AN EHERIMENTAL COMPARISOTT 0F
TREATMENT METHODS IN GROUP

T’SYCHGTHERAPY WITH LATENCY AGE CHILDREN:
A PTLOT STUDY

Thesis {or “19 Degree of M. A.
WCHTGAN STATE UNIVERSITY

Neil E. Rand
1974

T’HFSE

 

 

 

 

 

AN EXPERIMENTAL COMPARISON OF TREATMENT METHODS
IN GROUP PSYCHOTHERAPY WITH LATENCY AGE CHILDREN:

A PILOT STUDY

BY

Neil E? Rand

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF ARTS
Department of Psychology

1974

(9‘0 TABLE OF CONTENTS

Page
Introduction and Review of the Literature . . . . . . l
The Problem . . . . . . . . . . . . . . . . . . 1
Types of Group Psychotherapy for Children . . . 2
Advantages of Group Psychotherapy . . . . . . . 9
Indications for Group Psychotherapy . . . . . . 12
Process of Group Psychotherapy . . . . . . . . 15
Validity of the Group Psychotherapy Approach . . 21
Hypotheses . . . . . . . . . . . . . . . . . . . . . 31
Method . . . . . . . . . . . . . . . . . . . . . . . 32
Subjects . . . . . . . . . . . . . . . . . . . 32
Instruments . . . . . . . . . . . . . . . . . . 33
Procedure . . . . . . . . . . . . . . . . . . . 34
Results . . . . . . . . . . . . . . . . . . . . . . . 37
Discussion . . . . . . . . . . . . . . . . . . . . . 42
Methodological Considerations . . . . . . . . . 42
Findings . . . . . . . . . . . . . . . . . . . . 47
Implications for Future Research . . . . . . . . 49
Summary and Conclusions . . . . . . . . . . . . . . . 53
Bibliography . . . . . . . . . . . . . . . . . . . . 55
Appendices
Appendix

A. The Instruments . . . . . . . . . . . . . . 59

ii

Page

Appendix (continued)
B. Scoring System for Instruments . . . . . . . 80

C. Scoring Scheme for Children's Composite
Negative Behavior Score . . . . . . . . . 82

D. Children's Composite Negative Behavior Scores 83
E. Comparison of the Clinic Referred Children of
this Study with the Rest of the Total Clinic

Referred Child Population at the M.S.U.
Psychological Clinic . . . . . . . . . . . 84

iii

LI ST OF TABLES

Table Page
1. Results of Analysis of Variance: All Groups 39
2. Results of Analysis of Variance: Treatment

Conditions. Clinic referred versus
Siblings O O C O O I O O O O O C O O O O O 40

iv

ABSTRACT

AN EXPERIMENTAL COMPARISON OF TREATMENT METHODS IN
GROUP PSYCHOTHERAPY WITH LATENCY AGE CHILDREN:
A PILOT STUDY
BY

Neil E. Rand

The present study was designed to experimentally in-
vestigate two forms of group psychotherapy with children.
The effectiveness of group play therapy and an adaptation of
Bessell and Palomares' Human Development Program into a group
therapy design were compared with a control group which re-
ceived no treatment. It was expected that these two types
of group psychotherapy for children would eliminate or at
least diminish the problem behaviors in the clinic referred
children and their siblings who received the treatment. The
following specific hypotheses were then formulated: l) The
clinic referred children and their siblings who attend twenty
sessions of Human Development Group Therapy would show a
greater number of measured positive changes in their behavior
than a comparable group of children who attend twenty sessions
of Group Play Therapy and 2) Both therapy groups would show
a greater number of measured positive changes in their behavior

than the control group.

Neil E. Rand

Subjects were seven clinic referred children and
seven of their siblings, all of whom were six to ten years
of age at the time of referral. The instruments used to meas-
ure the behavior change in these children were the Bessell-
Palomares Rating Form, the Problem List, and the Children's
Behavior Checklist. The children were randomly selected for
placement in the two experimental conditions and the control
group. The instruments were administered to the children's
parents before and after the twenty weekly sessions. Two
analyses of variance were performed upon this data.

The results showed that there were no statistically
significant differences between any of the three experimental
conditions. Both of the treatment groups and the control
group all improved at post-testing at a statistically signifi-
cant level over pre-testing, with no significant difference
between the improvement rates for any of the conditions. A
second statistical analysis revealed that there were no sig-
nificant differences between the clinic referred children as
a group and their siblings at either pre-testing or post-
testing. There were also no statistically significant dif-
ferences between the two types of group treatment. Neither
of the hypotheses in this study were supported.

It was concluded that additional data and further
research is needed to clarify some of the trends which re-
sulted from this study. Improvements in the methodology were

proposed. Limitations of the present research, such as the

Neil E. Rand

small number of children used, the short time period, the
lack of experience of the therapist, and the type of measure-
ment utilized were reviewed. Directions for future research

A “/4 7/

were explored.

  

INTRODUCTION AND REVIEW OF THE LITERATURE

The Problem

In today's American society the demand for psycho-
therapeutic services for children is growing at a rapid rate.
Child clinics, institutions, special schools, and private
practitioners are only able to serve about one-third of the
present demand and the outlook for meeting future needs ap-
pears to be bleak. One solution to this problem is to train
more child psychotherapists, but for the present at least,
this seems to be a lost alternative. With this in mind, new
techniques of psychotherapy must be devised and instituted
which are effective, and at the same time more efficient than
the commonly used techniques of the present. One approach
that has been surprisingly little used, but that seems to
hold great promise for the child mental health field, is group
psychotherapy for children. It appears obvious that purely
in terms of serving the most people most efficiently that
there is a clear numerical advantage to group over individual
psychotherapy, but the more important issue of the relative
effectiveness of group PT needs to be dealt with before cam-
paigning for its widespread acceptance.

In order to examine the utility of group PT the follow-
ing questions need to be answered: 1. Is group PT effective
in eliminating or at least diminishing problem behaviors in

children? 2. Is group PT also effective in developing aspects

of positive mental health in children? 3. Is group PT at
least as effective as the presently more commonly used types
of individual therapy in achieving these two goals? 4. Do

any special requirements of group PT make it less efficient

or more costly in terms of either economics or manpower than
present methods? 5. Are the effects of group PT qualitatively
different than other methods now being used, and if so, how?
6. What is the relative involvement necessary for significant
adults in the child's environment as compared to other methods
and how will this involvement effect outcome? These are some
of the more important questions concerning group PT as a treat-
ment modality for children. A review of the literature shows
that more of these questions are covered at least in part,

but that others still remain unanswered. The proposed study
will try to use a controlled experimental procedure to ex-
amine the effects of group PT alone, and hopefully shed some

light on the first two and the sixth questions presented here.

Types of Group Psychotherapy for Children

 

1. Activity Group Therapy

One of the two main methods of group PT for children
in practice today originated in a child clinic in 1934 and
came to be called Activity Group Therapy (Slavson, 1943a,
1943b, 1945a, 1945b, 1947, 1948, 1950, 1951, 1952; Scheid-
linger 1948, 1953, 1959, 1966; Lowry, 1943, Becker, 1948;
Commission on Group PT, 1952, Frank and Zilbach, 1968, Schiffer,
1969). This is a permissive type of group treatment consist-

ing of six to eight latency age children in a playroom with a

therapist who is "neutral," which Slavson (1943, 1947, 1952)
describes as not initiating or directing activities or behavior.
Slavson (1947) goes on to describe the purpose of this type of
group as "to give substitute satisfactions through the free
acting out of impulses, opportunities for sublimative activi-
ties, gratifying experiences, group status, recognition of
achievement, and unconditional love and acceptance from an
adult." The activity group for the child "becomes for a

time, the psychological parallel of the primary group, the
family (Schiffer, 1969)." The family group, then, is recre-
ated for the child at the same time that the permissive en—
vironment allows the child to relax some of his superego con-
trols. This results in a behavioral and emotional regression
of each back to the level where some unresolved conflict with
his parents has fixated libidinal energy causing his emotional
problems (Slavson, 1943, 1947). The activity group through
the accepting therapist allows the child "to release (the
connected) feelings which were completely suppressed or in—
appropriately manifested in the form of atypical behavior or
symptoms (Schiffer, 1969)." This provides a corrective emo-
tional experience for the child which alleviates the need for
problem behavior as a means of expression of these blocked
feelings. One of the most important aspects of this form of
group treatment is that the therapist makes no interpretations
and does not reflect any child's feelings, thoughts, or actions;
he has an extremely passive role. (Slavson, 1943, 1947, 1952).

The children through the establishment of group norms and

mutual acceptance are the ones who actually do the therapeutic
work for each other. Slavson (1943) explains this phenomenon
as "The desire to be accepted by the group we designate social
hunger, which in our Opinion is one of the strongest drives in
human beings. It is also the major incentive for improvement
in a therapy group. Just as the longing for adult affection
causes the child to submit to the will and direction of the
parent and to take on his characteristics, social hunger impels
the individual to take on the values and mores of the group...
The desire to be accepted serves the same function as does
transference in individual treatment." Slavson (1943) credits
the success of his treatment to the meeting of the child's
four cardinal needs: "First, Every child needs the security
of unconditional love from his parents and other adults who
play a significant role in his life. If love is not forth-
coming from these sources, a substitute for them must be sup-
plied...Second. The ego and the sense of self-worth which are
usually crushed in problem children must be built up...Success
gives one the sense of self-worth which is essential to whole-
some character formation...Third. Every child needs some
genuine interest to occupy his leisure time...Fourth. A major
value of Group Therapy lies in the opportunity it presents for
significant experiences in group resistance leading to accept-
ance by the group." Slavson and his followers characterize

their approach as strongly psychoanalytic.

