of many which
138
WILLIAM
J. WARZAK
may have significant impact upon the occurrence of school-age pregnancy. Developmental factors. societal norms, familial and peer pressure also play important roles in fomenting adolescent sexual activity. Comprehensive solutions to the problem of school-age pregnancy might also include provision of adequate information regarding reproductive behavior. the potential consequences of unprotected sexual intercourse and the negative consequences associated with pregnancy (Melton, 1988; Rogel. et al., 1979; Smith. Weinman, & Mumford, 1982). The present study is limited by difficulties inherent in extrapolating from role-play assessment to the extra-therapeutic environment (Bellack. Hersen, & Lamparski, 1979). Difficulty obtaining generalization of refusal skills to situations not covered in training sessions has also been noted in the literature (Franzini, Sideman. & Dexter. 1988; Schinke, Gilchrist, & Small, 1979). Additionally, the difficulties in obtaining valid data relative to adolescent sexual behavior also affect the generalization of the results. Nevertheless. there is much to recommend continued research into the potential of refusal skills as a means of reducing the rate of pregnancy among sexually active adolescents. Learning to say No effectively may be the most convenient and readily available of all current birth control strategies, Refusal skills require no advanced planning although to be most effective they need to be inserted early in the chain of critical interpersonal behaviors that lead to sexual intercourse. Although most would agree that abstaining from intercourse is a desirable goal for adolescent populations, refusal skills need not be limited to abstention in order to effect a reduction in the rate of school-age pregnancy. For example. they might also be employed effectively to assure the use of desired birth control methods. such as prophylactics, when engaging in intercourse. Refusal skills procedures need to be tailored to individual circumstances. Nevertheless, efforts to identify behavioral commonalities
and
TERRY
J. PAGE
among sexually active adolescents may reveal the key to the most effective refusal skills intervention. Determining the most common and difficult situations encountered by adolescents and the methods presently used to cope with those situations would be a start toward developing empirically based refusal skills procedures for this population. - The authors express then apprectation to Susan Hobart, Ph.D., Craig Rehabilttatton Hospital, Denver and Sandy Tuttles, Johns Hopkins Untversit! for their assistance in providing social skills tramins to these subjects. The stattstical assistance of Joseph Evans. Ph.D. and Karen Ostern. M.S. (UNMC) and the comments of Vincent Barone. Ph.D. (UNMC). and Christme Majors. M.S. (Immanuel Hospital. Omaha) on an earher draft of thts manuscript are also gratefully acknovvledged.
Acknou~[rdgemenfs
References Baldwin. W. H. (1980). Adolescent pretmancy bearing -Growing concerns for Amerrcans. Bulletin.
31.
and childPopulation
l-37.
Baldwin. W. H.. & Cain, teenage parents. Family
V. S. (1980) Planmng
The children
Pcrspecrrres.
01
12. %I-
33.
Bellack. A. S.. Hersen. M.. & Lamparski. D. (1979). Role play tests for assessing social skills: Are thev valid’! Are they useful? Journal of Consulrmg and Clir&al Psychology.
47.
335-342.
Belmont. L.. Stein. Z.. & Zybert. P. (19781. Child spactng and birth order: Effect on intellectual ability in two-child families. Science. 202. YYS-YYh. Blythe. B. J.. Gilchrist, L. D.. & Schinke. S. P. (1981). Pregnancy-prevention groups for adolescents. Social Work.
26.
503-5~.
Campbell. B. K.. & Barnlund. cation patterns and problems Journal
of Orthopsychiatry
D. C. (1977). of pregnancy. 47.
CommuniAnrerrcan
133-139.