2. Client-Centered Group Therapy

Axline (1947) mentions group treatment for children
in passing, "Group Therapy is a non-directive therapeutic ex-
perience with the added element of contemporary evaluation of
behavior plus the reactions of personalities upon one another.
The group experience injects into therapy a very realistic
element because the child lives in the world with other
children and must consider the reaction of others and must
develop a consideration of other individuals' feelings." In
essence, Axline sees the group as another technique in apply-
ing her client-centered method, but fails to elaborate further.

Ginott (1958, 1961) promotes the other major group PT
approach in the literature. This method is also group play
technique but is different from activity group therapy in its
definition of permissiveness and in its setting of limits.
Whereas Slavson (1943) feels that "the slightest denial may
constitute a major rejection to an intensely deprived child,"
Ginott (1961) believes that "when limits are applied thera-
peutically, they may lead to voluntary acceptance by the child
of the need to inhibit antisocial urges" and that "limits are
(thus) conducive to the development of self-discipline."
Ginott (1961) further feels that children "feel safer when they
know the boundaries of permissible action," that limits help
the child to better deal with reality, and help direct cathar-
sis into symbolic channels.

The main therapeutic processes that are in operation

according to Ginott (1958,1961) are symbolic catharsis and

identifiction. Permissiveness, warmth, and acceptance on the
part of the therapist enable the children to express their
feelings, and to act out their thoughts and fantasies with
limits forcing this acting out into symbolic channels.
"Symbolic release enables children to channel even incestuous
and destructive urges into harmless outlets and to develop
sublimatiOns compatible with social demands and mores...A11
feelings, fantasies, thoughts, wishes, passions, dreams and
desires, regardless of their content, are accepted, respected,
and allowed expression through words and play. Direct acting
out of destructive behavior is not permitted; when it occurs,
the therapist intervenes and redirects it into symbolic out-
lets. (Ginott, 1961)" The child then identifies with the
therapist or another child in the group and adopts the values
belonging to this figure. Ginott (1961) sees the individual
as all-important with little emphasis on group identity or
group cohesion. In this manner the child releases his pent
up feelings, can rid himself of his symptomatic behaviors,
can better express his emotions, feel accepted, and has de-

veloped better social interaction skills.

3. Other Methods of Group Therapy

Anthony (Foulkes and Anthony, 1965) practices an inter-
view approach in which there is no formal activity or play or
playroom. Anthony claims that the use of play as a medium is
unnecessary if one learns how to talk to children. The way
to talk to them is to temporarily surrender one's adult per-

sonality, to not be didactic or condescending or demanding of

a factual presentation from the child, to accept the child's
subjective or distorted view of the world, and to be interest-
ed in what the child has to say. In this way there is a two-
way communication instead of the usual one way process which
is in the form of "information, advice, and prohibition...allow—
ing for minimum feedback."

Anthony (1965) sees the role of the therapist as essen-
tially similar to the role played in adult analytic group PT.
The therapist of the latency aged group interprets feelings,
wishes, impulses, and transference. Everything is brought
into the here and now of the therapy situation. Eventually
the children pick up the interpretative technique until they
are constantly searching for the latent content of all their
manifest actions and verbalizations. Insight and catharsis
seem to be the key points in Anthony's psychoanalytic inter-
view method.

Anthony (1965) developed his therapy style from a
second technique evolved by Slavson (1947, 1950, 1952) called
activity-interview group therapy. This is a combination of
a half hour of Anthony's interview technique followed by a
half hour of activity group therapy. This composite method
was little favored by Slavson (1952), however, and only used
by him in order to treat psychoneurosis which he felt could
not be treated in activity group therapy alone.

The claims made by Anthony (Foulkes & Anthony, 1965)
based on this vast experience with group treatment of children

brings up an ongoing theoretical controversy that has yet to

be settled. Slavson (1943, 1947, 1950, 1952) strongly empha-
sizes that the latency age child's main form of self-expression
is motoric and that the most beneficial method for therapy to
proceed in is to use this developmental factor exclusively.
He believes that children in the activity group achieve what
he calls derivative insight, which is the accumulation of self-
knowledge through experience with many different relationships
in the group. He states (1952), "In activity groups in which
no interpretation is given, children become aware of the change
within themselves and of their former motives and reactions."
Ginott (1961) ascribes to this notion but adds to it that the
child also receives direct insight from the verbal feedback
he gets from the other children as he interacts with them.
Axline (1947) takes the next step by using reflections of be-
havior and feelings, the latter being very close to formal in-
terpretation. However, she makes the distinction between re-
flection of feelings and interpretation, although it may be a
difference in degree. Anthony (1965) is the only voice raised
in favor of the psychoanalytic interpretive style in group
treatment. Strangely enough, Slavson, Ginott, and their re—
spective followers seem less concerned with dealing with Anthony
than with the adult psychoanalytic theorists, from whom they
appear to seek acceptance, approval, and legitimacy.

Slavson (1947) also sees this difference in approach
in terms of the divergent processes that characterize the ac-
tivity and interview methods. He sees activity group therapy

as an ego therapy where derivative insight is used, where

ego-strengthening occurs, where the main emphasis is on ex-
periencing and motor activity, where the child's hostility

and aggression can be acted out directly, and where the child
works through his problems via a feeling of acceptance. Slavson
views interview group therapy as insight-oriented, as dealing
with libidinal fixations and difficulties, as the place where
transference to the therapist is used, as having more intense
feelings expressed and creating greater anxiety, and as reach-

ing more deeply into the personality.

Advantages of Group Psychotherapy

Although there are only a few workers in the field who
actively practice group PT with children, there are many more
psychotherapists who avow to its advantages over individual
therapy, or at least to its equivalence.

Slavson (1947) states,

The chief and common value of the group is
that it permits acting out of instinctual
drives, which is accelerated by the catalytic
effect of the other members. There is less
caution and greater abandon in a group where
the members find support in one another and
the fear of self-revelation is strikingly re-
duced. As a result, patients reveal their
problems more easily, and therapy is speeded
up. Defenses are diminished, the permissive-
ness of the total environment and the example
set by others, allow each to let go with de-
creased self-protective restraint...At the
same time it brings patients face to face with
‘ their problems more easily, and therapy is
speeded up. Defenses are diminished, the per-
missiveness of the total environment and the
example set by others allow each to let go
with decreased self—protective restraint...
At the same time it brings patients face to
face with their problems quite early in treat-
ment. The defenses against injury to one's

 

10

self-esteem are also reduced. The friendly
group climate and the mutual acceptance do
not require one to be on the defensive...
Release and catharsis occur much more easily
and intensively (in group) than is usual in
any other treatment situation. The ego de-
fenses are reduced, and as Freud pointed out,
the primitive impulses flow more easily in
groups than they do in individual relation-
ships. Transference is greatly facilitated
because the group is a protection against the
therapist and what he stands for: a symbol
of parental and environmental authority.

The other advantages that Slavson describes (1943, 1947,
1950, 1952) in comparison to individual treatment are the re-
creation of the family group, the opportunity to work out
sibling rivalry, the chance for "vicarious" or "indirect"
catharsis, and the opportunity for working on problems with
other children as support in those cases where an individual
approach would be too frightening and anxiety-producing for
the child.

Ginott (1958, 1961) overviews the experience of many
therapists and summarizes their observations as, "In the course
of trial and error, many have found group therapy to be not
just a watered down individual therapy extended simultaneously
to several participants but a qualitatively different experience
with rich potentialities of its own." More specifically,
Ginott (1961) lists the advantages as, "The presence of several
children seems to facilitate the establishment of a desired re-
lationship between the therapist and each child...The group
provides for multilateral relationships unavailable in individ-

ual p1ay-therapy...The therapeutic process is enhanced by the

fact that every group member can be a giver and not only a

11

receiver of help...Group play-therapy has an advantage over
individual treatment in regard to catharsis. Besides "free
associative" catharsis, it provides also "vicarious" and "in-
duced" catharsis...In group play-therapy children are forced
to reevaluate their behavior in the light of peer reactions...
Unlike individual treatment, group play-therapy provides a
tangible social setting for discovering and experimenting with
new and more satisfying modes of relating to peers. The group
constitutes a milieu where new social techniques can be tested
in terms of reality mastery and inter-individual relationships."
Axline, although not an active participant in group
treatment states (1947), "It is obvious that, in cases where
the child's problems are centered around social adjustments,
group therapy may be more helpful than individual treatment."
Finally, Bender (1952) describes her experience with
group therapy as, "Our success with group therapy in various
activities has led us to realize that there is an actual emo-
tional advantage in having several children with similar prob-
1ems...deal with these problems together" and she concludes
that "There is practically no limit to the usefulness of such
group activity. The group or social situation rather than de-
tracting from the value of the treatment adds a new factor of
freer and more fertile associations and better catharsis as
well as the opportunity of experiencing the emotions of the
other members of the group and of finding that one's own ex-

periences have social value for the other children and for the

psychiatrist."