Card. J. J.. & Wise. L. L. (1978). Teenage mothers and teenage fathers: The impact of early childbearing on the parents’ personal and professional lives. Family P&ning Perspectives. IO. l9Y-205. Cvetkovich. G.. Grote. B.. Lieberman. E. S.. ;Y Miller. W. (1978). Sex role development and teenage Icrttlityrelated behavtor. Adolescence. 8. 731-7% Eisler. R. M.. & Frederiksen, L. W. (1980). Prrf~rtrng social skills: A guide to interper.sorlal behavioral ment. New York: Plenum.
develop
Elster. A. B.. & Lamb. M. E. (19%). Adolescent fathers: The under studied side of adolescent pregnancy. In: J. B. Lancaster. dt A. Hamburg. School-age pregnant! and parenfhood. Biosocral dimensions (pp. 177-190). New York: de Gruyter. Finkelstein. J. W., Finkelstcin. J. A.. Christie. M.. Roden. M.. & Shelton. C. (1982). Teenage pregnancy and
Refusal parenthood: Outcomes for mother and child. Journal of Adolescent Health Care. 3. 1-7. Franzini. L. R.. Sideman, L. M.. & Dexter. K. E. (1988). Promoting AIDS risk reduction via behavioral training. Presented at the Association for Advancement of Behavior Therapy. New York, NY. Gilchrist, L. D.. & Schinke. S. P. (1983). Coping with contraception: Cognitive and behavioral methods with adolescents. Cognitive Therapy and Research. Gunter. N. C.. & LaBarba, R. C. (1980). The consequences of adolescent childbearing on postnatal development. International Journal of Behavioral Development. 3. 191-214. The Alan Guttmacher Institute (1981). Teenage pregnancy: The problem that hasn’t gone away. New York: The Alan Guttmacher Institute. Hamburg, B. A. (1986). Subsets of adolescent mothers: developmental, biomedical. and psychosocial issues. In: .I. B. Lancaster & B. A. Hamburg, School-age pregnancy and parenthood. Biosocial dimensions (pp. llS145). New York: de Gruvter. Heifer, R. E. (1973). The etiology of child abuse. Pediatrics, 5I. 777-779. Howard, M. (19858). How the family physician can help young teenagers postpone sexual involvement. Medical Aspects of Human Sexuality, 19. 76-87. Howard. M. (1985b). Postponing sexual involvement among adolescents: An alternative approach to prevention of sexually transmitted diseases. Journal of Adolescent Health Care, 6, 271-277. Kellam, S. G., Adams, R. G.. Brown. C. H., & Ensminger, M. E. (1982). The long-term evolution of the family structure of teenage and older mothers. Journal of Marriage and the Family. 44, 539-554. Kelly. J A. ( 1982). Social skills training: A practical guide for interventions. New York: Springer. Kirby. D. (1984). Sexuality education: An evaluation of programs and their effects. Vol. I, U.S. Department of Health and Human Services. Atlanta. Georgia. Kterman. L. V. (1986). The economic impact of school-age child rearing. In: J. B. Lancaster & B. A. Hamburg. School-age pregnancy and parenthood. Biosocial dimensions (pp. 361-377). New York: de Gruyter.