Thus it seems that there is a general confirmation of
the value and advantages of group psychotherapy with children
based upon theoretical considerations and many years of ex-
perience in working with children both individually and in

groups.

Indications for Group Psychotherapy»

All of the therapists in the field feel that there is
a definite inclusion criteria as well as a definite exclusion
criteria when forming children's groups, although the different
theoretists propose different criteria. However, from the
literature it is difficult to determine whether these criteria
are solely based upon theoretical considerations or whether
there have been at least some experiences with exclusion types
in group treatment. To date there have been no experimental
studies done to test out the validity of any of these criteria.
Adding to this confusion are a few reports of case studies
where children belonging to the various exclusion criteria
have been successfully treated (e.g. Schiffer, 1969, Foulkes
and Anthony, 1965).

Slavson (1943, 1947, 1950, 1952) makes a point of
clearly distinguishing between children that are acceptable
and not acceptable for group therapy. His inclusion criteria
and that of his followers including Schiffer (1969) are symp-
tomatically based and contain: 1. social maladjustment cate-
gories such as aggression, submissiveness, inability to func-

tion in groups, extreme suggestibility, withdrawal, and habit

13

malformations, and 2. children with character malformations
which include schizoid personalities, neurotic traits and
symptoms, conduct disorders, sibling rivalry and symbiosis,
emotional exploitation, and infantilization. Ruled out are
children who are characterologically narcissistic, psycho-
paths or sociOpaths, severe sibling rivalry problems, autistic,
psychotic, or psychoneurotic with other than transference
neuroses.

Ginott (1961) has a similar but less comprehensive
list for inclusion in groups: withdrawn, immature, phobic, ef-
feminate (boys), having pseudo assets, habit disorders, or
conductive disorders. The basic criterion for group treatment
for both orientations is the presence of social hunger which
can be defined as the child's "desire to gain acceptance by
his peers, to act, dress, and talk as they do, and to attain
and maintain status in his group. (Ginott, 1961)." Ginott
excludes children who are sociopathic, have intense sibling
rivalry, have accelerated sexual drives, have been exposed to
perverse sexual experiences, steal, are extremely aggressive,
or have gross stress reactions. Both authors base their
criteria on theoretical assumptions, plus usually unspecified
experiences of success or failure in their groups.

Other researchers (Coolidge and Grunebaum, 1964;
Scheidlinger, et a1, 1959) have found that activity group
therapy is optimally and uniquely suited for mild character
and neurotic disorders. Scheidlinger (1960) has also developed

a modified form of activity group therapy which he found

14

successful with severely disturbed and atypical children who
had ego deficiencies, inadequate impulse control, poor peer
relationships, low self-image confused identity, and oral
greediness.

Anthony (1965) disagrees with Slavson only partly in
describing activity-interview group therapy as the treatment
of choice for "the mildly to moderately neurotic child with
a largely internalized conflict and a good deal of super-
imposed inhibition." But Anthony takes the full plunge into
the conflict with Slavson when he depicts his interview group
therapy as "especially effective with the more acting-out,
pre-delinquent or delinquent type of child who has to become
more neurotic before he can be treated effectively by PT, that
is, his tendency to activity must give place to the need to
verbalize." This theoretical challenge to Slavson and his
followers is, of course, not backed up by experimental data,
but only inference from experience, but then again, so is
Slavson's position.

Friedlander (1953) makes a claim that group therapy is
fluamost suitable form of treatment for "all types of social
disturbance." Little and Konopka (1947) state from their dif-
ferent viewpoint that indications for group PT are the child's
need "to get a satisfying experience with other children; need
for warmth and acceptance from an adult; need for a construc-
tive outlet for aggressive drives; (and the need to) overcome
shyness in social situations." Finally, the Commission on

Group PT (1952) stated in a review of group therapy for latency

15

age children, "A desire to be a part of the group, (and) an
ability to curb one's behavior in response to group influences--

which Slavson has termed 'social hunger'--is a sine qua non

 

‘for a child to be acceptable to such treatment. This would
exclude children with severe primary behavior disorders or
serious psychoneurosis, children with active psychoses, psycho-
paths and the like. Experience has shown that mild behavior
disorders, schizoid children, character disturbances and those
with milder neurotic traits or symptoms can be treated quite
effectively through activity group therapy."

Thus the question of indications and contraindications
for the use of group treatment is by all means still an open
issue, and an area where research is sorely needed if the ex-
tent to which group therapy with children can be utilized is

to be explored.

Process of Group Psychotherapy

For activity group therapy there are several approaches
to viewing its therapeutic process. Schiffer (1969) descrip-
tively breaks down the process into four evolutionary phases:
1. preparatory phase which contains an introduction to the
play group, the child's initial reaction to permissiveness,
testing the reality of the new experience, and discovery and
relaxation, 2. therapeutic phase, the elements of which are
the development of transference on multiple levels, regression,
aggression, abatement of anxiety and guilt, and catharsis,
3. reeducative (or integrative and maturational) phase to which

there is increased frustration tolerance and capacity for

16

delaying gratifications, development of personal skills, ex-
pansion of interest areas, improved self-image, sublimation,
success in intragroup participation and recognition from the
group, more efficient group controls, dilution of transfer-
ence, and identifications move closer to reality, and 4. ter-
mination in which there is a temporary regression in behavior
resulting from separation anxiety, acceptance, and conclusion.

Scheidlinger (1959). sees the description of the pro-
cess in a similar manner but interprets it somewhat differently.
He sees (1972), "three major therapeutic elements:...guided
gratification in both a real and symbolic sense. This involved
restitution for past deprivations as well as minimizing current
frustrations...guided regression wherein the child was enabled
to relive with different actors and with a different ending,
conflicts from early fixation levels. The final and perhaps
most decisive treatment element involved a guided upbringing
and socialization. Building on the earlier climate of grati-
fication and the ensuing attachment to the adult and to the
Vgroup, demands for control and socialization (are) posed."

This is closest to Slavson's (1943, 1947, 1950, 1952)
ideas that a permissive group climate promotes benign regres-
sion in which earlier and current conflicts can be relived in
the context of a stable and accepting environment. The main
dynamics occurring in activity group therapy are transference
dilution, target multiplicity, displacement, escape, deflection,
catalysis, mutual support, identification, and universaliza-

tion (Slavson, 1950). But the five main factors that Slavson

17

(1943, 1947, 1950, 1952) stresses as the primary therapeutic
components of any psychotherapy are transference, ego-
strengthening or insight, catharsis, sublimation, and reality
testing, and he claims that only activity group therapy affords
all five to latency age children.

Ginott's (1958, 1961) view of the therapeutic process
is almost identical to Slavson when he states (1961), "The
aim of all therapy including group therapy, is to effect
basic changes in the intrapsychic equilibrium of each patient.
Through relationship, catharsis, insight, reality testing,
and sublimation therapy brings about a new balance in the
structure of the personality, with a strengthened ego, modified
superego and improved self-image."

Anthony (Foulkes and Anthony, 1965) describes his
therapeutic process as the traditional psychoanalytic one,
but having three group phases, "A first phase is one of de-
fensive pandemonium which the group has to work through and
the therapist has to live through...In the second phase, the
amount of movement, aggression, and noise is reduced con-
siderably. The (children) actually sit around for periods
and begin to examine highly charged emotional material brought
in from the outside or generated within the group situation.
In the third phase, the insight of the group is at its height,
and the group begins to interpret its own behaviour so that
less use is made of the therapist in this connexion." Anthony
here describes the motor control and insight gains made by

these psychoneurotic children as a way of painting the setting

18

in which the transference, catharsis, and other psycho-
analytic therapeutic factors Operate, all without the use of
activity or play.

Karson (1965) explains her phases as a modified form
of Ginott's description, where the children eventually come
to plan their own activities as a group, which for her is an
important therapeutic factor. Maier and Loomis (1954) depict
the process of achieving impulse control in boys by the boys
encountering in one another the "expression and consequences
of their impetuous thoughts or actions," seeking new roles in
one another through identification, self-disclosure, their
concern with similar fantasy material, and "they are met by
acceptance plug necessary imposed limits in a setting con-
ducive to successful peer contacts." This seems to be a view
of the process of a specialized form of a client-centered
play group in the style of Ginott conceived of to deal specifi-
cally with impulse control.

Bettelheim and Sylvester (1947) describe the process
of group therapy for children on a somewhat different plane
in their explanation of how the use of group treatment in-
fluences the behavior, interpersonal relations, and self-
concept of the child. They look at the process in group dynamic
terms, stating that "Therapeutic influence of the group on the
individual...can be differentiated...as two main types...In
the first type, the group as such, or individual group members,
exercise active influence. In this situation, group influence

can be relatively easily recognized and analyzed. In the

19

second type, the group or its individual members do not take

 

ppsitive actions. The group exercises a therapeutically

 

significant influence through attitudes which originate in
the group structure (Bettelheim and Sylvester, 1947)."

Of the factors composing this second type of influence,
only the first is similar to Slavson's or Ginott's formulations.
Bettelheim and Sylvester (1947) go on to list these therapeu-
tically influencing factors as,

"1. The group's example demonstrates safety of per-
missiveness and indulgence to the child; the group members
are not subject to consequences which the child had expected
for undesirable activity. Fantastic fears are diminished and
reality testing becomes possible, allowing actual participa-
tion in indulgent behavior at a later time.