Skills
13’)
Lancaster. .I. B.. & Hamburg. B. A. (19X6). The Biosocial dimensions of school-age pregnancy and parenthood: An Introduction. In: J. B. Lancaster & B. A. Hamburg, School-age pregnancy and parenthood. Btosocial dimensions (pp. 3-13). New York: de Gruyter. Libby. R., & Carlson. J. (1973). A theoretical framework for premarital sexual decisions using contraceptives. Archives of Sexual Behavior. 2. 36S37X. Melton, G. B. (1988). Adolescents and prevention of AIDS. Professional Psychology: Research and Practice, 19. 403-408. Private Line (1988). “No!” and other merhods of birth control. P.O. Box 131 Kenilworth. Illinois. Rogel. M. J.. Zuehlke. M. E.. Petersen, A. C.. TobinRichards. M.. & Shelton, M. (1980). Contraceptive behavior in adolescence: A decision-making perspective. Journal of Youth and Adolescence. 9. 491-506. Scharff. D.. Silber. T.. Tripp. G.. McGee. E., Bowie. S.. & Emerson. B. (1980). Use of a sex rap group in an adolescent medical clinic. Adolescence. 60. 751-762. Schinke. S. P. (1984). Preventing teenage pregnancy. In: M. Hersen. R. M. Eisler, & P. M. Miller (Eds.). Progress in Behavior Modification (pp. 31-64). Orlando: Academic Press. Inc. Schinke, S. P.. Gilchrist. L. D.. & Small, R. W. (1979). Preventing unwanted adolescent pregnancy: A Cognitive-behavioral approach. American Orthopsychiutric Association. 49, 81-88. Smith. P. B.. Weinman, M. L., Kc Mumford, D. M. (1982). Social and affective factors associated with adolescent pregnancy. The Journal of School Health. 52 90-93. Spivak. H., & Weitzman, M. (1987). Social barriers faced by adolescent parents and their children. Journal of the American Medical Association. 258. 3500-1504. Toohey. J. V.. & Valenzuela. G. J. (1982). Values clarification as a technique for family planning education. Journal of School Health, 53. 121-1.53. Zellman. G. L. (1982). Public school programs for adolescent pregnancy and parenthood: An assessment. Family Planning Perspectives. 14. 15-21.
Vol
21. No. 2. pp 13.%139. 1990
TEACHING
REFUSAL SKILLS TO SEXUALLY ADOLESCENTS WILLIAM
University
of Nebraska
ACTIVE
J. WARZAK
Medical Center.
Meyer Children’s
Rehabilitation
Center
and TERRY
J. PAGE
New Medico Rehabilitation
Center
of Philadelphia
Refusal skills training was extended to sexually active handicapped female adolescents who lacked an effective refusal strategy. Role-plays for assessment and training were developed using the who. what. when and where of situations which resulted in unwanted intercourse. Refusal skills were trained following the format of rationale. modeling, rehearsal. feedback. and reinforcement. Baseline rates of most target behaviors were quite low. High frequencies of target behaviors were observed as each behavior became the focus of training. Generalization across staff and time was also observed. The skillfulness and effectiveness of the subjects’ refusal skills were judged to be improved as a function of training. One-year follow-up showed decreased sexual activity for each girl. Summary
their teenage years than post-adolescent mothers (Elster & Lamb, 1986). Children born to school-age mothers are at increased risk for a variety of medical and emotional problems relative to children born to nonadolescents (Spivack & Weitzman. 1987). Behavioral disorders and school conduct disorders are also more common for this group (Belmont, Stein, & Zybert, 1978; Finkelstein, Finkelstein, Christie, Roden, & Shelton. 1982; Gunter & LaBarba, 1980). These children are also at greater risk for teen pregnancy themselves than are the children of postadolescent mothers (Baldwin, 1980). There have been many and varied attempts to curtail adolescent pregnancy. The development of psychological and sociodemographic profiles of sexually active adolescents has failed to identify commonalities leading to an effective intervention to reduce school-age pregnancy (Schinke. Gilchrist. & Small, 1979).
Approximately 500,000 teenage girls give birth each year (Guttmacher Institute, 1981) with approximately ten per cent of these births occurring to school-age mothers who are 15 years old or less (Hamburg, 1986). The potential negative impact of pregnancy for these young women and their children is enormous. Many school-age parents do not marry and those who do experience higher rates of divorce and marital distress than their older nonschool-age peers (Baldwin & Cain, 1980). Future academic and vocational achievement is typically curtailed for both adolescent mothers and fathers (Card & Wise, 1978; Klerman, 1986; Zellman, 1982). Additionally, teenage mothers tend to be more socially isolated than nonadolescent mothers (Kellam, Adams, Brown & Ensminger, 1982). a factor that may increase the potential for future child abuse (Helfer, 1973). Indeed, adolescent mothers tend to exhibit more child abuse subsequent to Requests U.S.A.
for reprints
should
be sent to William
J. Warzak.
Ph.D.,
133
MRIKJNMC.
444 S. 44th Street.
Omaha.
NE 68131.
133
WILLIAM
J. WARZAK
Many prevention programs have emphasized providing adolescents with information about conception and contraception (Rogel. Zuehlke, Peterson. Tobin-Richards. & Shelton, 1980; Scharff, Silber, Tripp, McGee, Bowie, & Emerson. 1980), or provided values, clarification and informed decision making skills as the basis of adolescent preventive pregnancy programs (Howard, 1985a; Toohey & Valenzuela. 1982). These approaches have met with limited success, however, perhaps because information alone may have little impact on sexual behavior (Howard. 1985b; Kirby, 1984). Moreover. adolescent cognitive immaturity puts added limits on the ability of some adolescents to use such information effectively (Howard. 1985b; Lancaster & Hamburg. 1986). More recent attempts to curtail adolescent pregnancy have acknowledged the necessity of providing new behavioral competencies to adolescents in addition to simply providing them information about sexuality and sexual functioning (e.g.. Hamburg. 1986; Melton, 1988). Several of these strategies take a skills acquisition approach to teaching decision making, problem solving skills. and interpersonal communication skills (Blythe. Gilchrist, & Schinke, 1981; Franzini, Sideman, & Dexter. 1988; Gilchrist & Schinke. 1983; Libby & Carlson. 1973: Schinke. Gilchrist. & Small. 1979). Assertiveness training. including Jusr say ‘No’ strategies have also been advocated (Private Line. 1988) as some individuals have reported that they have difficulty saying no or have difficulty communicating decisions about their preferences regarding sexual activity to their partners (Campbell & Barnlund. 1977; Cvetkovich. Grote, Lieberman, & Miller, 1978; Howard. 1985b). However. an empirical basis by which to guide efforts to say no effectively has yet to be reported for this population (e.g., Howard, 1985a. b; Private Line, 1988). Additionally, previous studies have not obtained social validation measures pertaining to the general effectiveness or skillfulness of refusal skills procedures.
and TERRY
J. PAGE
In the present study. refusal skills were taught to two sexually active handicapped female adolescents who had expressed an interest in learning an effective refusal strategy for use when they wished to avoid unwanted sexual intimacy. Refusal skills technology was extended beyond Just .~a>!HO by (a) socially validating the general effectiveness and skillfulness of each girl’s refusal skills as a function of training in individual components. and (b) extending refusal skills training to special populations. among whom skills deficits may be more prevalent and the need for refusal skills the greatest.
Method Participants The participants were two adolescent females. Amy was a 16-year-old deaf girl who lived in a residential school setting for deaf youngsters. She had been repeatedly suspended from school because of sexual intimacy with male residents. At the time of treatment Amy was hospitalized on a psychiatric unit which specialized in treating sexual disorders. Karen was a 14-year-old developmentally delayed girl who resided in a residential treatment center for developmentally delayed adolescents. Karen was hospitalized following an automobile accident. During the course of her rehabilitation it was learned that she had a history of precocious sexual behavior. Both girls reported difficulty effectively refusing unwanted sexual advances and each expressed interest in learning skills that might help them avoid unwanted sexual intimacy. AssessmerIt Each girl described situations that resulted in unwanted intercourse. The who. what, when and where of these situations was used to develop role-play vignettes for each girl. Their performance during role-play was used to
Refusal
identify the particular deficits in refusal assertion which were to be addressed during training. Two scenes were used for pre/post assessment and three scenes were used for daily training. Two-person two-prompt structured roleplays (cf. Kelly, 1982) were used. Each roleplay began with a reading of the problem situation followed by a prompt delivered by a confederate, suggesting that the patient and the confederate engage in sexual behavior. All role plays were video taped. Dependent
Measures
Eye-contact. Any directed gaze by the participant to the face of the confederate was scored as an occurrence. Refusal. observable) occurrence.