"2. The group permits consolidation of the child's
status...Success or failure does not become a matter of fate
but a result of spontaneous eXperimentation.

"3. The group allows the individual to acknowledge
hostile impulses which then may be integrated. The cohesive-
ness of the group as an already existing organization makes
countereaggression unnecessary. Aggressive impulses of the
individual do not have to become self-perpetuating.

"4. The group permits integration of disparate ten-
dencies in the child. The individual uses group members as
representatives for his discordant tendencies. Their isolation
facilitates their mastery, and inner unification becomes
possible.

"5. The group permits the child to face the traumatic
past by providing strength in the present.

"6. Finally, the group permits the child to gain
status as an equal in the group which gives him strength
through belonging. Such strength is internalized and has to
be differentiated from the former examples in which the child
derives strength from the cohesiveness of a group of which he
has not yet become an integral part...

"Among emotionally disturbed children, the group ex-
erts active influence on the individual mostly at the time he
threatens to increase the anxiety of the group...

'"Where the group permits the child to act out patho-
logical behavior, it may be used to confront him realistically
with the consequences of such behavior."

These group dynamics are descriptive of events and

processes that sound similar to Slavson, Scheidliner, Schiffer,

20

and Ginott but the approach to understanding is more from the
group process end and less from the vieWpoint of the child's
intrapsychic dynamics. Unfortunately, the literature yields
only one exploration that follows the group dynamics approach
in dealing with children. This appears to be a tremendous
hiatus in the understanding of children's therapy groups, es-
pecially in comparison to all there is yet to be learned about
adult therapy groups after twenty years of accumulation of
knowledge in the realm of group dynamics.

The only study examining the group dynamics of a
children's group was done by Hicks (unpublished doctoral dis-
sertation) in 1968. He studied three activity and one aca—
demic achievement oriented therapy groups for nine weekly
sessions each. He found that "Certain types of psychothera-
peutic groups for children d9 exhibit systems properties" as
described by Bales (1970), "Groups guided...by different
therapeutic theories and methods d2 exhibit similar system-
properties," and "The clarity and consistency of system-
properties varied directly with the experience of the thera-
pist." The implications and impetus for continued research
along these lines are indeed great. In addition Hicks found
that there are three phases in group psychotherapy with
children, and they are "1. low affect, high isolation, high
in actions directed directly to the therapiSt, and high in
his reactions; 2. Increased affect, less isolation, less
actions directed to the therapist, less reaction and more ini-

tiated actions from him; 3. The highest period in affect,

21

lowest in isolation, only a very slight increase in actions
directed to the therapist, and the highest in the therapist's
initiating actions."

Thus the process of group psychotherapy with children
is viewed in various ways and from different angles, but with
only one exception it is described through its effects upon
the children's personalities, and even that exception joins
the rest in being only a description of the mean observed
.behavior of all the children in the group. The literature
reflects that to date no one has experimentally examined in
an empirical manner what is actually occurring in children's
therapy groups or what are the factors responsible for what
is happening. There is also a need for discovering what the
therapeutic elements are in group treatment for children and
how these elements can best be arranged to maximize their

effects.

Validity of the Group Psychotherapy Approach

Although in terms of volume the bulk of the publica-
tions concerning group psychotherapy for children deals with
the theoretical framework and practical applications of the
treatment, there have been a considerable number of research
studies executed in an attempt to gather some empirical data
in this field. Unfortunately, much of the experimental work
done is poor in either conception, methodology, measurement,
controls, or reporting. Many of the studies are purely case
reports or descriptions of experiences in working with children's

groups and give no data other than subjective evaluations. Other

22

publications report controlled experiments but pay little or
no attention to determining the appropriateness of their meas-
ures or their reliability, to matching up the subjects on some
important variables to equate the experimental conditions, in
reporting the data, or in defining their descriptive terms,
especially what is meant by "improvement" or "cured." The
most common methodological mistake, however, was the failure
to include a control group, an important facet that is rarely
even mentioned and seems to be just simply overlooked. This
last error in technique is a substantial one, for it must be
known what the effects of no treatment are, if any, if the
treatment modalities are to be considered to have had any
effect. However, not all of the studies performed contain
these experimental errors, with some showing important and
noteworthy results.

First, a brief survey of those studies that are mainly
descriptive and experientially oriented is in order. Papanek
(1945) gives a colorful description of one of the earliest ex-
periences in group treatment which occurred in Vienna, 1924—
1926. Friedlander (1953) informally presents the results of
various types of groups in a clinic setting but exhibits no
data. He ran four groups of three to four children each with
two groups solely of girls and two containing children of both
sexes, and found activity group therapy to yield the best re-
sults. Maier and Loomis (1954) describe their experience with
one group of ten year old boys treating impulsiveness. They

report that impulse control was achieved. Graf (1958) reports

23

on six years of work with group play therapy. He claims
"therapeutic success" with 70% of 60 cases, but fails to de-
fine this term. He attributes his success to noninvolvement
of the therapist in the group play, screening, the "abreactive
value" of the permitted "acting out," and the father trans-
ference to the therapist. Finally, Wellington (1965) gives

a description of four twelve year old girls in one play group
and how their behavior changed.

A number of studies which were experimental in design
failed to utilize control groups and thus diluted the signifi—
cance of their reported results. Burlingham (1938) placed
eight children aged two to five years in a single play group
for two and one-half years. Six of the eight showed improve-
ment in the form of stopped or reduced problem behaviors, and
experienced real emotional growth, while two did not. The
play group was considered the basis for growth in the six
children, but change in the family situation was seen as the
cause for sustaining that development.. A combination of both
factors was viewed as a necessity for behavior change and
emotional development. Lowry (1943) studied the records of
one-hundred-one children who had been in activity group
therapy in the clinic Slavson supervised during the period
1934-1941. Based solely upon his clinical judgment he rated
seventy-four children as having "good results" and twenty-
seven with "poor or no results." Becker (1948) selected
twenty-six cases for activity group therapy where the present-
ing problem was sibling rivalry, and where a year of individ-

ual therapy had not resolved the problem behaviors. His results

24

showed that three eliminated and fourteen diminished their
sibling rivalry behaviors. Of these successful cases ten
also showed "marked improvement" in their "general adjustment,"
but four of the non-successful cases also showed this. Mendes
Leal (1966) reported on one group lasting eighteen months that
had activity group therapy for two months, then interpretive
play therapy, and finally a discussion group. It was stated
that all of the children improved, although it was in varying
amounts. Shere and Teichman (1971) studied eight eleven year
old girls in a single activity-interview group that had one
and one-half hour weekly sessions spanning the course of two
years. Pre- and post-testing using the Rorschach showed sig-
nificant differences at the p$.05 level in the areas of in-
creased ability in interpersonal relationships, to cope with
stressful situations, and to be in contact with one's human
environment. There was also an improvement at the ES .10
level of significance in emotional control and realistic view
of the world. Lastly, B011 (1971) compared the effects of
twenty sessions of non-directive and analytic group therapy
of eight to eleven year olds. He observed the exhibited be-
havior and rated activity on six scales. He found that
children in the client-centered group "increased their amount
of play, vocalization, speech and movement markedly," while
the analytic group "did not noticeably increase their activity
levels."

A few researchers have followed much better methodo-

logical procedures and the results of their studies must be

25

given greater validity. Fleming and Snyder (1947) executed

a controlled study with a single experimental group of non-
directive play therapy which resulted in improvement in test
scores for the three girls and four boys in that group on the
Rogers Personality Test, Guess Who Test, and a sociometric
test, while controls did not change. They also reported that
the gains along the personal adjustment dimensions were greater
than in social adjustment. Moulin (unpublished doctoral dis-
sertation, 1968) performed a controlled study using twenty-
four underachieving elementary school children. Two groups

of six children each received twelve weeks of group play
therapy, while the other twelve children experienced no treat-
ment. The experimental groups made gains over the control
groups that were significant at the .05 level in the areas of
language and non-language intelligence, and on psycho-linguistic
abilities, but there was no significant difference between the
two groups in mean academic achievement or in mean total in-
telligence. House (unpublished doctoral dissertation, 1970)
executed a controlled study using thirty-six children who were
underchosen on a sociometric test. He then formed three
groups of twelve children each, with one group receiving non-
directive play therapy, the second became a placebo reading
group, and the third a control group of no treatment. Positive
change occurred for the experimental versus the placebo and
control groups on the Scamin Self-Concept Scale with signifi-
cance at the .01 level. However, all three groups increased

on post-testing at the .01 level in sociometric status with

26

no statistically significant differences between the groups.
Garner (unpublished doctoral dissertation, 1970) performed

a controlled experiment using human relations groups combin-
ing normal and low emotionally adjusted third grade children.
He placed three subjects and five normal children in each of
the three groups. There was an experimental group which had
twenty-four human relations sessions, a placebo group which
had twenty—four sessions of activities, and a control group
which received no treatment. At post-testing there were
statistically significant differences in the positive direc-
tion for the experimental group over the other groups at the
p=.05 level on the amount of maladaptive classroom behavior
rated by the teacher and on a self-concept scale. There were
no significant differences, however, on observed classroom
behavior or on peer status. Finally, Schiffer, in 1965 (un-
published doctoral dissertation) ran a controlled study using
thirty-three children in five groups of nine to eleven year
old boys meeting once weekly in a child clinic. Two groups
received play therapy in the style of Axline combined with

a therapy group for their parents, one group received play
therapy without parent participation, one group was a placebo
group led by a recreation leader, and one group served as a
control by remaining on the clinic waiting list. All experi-
mental conditions met for six months. The Peer Nomination
Inventory was broken down into nine maladjustment scales and
administered pre- and post-treatment. 'All the treated children,

including the placebo group, remained stable on the nine scales,

27

showing no significant positive change. Schiffer's interest-
ing finding, however, was that the untreated control group
deteriorated on eight of the nine peer rated social deviance
scales at the pfl.05 level of significance. Thus Schiffer
found that 1) while treatment did not improve the children,
they did stabilize, 2) there was no significant difference
between placebo and treatment conditions which may indicate
what some of the beneficial factors involved are if a process
study could be done, and 3) there was no statistically signi-
ficant difference when a parent therapy group was used. This
was the only study in the literature that in any experimental
manner deals with the involvement of parents in the treatment
process, and it seems to indicate that the concurrent treat-
ment of the parents has no real effect. However, more con-
clusive studies are needed to verify and strengthen this posi-
tion before it can be accepted as valid.

Lastly, there have been two studies which have com-
pared the relative effectiveness of group versus individual
psychotherapy. Gibbs (1945) studied sixty-three children
aged four to twelve years over a three year period in which
play groups of four children each were utilized on a weekly
basis and mostly lasting under twenty sessions. He reported
the results as "recovered" 24%, "improved" 28%, "not improved"
48%, but failed to define his terms. Gibbs then compared this
to the results obtained from all forms of treatment practiced
at his clinic including group therapy and found 44% "recovered,"

55% "improved," and only 6% "not improved." Very sloppily,

28

Gibbs counts those children who did not improve in group treat—
ment but did later in individual treatment twice, making for a
distortion in the comparison in the negative direction for
group treatment. At any rate, the results of this study seem
to indicate that individual treatment is more effective than
group therapy. Another finding of Gibbs' was that improvement
did not correlate with length of treatment. The second com-
parative study was done by Novick (1965), who did not use a
control group. He studied forty-four mildly disturbed boys
aged eight to ten years in groups of three to five children
each for twenty sessions. The subjects were divided into good
and poor short-term prospects which was based upon high and

low ego strength respectively. The children were then matched
for age, sex, IQ, and rating on the Behavior Problem Rating
Scale, and assigned to individual or group activity-play com-
bined with verbal communication therapy. The children's
parents were seen in the clinic on a weekly basis. The re-
sults were that both the high ego strength individual and group
subjects improved at the .05 level of significance with no
statistically significant differences between the two treatments,
while the low ego strength condition did not show any statisti-
cally significant change. The high ego strength group improved
significantly on six behavior scales: disinterest in schoolwork,
defiance to authority, marked overactivity, temper outbursts,
bullying, and undue stubbornness. The same children also had

no statistically significant change on five other scales: un-

necessary tardiness and general unreliability, marked shyness

29

or withdrawal behavior, annoying or anxious behavior habits,
sleeping difficulties, and extreme moodiness. Novick con-
cludes that these five behaviors are "not amenable to change
by limited therapeutic experience." Some of the procedures
that Novick uses to control the variables in his experiment,
with special reference to the separation of high and low ego
strength children, may very well account for the disparate
results obtained in these two conflicting comparative studies.
Unfortunately, neither study contained a control group, but
an even more discouraging fact is that there are no other
studies comparing group and individual psychotherapy in the
literature, so the question of relative effectiveness is as
unsettled as ever. With the amount of therapy being received
by children today this is a matter of serious concern which
should be rectified as soon as possible.

This review of the literature on group psychotherapy
for children indicates that there is a good deal of theoretical
material being written, but little is being done to verify any
of the hypotheses being formulated. In response to the ques-
tions stated earlier in this review as needing to be answered
about group treatment for children, the literature does poorly.
Some researchers have reported varying amounts of success with
this method, but most of the reports have tended to be anecdotal
and list little, if any, data. The experimental studies done
have generally been poorly constructed or inconclusive. This
state of affairs leaves the questions of effectiveness, re-

lative effectiveness compared to individual treatment, the

30

development of positive mental health in children, efficiency
and economy, qualitative differences, and the involvement of
parents all open to theoretical speculation, which is the
point at which group therapy for children was at forty years
ago. Thus, exceedingly little progress has been made in de-
monstrating that group psychotherapy for children either is

or isn't a worthwhile treatment modality. But with the
limited amount of therapeutic resources available at the
present, the best, most effective, most efficient, and most
economical treatment methods must be identified if we are to
have any effect at all in promoting mental health in children,
and in providing a better future for the next generation.
Group psychotherapy for children appears to hold great promise
in this area and the scientific exploration of this potential

should receive high priority.

HYPOTHESES

The hypotheses to be tested by this study were:

1. That the clinic referred children and their siblings who
attend twenty sessions of Human Development Group Therapy will
show a greater number of measured positive changes in their
behavior than the clinic referred children and their siblings
who attend twenty sessions of Group Play Therapy, and that
these differences will attain a p5 .05 level of statistical
significance at post-testing.

2. Both those groups will show a greater number of measured
positive changes in their behavior than the control group,
and that these differences will attain a pf .05 level of

statistical significance at post-testing.

31

METHOD

Satir (1967) describes the family with one or more
children ascribed the role of "identified patient" as really
involving all of the family members in a dysfunctional unit,
although no other family members may exhibit symptoms or be-
haviors traditionally labeled as pathological. Even though
the parents of such a family may describe the siblings of the
identified patient as "normal" or more simply "not problem
children," Satir relates that her experience has shown her that
all of the children in a dysfunctional family feel pain, even
if they do not show it behaviorally. In light of this, it was
the intention of this study to treat via group techniques both
the child who was referred to the clinic because of his problem
behavior and all of his siblings who fell within the age range

of six to ten years.

Subjects
The subject pool for this study consisted of all

children (and their siblings) who were referred to the Michigan
State Psychological Clinic for treatment during the 1972-1973
academic year who fell within the age range of six to ten years
at the time of referral and whose parents were interested in
placing them in group therapy. Children who were diagnosed in

this clinic as psychotic, brain—damaged, or mentally retarded

32

33

were eliminated from the available subject pool. These
diagnoses were controlled for inter-diagnoser variance by
having all diagnoses discussed with and confirmed by a single

supervising Ph.D. clinical psychologist.

Instruments

The following instruments were used to measure un-
desirable and problem behavior, and in addition, as a means
of controlling diagnostic categories:

1. Bessell-Palomares (B—P) Rating Form
2. Problem List
3. Children's Behavior Checklist (Numerical Type)
4. Description of presenting problem
These instruments can be found in their entirety in Appendix
A.

The first three scales listed here were also utilized
to determine personal growth, psychological maturation, and
the development of positive mental health factors in the
children. These factors were determined by a scoring system
described in Appendix B.

A questionnaire completed by the parents was used to

gather the necessary background data concerning each child.

Procedure

 

Subjects, including both the clinic referred children
and their siblings who fell within the age range of six to
ten, were rated by their parents on the Children's Behavior

Checklist, Problem List, the B-P Rating Form, and described

34

by their parents on the background questionnaire. The present-
ing problems were described by the clinic's intake staff. The
scores from the Children's Behavior Checklist, Problem List,
and B—P Rating Form were combined and weighed according to the
reported validity of each measurement. A sum of the weighed
scores from these three measures constituted the composite be-
havior rating for each child. The manner in which this was
done is described in Appendix C.

The children were then randomly assigned to one of the
four groups composing the three experimental conditions:

1. Group Play Therapy

2. Human Development (Bessell-Palomares)
Group Therapy - two Groups

3. Control Group
Each group contained four children. The only restriction upon
the random assignment were that siblings were not placed in the
same group.
The leader for all these groups was the experimenter,

a male graduate student in clinical psychology.

The Experimental Conditions

1. Group Play Therapy

This treatment modality consisted of four children meet-
ing for one hour per week in a non-directive play session in the
clinic playroom. The therapist created an atmosphere of warmth,
security, and acceptance through permissiveness. He attempted
to verbally reflect the actions, behaviors, thoughts and feel-

ings of the children. Interpretations of the children's

35

thoughts, feelings, and behaviors were made when the therapist
felt that he had enough information to formulate a hypothesis
or make a guess. He also attempted to express no judgmental
approval or disapproval of particular behaviors and no criti-
cism or encouragement of specific actions exhibited by the
children, except for a few protective limits. These limits
were set, but only to prevent physical harm to the therapist,
other children, or the room, and to prevent any children from
leaving the room. With these modifications, then, this treat-
ment generally followed the guidelines set up by Ginott (1961)
and Axline (1947) for client-centered or non-directive play
therapy.