An explicit and audible (or readily NO was required to score as an
Specification. A specific statement regarding the unacceptability of sexual behavior was required to score as an occurrence. Leaving the situation. Walking away from the confederate, following the confederate’s request for sexual intimacy, was required to score as an occurrence. Method of recording. Refusal, Specification, and Leaving the situation were scored on an occurrence/nonoccurrence basis for each scene. A 10” partial interval recording procedure was used to record the presence/absence of Eye-contact. Eye-contact was then scored on an occurrence/nonoccurrence basis, with a criterion of 50% of intervals scored, per role play, required to be scored as an occurrence. General Procedure Each session began with role-play assessment, followed by a review of previously learned refusal skills components, training in
Skills
1.15
refusal skills and additional role play assessment. Refusal skills training followed the format of rationale. modeling. behavioral rehearsal, feedback, and reinforcement (cf. Eisler & Frederiksen. 1980; Kelley. 1982). A female interpreter fluent in American Sign Language (ASL) for the deaf served as confederate for Amy throughout training. Followup trials for both girls took place approximately two weeks following the completion of refusal skills training. Novel role-plays and different confederates were used during this assessment. A male ASL interpreter served as confederate for Amy during these latter trials. Social Validity Ten female psychology graduate students rated videotaped role-plays randomly selected from those obtained at the conclusion of training each refusal skills component. A total of eight randomly ordered role plays (i.e., two from baseline, and two each following training of the three target behaviors taught each girl) were rated. Each vignette was rated using ninepoint (low to high) Likert Scales for refusal effectiveness and refusal skill. The ratings for baseline role-plays and those following training in each refusal skills component (i.e., eyecontact. saying no, etc.) were used in a repeated measures ANOVA to evaluate social perception of client refusal skills and effectiveness.
Results Reliability Seventy percent of all role plays were scored by two observers for purposes of reliability. Cohen’s Kappa (K) was computed across both subjects. K for eye-contact was 0.84, for refusal was 0.85, for leaving the situation was 1.0, and for specifying objectionable behavior was 0.90. Mean Kappa across all variables was 0.90.
136
WILLIAM
Treatment
J. WARZAIi
Effects
A multiple baseline design across target behaviors was used to evaluate the acquisition of refusal skills. Each girl’s data are presented separately as Figures 1 (Amy) and 2 (Karen). Amy exhibited high levels of eye-contact during baseline. perhaps as a function of her deafness and a need to attend to visual communication cues. She failed to exhibit any other components of refusal skills prior to treatment. Karen exhibited verbal refusal prior to treatment but without the additional components of eye-contact, specification of the objectionable behavior or leaving the scene upon repeated prompts to engage in sexual behavior. Subsequent to intervention each girl exhibited high frequencies of target behaviors as each behavior became the focus of training. Two-week follow-up yielded short-term maintenance of refusal skills with treatment staff not previously included in training. Long-term
Figure
1. Presence/absence
of refusal
skills components
and
TERRY
J
PAGE
telephone follow-up (one year). with residential staff serving as informants. indicated decreased sexual activity for each girl, as noted by patient incidence reports. A repeated measures analysis of social validation data confirmed each girl’s acquisition of refusal behavior within role-play contexts. For Amy. significant differences between baseline and post-treatment performance ratings were obtained for both refusal effectiveness (F = 243.7; df = 27.3; p = < .OOl) and skill (F = 103.02: df = 27.3; p = < ,001). Tukey’s test yielded critical differences on effectiveness ratings between baseline performance and the addition of the refusal component for Amy. Critical differences were also found for skillfulness measures obtained at baseline and after the addition of each of the other skill components (i.e.. refusal. specifies objection and leaves scene). A significant increment in skillful ratings was also obtained when comparing data between the addition of the second
as a function
of refusal
skills tramlnp
for Am!