2. Human Development Group Therapy

For this treatment condition two groups of four children
each met for weekly sessions of one hour duration in the clinic
playroom. Following Bessell and Palomares (1967, 1970) this
group functioned via self-expression and discussion. The object
of this treatment was to develop self-awareness, mastery skills
or competency, and social interaction abilities in the children
through a programmed sequence of educational lessons. The
children, hopefully, would learn these skills and develop more
adequate functioning and coping abilities through their own
self-disclosure and mutual sharing. The role of the therapist
was to initiate the discussion planned for that day, encourage
the children to share their thoughts and feelings, make sure
that all the children had a chance to speak, and to see that

the discussion continued smoothly within the guidelines set down

36

for that lesson. Since these lessons were designed to be fol-
lowed daily for twenty minutes by fifteen children, a full
five-day week's worth of lessons were covered each week with
these groups of only four children. These lessons consisted of
all five lessons described by Bessell and Palomares in their
Lesson Guides for each week. The Lesson Guides chosen were

the ones that were appropriate for the age of the majority of
the children in the group. These lessons spanned the first
half—hour of each session, with the second half-hour devoted

to group play therapy as described above.

3. Control Group

The control population consisted of children (both
clinic referred children and their siblings) who remained on
the clinic waiting list after their diagnostic evaluations had
been completed, and who received no treatment during the ex-
perimental period.

All groups met for the same treatment duration of
twenty sessions, or approximately twenty weeks. The B-P Rating
Form, Children's Behavior Checklist, and Problem List were com-
pleted by the parents again after the twentieth session.

There were conferences between the parents and the
therapist after ten weeks and after twenty weeks in order to
receive a more descriptive account of their children's progress,
or lack of it. These conferences also enabled the therapist to
determine if there were any significant changes in any child's
environment which might account for any change in the child's

behavior.

RESULTS

The dependent measure selected for study in this ex-
periment was the composite negative behavior score derived
from a devised scoring system utilizing the Children's Behavior
Checklist, the Bessell-Palomares Rating Form, and the Problem
List. The mean of both parents' scores for each child was taken
in order to form the composite score for pre-testing and post-
testing.

An analysis of variance performed upon the data revealed
that there were no statistically significant differences between
any of the three experimental conditions or between any of the
four groups. However, there were differences obtained at the
E1<-05 level of significance (F = 5.56) between measurements
for all groups in the experiment. While this result indicated
that all of the groups improved at post-testing at a statisti-
cally significant level over pre-testing, there was no signifi-
cant difference between the improvement rates for either the
conditions or the various groups (F = 0.36 for Measurements x
Conditions). A summary of the results of this analysis of
variance is presented in Table l.

A second analysis of variance performed upon only the
scores from the children of the three treatment groups revealed

that there was no significant differences at the py= .05 level

37

38

between the clinic referred children and the siblings at either
pre-testing or at post-testing. This result appears to verify
the assumption that, following Satir (1967), all of the children
in a problem family feel the pain instead of just one child, and
that as far as the parents' View is concerned, these siblings
as a group exhibit a similar amount of problem behavior as the
clinic referred children. Another result that was unveiled was
that with the control group removed from consideration, the dif-
ferences between pre—testing and post-testing decreased to a
level of significance just below the p_= .05 level. This in-
dicates that the control group accounts for a substantial part
of the difference between the two measurements. This second
analysis of variance is presented in summary form in Table 2.

The raw data produced from this study showed that
while some children in the treatment groups improved in their
behavior as rated by their parents, others either did not change
at all or even received slightly worse ratings after twenty
weeks of treatment. However, the trend is definitely in the
positive direction with eight out of twelve children from the
three treatment groups rated as having improved, one not changed,
and only three becoming somewhat worse. Of the clinic referred
children in the treatment groups four improved and two worsened,
with the siblings having four improved, one unchanged, and one
worse.

Comparing the two different treatments, the play ther-
apy group had somewhat better results than the Bessell—Palomares

groups. Three out of four children improved with only one

39

TABLE I

Results of Analysis of Variance: All Groups

 

 

 

Source df MS F
Total 27 - -
Between Subjects l3 - -
Groups (Conditions) 3 5146.4 3.31**
Error
Between 10 1552.6 -
Within Subjects 14 — -
Measurements 1 295.7 5.56***
Measurements X Groups 3 19.1 .36*
Error
Within 10 53.2 -

 

* Not significant
** E1<°10

*** p_< .05

40

TABLE II

Results of Analysis of Variance: Treatment Conditions.

Clinic referred versus siblings

 

 

 

Source df MS F
Total 23 - -
Between Subjects ll - -
Clinic referred versus
siblings 1 4873.5 2.29*
Error
Between 10 2131.4 -
Within Subjects 12 - -
Measurements 1 181.5 4.69**
Measurements X Groups 1 4.2 .11*
Error
Within 10 38.7 -

 

* Not significant

** p<.10

41

worsening in the play therapy group, while five of eight children
in the two B-P therapy groups improved, with one child remaining
unchanged, and two becoming worse.

As to raw data for the control group, one child improved
and one remained the same, which makes this group the one that
fared best over all in terms of improvement versus worsening.

A comparison of the clinic referred children used as
the sample for this study was made with the children who formed
the clinic population from which this sample was taken. There
were only minor differences between these two populations on
the child characteristics of age, grade, sex, race, number of
siblings and referral problem. There were some differences in
the areas of type of parents, socio-economic status of the
family and previous treatment. A summary of this data can be
found in Appendix E. An inspection of this data seems to in-
dicate that although there were minor disparities between the
background of these six children and that of the rest of the
clinic referred population, there were apparently no major dif—
ferences between these two populations in regard to the de-

scriptive characteristics of the children.

DISCUSSION

The present study was undertaken to explore whether
group therapy for children was an effective means for dealing
with problem behaviors and other symptoms of neuroses in chil-
dren. An experiment was designed which compared the types of
group therapy with a control group receiving no treatment.
This section contains a discussion of: 1) methodological con-
siderations affecting the results, 2) the inferences that can
be derived from the results of the experiment, and 3) the im-

plications of the present study for future research.

Methodological Considerations

 

'The difficulty involved in organizing, coordinating,
and evaluating children's groups makes it easy to understand
why so little controlled, or for that matter uncontrolled, re-
search takes place in this area. It is these difficulties
which may have obscured the results of this study and enshrouded
in confusion any conclusions that may be drawn from it.

The first variable, which may be most significant, is
the choice of raters utilized in this experiment. Parents were
determined to be the best single choice in this regard due to:
1) they have the most contact with the children involved, 2)
the treatment period for this particular study commenced in the

summer, which effectively eliminated the possibility of school

42

43

teachers' ratings, 3) the experimenter or therapist would not

be an unprejudiced observer, and 4) trained naive raters could
not be obtained who could observe more than solely the therapy
sessions, to which the control group could not be compared.
Parents, however, are far from unbiased judges; they are an
intrinsic part of the child's environment and the pivotal points
upon which the family systems in which these children live center.
An uncontrolled source of variance, then, that interferes with
objective parental ratings stems from the influences that the
parents and children have upon each other, the parents' ever-
changing views about what constitutes a problem behavior, the
parents' investment in wanting to see their child or children
change, the parents' willingness to change themselves and their
family system to accommodate and reinforce any positive changes
in the child, and the parents' unawareness of how they reinforce
their child's problem behaviors.

In addition, there appeared to be a great deal of dis-
parity among the parents in rating the severity of behaviors,
causing considerable inter-rater variance. This in part accounts
for the lack of significant differences between the clinic re-
ferred children of some families and the not referred siblings
of other families. This variance also can account for certain
perceived behavior changes in the children which were reflected
in the numerical scores given by some parents and not by others.

A further consideration which was not reckoned with and
which may have contributed to the variance is the parents' vary-

ing attitudes toward the course of the project. Parents with

 

11
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44

little patience and a low tolerance for frustration may have
expressed their anger or other feelings about not receiving an
immediate cure for their children's problems toward the thera-
pist via the indirect means of exaggerating or otherwise modify-
ing the ratings. Another problem sometimes discovered along
this connection is an initial exaggeration of the child's
problem behaviors in order to gain the therapist's attention

and rapid delivery of treatment. Parents, then, have the po-
tential for being a very unreliable source for objective be-
havior ratings for their children although they have the best
opportunity for observing the greatest range of their children's
activities.

A second methodological consideration is the small
number of subjects employed in the study, especially in the con-
trol group. Few parents from the available clinic population
were willing to accept group therapy as the treatment of choice
for their children, and only one family was willing to wait six
months for treatment in order to be part of the control group.
It is unknown whether these parents, and especially the two
parents in the control group, had motivations which would dif-
ferentiate them from other parents who bring their children to
psychological clinics.

Another methodological consideration concerns the treat-
ment duration and process. Most of the major contributors to
the field of group therapy for children claim that this tech-
nique requires a minimum of one to two years for real person-

ality change to occur, although some of the problem behaviors

45

may disappear before that. Almost all of these authors agree
that consistency in meeting times, behavior limits, and thera-
pist behavior is essential to the therapy process. Unfortunately,
in the midst of treatment (after week seven) the therapist became
ill and the group therapy sessions were cancelled for the next
seven weeks. The therapy process was severely interrupted and
the essential ingredients of stability and consistency were
ruined. In the subjective opinion of the therapist, it took

many weeks for the children to return to the point of group
cohesion that they had formed just prior to the break.