Refusal
Figure
2. Presence/absence
of refusal
skills components
component to Amy’s program (i.e., refusal) and following the addition of specifying her objection and leaving the scene. A significant difference was obtained for Karen’s refusal skill rating (F = 22.06; df = 27,3; p = < .OOl) at baseline vs. the conclusion of treatment but not for her effectiveness (F = 7.19; df = 27,3; N.S.). Tukey’s test yielded critical differences at each level of intervention as additional components of refusal skills were added to her repertoire.
Discussion In the present case, refusal skills were extended to two sexually active handicapped adolescents to reduce the occurrence of unwanted sexual intercourse. Training to eliminate all occasions of sexual intercourse was not attempted. Rather, training was designed to teach patients to effectively refuse sexual advances when they deemed it necessary and
137
Skills
as a function
of refusal
skills training
for Karen.
desirable to do so. This more modest goal was chosen because it increased the likelihood of patient participation and the subsequent likelihood of reducing their sexual behavior. The reports of staff responsible for their care confirmed reduced rates of sexual activity for each girl suggesting that refusal skills training served to reduce the frequency with which they engaged in sexual intercourse. The skill and effectiveness ratings of the social validation raters are consistent with this interpretation. Although raters considered Karen’s refusal effective. but unskilled, prior to training, their ratings suggest that increases in skill and effectiveness result from the training of additional refusal components. Additional research is needed to verify the actual effectiveness of refusal skills packages and their impact on the occurrence of unwanted sexual behavior. Which refusal components are most critical for this context remains to be determined. In addition, refusal comprises only one variable of many which
138
WILLIAM
J. WARZAK
may have significant impact upon the occurrence of school-age pregnancy. Developmental factors. societal norms, familial and peer pressure also play important roles in fomenting adolescent sexual activity. Comprehensive solutions to the problem of school-age pregnancy might also include provision of adequate information regarding reproductive behavior. the potential consequences of unprotected sexual intercourse and the negative consequences associated with pregnancy (Melton, 1988; Rogel. et al., 1979; Smith. Weinman, & Mumford, 1982). The present study is limited by difficulties inherent in extrapolating from role-play assessment to the extra-therapeutic environment (Bellack. Hersen, & Lamparski, 1979). Difficulty obtaining generalization of refusal skills to situations not covered in training sessions has also been noted in the literature (Franzini, Sideman. & Dexter. 1988; Schinke, Gilchrist, & Small, 1979). Additionally, the difficulties in obtaining valid data relative to adolescent sexual behavior also affect the generalization of the results. Nevertheless. there is much to recommend continued research into the potential of refusal skills as a means of reducing the rate of pregnancy among sexually active adolescents. Learning to say No effectively may be the most convenient and readily available of all current birth control strategies, Refusal skills require no advanced planning although to be most effective they need to be inserted early in the chain of critical interpersonal behaviors that lead to sexual intercourse. Although most would agree that abstaining from intercourse is a desirable goal for adolescent populations, refusal skills need not be limited to abstention in order to effect a reduction in the rate of school-age pregnancy. For example. they might also be employed effectively to assure the use of desired birth control methods. such as prophylactics, when engaging in intercourse. Refusal skills procedures need to be tailored to individual circumstances. Nevertheless, efforts to identify behavioral commonalities
and
TERRY
J. PAGE
among sexually active adolescents may reveal the key to the most effective refusal skills intervention. Determining the most common and difficult situations encountered by adolescents and the methods presently used to cope with those situations would be a start toward developing empirically based refusal skills procedures for this population. - The authors express then apprectation to Susan Hobart, Ph.D., Craig Rehabilttatton Hospital, Denver and Sandy Tuttles, Johns Hopkins Untversit! for their assistance in providing social skills tramins to these subjects. The stattstical assistance of Joseph Evans. Ph.D. and Karen Ostern. M.S. (UNMC) and the comments of Vincent Barone. Ph.D. (UNMC). and Christme Majors. M.S. (Immanuel Hospital. Omaha) on an earher draft of thts manuscript are also gratefully acknovvledged.
Acknou~[rdgemenfs
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