In addition to the therapist's absence, there were a
considerable number of absences on the part of the children.
Out of a possible two-hundred-forty child contact hours ( a
product of the total number of children multiplied by the total
number of weekly sessions) there were forty-eight absences, or
a full twenty percent absentee rate. The high rate of absence
served both to fracture the stability of group membership and
to dilute the possible therapeutic effects of the group.

Another methodological consideration which may have
had a profound effect upon the outcome of this study is the
fact that the clinic referred child in the control group was
taken for individual play therapy sessions at another mental
health facility in the area for several weeks before the ter-
mination of the experiment. His parents claim that this treat-
ment helped him a good deal, with this change reflected in a
twenty-five point swing in the positive direction on his be-

havior scores. The parental reports up to that point indicated

46

that this child was becoming worse. Coupled with the fact that
the only other control subject remained unchanged, it seems
reasonable to assume that the individual play therapy either
changed the child's behavior or at least his parents' view of

his behavior enough to greatly affect the outcome of this entire
study and bring the results of the analysis of variance present-
ed in Table I into question. The extent of the possibility that
this twenty-five point shift could have occurred by chance can-
not be determined, with the exact effect of the individual thera-
py remaining unknown. The best means of sorting out all of these
causes for variance and for eliminating them would be a replica-
tion of this study utilizing a better methodology.

A final area in which there may have been considerable
effects upon the outcome of this project was expertise in child
group therapy. The therapist for all three experimental groups
was the experimenter who was a graduate student in clinical
psychology who had had no previous experience in either group
therapy with children or in leading discussions with groups of
children. This lack of experience on the part of the therapist
may have had a significant impact upon the entire project's re-
sults, for an eXpert in the field of child group therapy and
child discussion groups could very well have managed to produce
far different results with these same children. The inexperienced
therapist utilized in this project was unsure of how-to handle
many of the problems that arose in the group and as a consequence
he may have deviated in his behavior from the therapeutic modes

of Axline and Ginott, and erred in his presentation of lessons

47

created by BeSsell and Palomares. An expert in either of these
areas in all likelihood would have avoided most or all of these
poor judgments. In addition, this experienced therapist could
probably have created much more of a therapeutic environment

for these children due to his greater knowledge, more advanced
technique, and superior ability in applying these conceptual
frameworks. It is clear then, that this lack of experience and
low level of expertise on the part of the therapist employed in
this project most likely had some effect in changing the results
away from what could have been accomplished by an expert in this
field, with this difference possibly achieving an alteration of

considerable size in the final outcome of this study.

Findings

The results of this study lend themselves to only a few
conclusions. From both the methodological and the statistical
standpoints the findings emanating from this experiment are
equivocal. An analysis of the empirical data lends little sup-
port to either the adherents or critics of child group therapy.

The data does demonstrate that most of the children
benefitted by the twenty weeks of group treatment, although the
improvement was generally only slight. Since the control group
was so small and one of those two control subjects was given
individual treatment, comparison with the control group in this
study cannot hold much weight. The degree to which the improve-
ments in the treated children were due to the group therapy
cannot be accurately determined, although it does seem reasonable

to attribute at least some, if not most, of these positive effects

48

to the treatment.

One important by-product of this study was the finding
that there was no statistically significant difference between
the clinic referred children and the sibling group as a whole,
which tends to lend supportive evidence to Satir's (1967)
theory that family problems affect all of the children although
only one child might have enough symptoms to scapegoat him as
the only "sick" one. Some of the "normal" siblings had much
higher ratings on their composite negative behavior scores than
clinic referred children from other families. Only one child
out of all fourteen had very few behavioral problems reported
and a very low score on her composite rating. In terms of their
improvement rate the clinic referred children and the sibling
group also came out at par with each other.

Hypothesis I for this study was not confirmed. The
clinic referred children and their siblings who attended twenty
sessions of any mode of group psychotherapy did not show a
greater number of measured positive changes in their behavior
than the control group at post—testing. There was some differ-
ence between these conditions (§.= 3.31, pg( .10) but this dif-
ference did not reach the predetermined p5 .05 level of signifi-
cance. However,the results do indicate a trend in this direction,
especially when the statistically significant change in the posi-
tive direction is taken into consideration. If the control sub-
ject who was tampered with is removed from consideration a far
better difference is achieved between the treatment and control

groups, although this remaining small N for the control group

49

greatly reduces the power of any statistical test. The raw
data does tend to indicate a trend in the direction of support
for this hypothesis.

The second hypothesis of this study was also not con-
firmed. The clinic referred children and their siblings who
attended twenty sessions of Human Development (B-P) Group
Therapy did not show a greater number of measured positive
changes in their behavior than the clinic referred children and
their siblings who attended twenty sessions of Group Play Thera-
py at post-testing. Not only was this hypothesis not supported
by the results of the analysis of variance, but the raw data
presents a slight trend in the opposite direction. While three
out of four children in the play therapy group improved, only
five out of eight children in the two Bessell-Palomares groups

improved.

Implications for Future Research

This study was one of a very few that attempted to re-
search the field of child group therapy. Only two types of
treatment were utilized and the numbers were small. The re-
sults of the experiment were mixed and only inferences could
be drawn from the data rather than any concrete conclusions.
The results, however, do indicate that group treatment for chil-
dren does seem to have a positive effect. The degree of this
positive effect and its comparison to individual therapy or
other modalities of therapy that include children has yet to be
determined. Other types of group treatment for children also

need to be empirically tested.

50

This study served to show that research in the field
of child group therapy can be performed in an empirical and
measurable manner, despite the inherent difficulties. Methods
different from those employed in this study can be successfully
utilized to improve the methodology for measurement and for
obtaining and holding in place control groups.

New and more comprehensive instruments are needed for
empirical measurement of child behavior and personality. These
instruments should have their reliability and validity clearly

established before use, be easily and quickly administered,
be objective, be adaptable to different types of raters, and
be quantifiable. Data should be collected from every person
who has a significant degree of contact with the child as well
as from the child himself. An even more objective means for
collecting empirical data would be the use of videotape in cap-
turing the child's behavior in his natural setting, which would
allow the comparison of untreated control groups with children
receiving group therapy in the clinic. These videotapes could
then be evaluated on predetermined scales by trained raters.
Videotaping the child in his usual environment would probably
be the ideal method for empirical research in child behavior,
for it would eliminate the biases and inconsistencies present
in parents, teachers, and other untrained raters.

Research involving child group therapy, or for that
matter, any type of psychotherapy should utilize highly skilled
professionals as therapists for the treatment modalities. In-

experienced therapists may not produce results due to their low

51

level of ability and competency in both therapeutic technique
and capacity to apply the theoretical framework involved to
the practical situation. If a highly experienced child group
therapist cannot produce results from the groups he runs, then
it can be said that group therapy with children is not an ap-
plicable therapeutic alternative. If a therapist who lacks
expertise fails to produce significant results, it cannot be
determined with any measure of certainty whether the outcome
was due to the therapeutic method employed or the lack of skill
of the therapist. An accurate picture of the results of group
therapy with children in the future requires that only thera-
pists with measured minimum levels of expertise be employed in
empirical research. This therapeutic skill could be measured
along predetermined scales by trained raters observing live or
videotaped therapy sessions.

The problem of treating siblings and perhaps the entire
family should be taken into account when a child is being con-
sidered for group treatment, especially if the case is part of
a research project. The similarities of scores between the
clinic referred children and the sibling group in the present
study indicates that future research must focus itself on a
much broader spectrum than simply the identified problem child
in the troubled family. Thus, further research in the field
of child group therapy is called for to more precisely determine
its relative effectiveness to other treatment modalities. In
addition, the feasibility of empirical research using a con-

trolled experimental model for testing child group therapy has

52

been demonstrated, with the emphasis on this type of scientific

research in the area in the future recommended.

SUMMARY AND CONCLUSIONS

The present study was designed to experimentally in-
vestigate two forms of group psychotherapy with children. The
effectiveness of group play therapy and an adaptation of Bessell-
Palomares' Human Development Program into a group therapy design
were compared with a control group which received no treatment.
It was expected that these two types of group psychotherapy for
children would eliminate or at least diminish the problem be-
haviors in the clinic referred children and their siblings who
received this treatment. The following specific hypotheses
were then formulated: l) The clinic referred children and their
siblings who attend twenty sessions of Human DevelOpment Group
Therapy would show a greater number of measured positive changes
in their behavior than a comparable group of children who attend
twenty sessions of Group Play Therapy and 2) Both therapy groups
would show a greater number of measured positive changes in
their behavior than the control group.

Subjects were seven clinic referred children and seven
of their siblings, all of whom were six to ten years of age at
the time of referral. The instruments used to measure the be-
havior change in these children were the Bessell-Palomares Rat-
ing Form, the Problem List, and the Children's Behavior Check-

list. The children were randomly selected for placement in the

53

54

two experimental conditions and the control group. The in-
struments were administered to the children's parents before
and after the twenty weekly sessions. Two analyses of variance
were performed upon this data.

The results showed that there were no statistically
significant differences between any of the three experimental
conditions. Both of the treatment groups and the control group
all improved at post-testing at a statistically significant
level over pre-testing, with no significant difference between
the improvement rates for any of the conditions. A second
statistical analysis revealed that there were no significant
differences between the clinic referred children as a group
and their siblings at either pre-testing or post-testing. There
were also no statistically significant differences between the
two types of group treatment. Neither of the hypotheses in this
study were supported.

It was concluded that additional data and further re-
search is needed to clarify some of the trends which resulted
from this study. Improvements in the methodology were proposed.
Limitations of the present research, such as the small number
of children used, the short time period, the lack of experience
of the therapist, and the type of measurement utilized were re-

viewed. Directions for future research were explored.

BIBLIOGRAPHY

10.

11.

BIBLIOGRAPHY

Axline, V. Play Therapy, 1947, New York: Ballantine.

 

Bales, R. F. Personality and Interpersonal Behavior,
1970, New York: Holt.

 

Bessell, H. and Palomares, U. Methods in Human Develop:
ment: Theory Manual, 1967, San Diego: Human Develop-
ment Training Institute.

 

Bessell, H. Methods‘in Human Development: Theory Manual -
1970 Revision, 1970, San Diego: Human Development
Training Institute.

 

 

Becker, M. The effects of group therapy on sibling rivalry.
Smith College Studies in Social Work, 1945, 16, 131-132.

Becker, M. The effects of activity group therapy on
sibling rivalry.‘ Journal of Social Casework, 1948, 29,
217-221. -

Bettelheim, B. & Sylvester, E. Therapeutic influences of
the group on the individual. American Journal of
Orthopsychiatry, 1947, 17 (4), 684-692.

Boll, T. Systematic observation of behavior change with
older children in group therapy. Psychological Reports,
1971 (Feb.), 28 (l), 26.

Burlingham, S. Therapeutic effects of a play group for
preschool children. American Journal of Orthopsychiatry,
1938, 8 (4), 627-638.

Commission on Group Psychotherapy. Report to the World
Federation for Mental Health: I. Group treatment of
preschool children and their mothers. International
Journal of Group Psychotherapy, 1952, 2, 72-75.

Commission on Group Psychotherapy. Report to the World
Federation for Mental Health: II. Group treatment for
children in latency. International Journal of Group
Psychotherapy, 1952, 2, 77-82.

55

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

56

BIBLIOGRAPHY (cont'd)

Fleming, L. & Snyder, W. Social and personal changes
following non-directive group play therapy. American
Journal of Orthopsychiatry, 1947, 17, 101-116.

Foulkes, S. H. & Anthony, E. J. Group Psychotherapy, 1965,
Baltimore: Penguin.

 

Frank, M. & Zilbach, J. Current trends in group therapy
with children. International Journal of Group Psycho-
therapy, 1968, 18 (4), 447-460.

Friedlander, K. Varieties of group therapy patterns in
a child guidance service. International Journal of
Group Psychotherapy, 1953, 3, 59-65.

Garner, H. Effects of human relations training on the
personal, social, and classroom adjustment of elementary
school children with behavior problems. Unpublished
doctoral dissertation, University of Florida, 1970.

Gibbs, J. M. Group play therapy. British Journal of
Medical Psychology, 1945, 20, 244—254.

Ginott, H. Play therapy: A theoretical framework. Inter—
national Journal of Group Psychotherapy, 1958 (Oct),
8, 410-418. ’

Ginott, H. Group Psychotherapy with Children, 1961, New
York: Random House.

Graff, A. Modified group therapy for children. 'Inter-
national Journal of Social Psychiatry, 1958, 4,
211-213.

Hicks, H. Selected system prOperties of four observed
psychotherapy groups: a quantitative study of inter-
action processes of children's groups in psychotherapy.
Unpublished doctoral dissertation, New School for
Social Research, 1968.

House, R. The effects of non-directive group play therapy
upon the sociometric status and self-concept of selected
second grade children. Unpublished doctoral disserta-
tion, Oregon State University, 1970.

Karson, S. Group psychotherapy with latency age boys.
International Journal of Group Psychotherapy, 1965,
15 (1), 81-89.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

57

BIBLIOGRAPHY (cont'd)

Little, H. & Konopka, G. Group therapy in a child guid-
ance center. American Journal of Orthopsychiatry,
1947, 17(2), 303-311.

Lowry, L. Group therapy. American Journal of Ortho-
psychiatry, 1943, 13, 648-650.

Maier, H. & Loomis, E., Jr. Effecting impulse control
in children through group therapy. International
Journal of Group Psychotherapy, 1954, 4, 312-320.

Mendes Leal, M. Group analytic play therapy with pre-
adolescent girls. International Journal of Group
Psychotherapy, 1966, 16(1), 58-64.

Moulin, E. The effects of client-centered group counsel-
ing utilizing play media on the intelligence, achieve-
ment, and psycho-linguistic abilities of under-
achieving primary school children. Unpublished
doctoral dissertation, University of Toledo, 1968.

Novick, J. Comparison between short-term group and in-
dividual psychotherapy in effecting change in non—
desirable behavior in children. International Journal
of Group Psychotherapy, 1965, 15(3), 366-373.

Papanek, E. Treatment by group work. American Journal
of Orthopsychiatry, 1945, 15, 223-229.

Scheidlinger, S. Group therapy-- its place in psycho-
therapy. Journal of Social Casework, 1948, 29(8),
299-304.

Scheidlinger, S.; Douville, M.; Harrahill, C.: and Minor,
J. Activity group therapy for children in a family
agency. Journal of Social Casework, 1959, 40, 193-201.

Scheidlinger, S. Experimental group treatment of
severely deprived latency-age children. American
Journal of Orthopsychiatry, 1960, 30, 356-368.

Scheidlinger, S. Three group approaches with socially
deprived latency age children. International Journal
of Group Psychotherapy, 1965, 15, 434-445.

Scheidlinger, S. The concept of latency: implications
for group treatment. Journal of Social Casework, 1966,
47, 363-367.

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

46.

47.

48.

58

BIBLIOGRAPHY (cont'd)

Scheidlinger, S. (Chairman) Symposium on the relationship
of group psychotherapy to the other group modalities
in mental health. International Journal of Group
psychotherapy, 1970, 20.

Scheidlinger, S. & Rauch, E. Psychoanalytic group
psychotherapy with children and adolescents. In
Wolman, B. Handbook of Child Psychoanalysis, New York:
Van Nostrand Reinhold, 1972.

 

Schiffer, A. The effectiveness of group play therapy as
assessed in a child's peer relations. Unpublished
doctoral dissertation, Michigan State University, 1966.

Schiffer, M. Permissiveness versus sanction in activity
group therapy. International Journal of Group Psycho-
therapy, 1952, 2, 255-261.

Schiffer, M. The Therapeutic Planyrogp, 1969, New York:
Grune and Stratton.

 

Shere, E. and Teichman, Y. Evaluation of group therapy
with pre-adolescent girls: assessment of therapeutic
effects based on Rorschach records. International
Journal of Group Psychotherapy, 1971, 21(1), 99-104.

Slavson, S. R. An Introduction to Group Therapy, 1943,
New York: International Universities Press.

 

Slavson, S. R. Differential methods of group therapy
in relation to age levels. Nervous Child, 1945, 4,
196-210.

Slavson, S. R. Innovations in Group Psychotherapy, 1947,
New York: International UniVersities Press.

 

Slavson, S. R. Differential dynamics of activity and
interview group therapy. American Journal of Ortho-
psychiatry, 1947, 17(2), 293-302.

Slavson, S. R. Group therapy in child care and child
guidance. Jewish Social Service Quarterly, 1948, 25,
203-213.

Slavson, S. R.; Thaun, G.; Tendler, D.; and Gabriel, B.
Children's activity in casework therapy. Journal of
Social Casework, 1949, 30, 136-142.

Slavson, S. R. Analytic Group Psychotherapy, 1950, New
York: Columbia University Press.

APPENDICES

APPENDIX A

THE INSTRUMENTS

CHILDREN'S BEHAVIOR CHECKLIST

Name of child: 4_ Age: Date:

 

Name of person filling out checklist

 

Relationship to child

 

Below is a list of items describing many aspects of
children's behavior--things that children do or ways they have
been or can be described by you and by others. We would like
you to consider the applicability or accuracy of each item as
descriptive of the child, and then circle the number alongside
each item which most represents your opinion or feeling accord-
ing to the following code:

1. Not at all applicable or descriptive of the
child. He is never this way.

2. Rarely applicable or descriptive of the child.
He is this way only infrequently.

3. Generally but not always applicable. A reason-
able but qualified description of the child.
He is this way frequently.

4. A very apt description of the child. Very
characteristic of him. He is this way very
often or most of the time.

Note: The items all describe a boy's behavior. If you are
describing a girl please regard the items as descrip-
tive of a girl's behavior also, and in your mind sub-
stitute the word "she" for "he.“

59

ll.
12.
l3.
14.
15.
16.
17.
18.
19.
20.
21.
22.

23.
24.
25.

26.

H

H F4 Ia H

H H-

H F‘ r4 be H

H H‘

60

He's (She's) absent from school a lot.

He's (She's) pretty short.

He's always losing things.

He's a fast runner.

He pushes when he's in line.

He doesn't want to play.

He talks when he's supposed to be working.
When he doesn't get his way, he gets real mad.
He doesn't play.

He doesn't care to join in and play on the
playground.

He makes it so other people can't think.

He likes an audience all the time.

He has a lot of friends.

He gets out of his seat and walks around the room.
He's a nice guy (girl).

He tries to get other people in trouble.

He makes fun of people.

He's a good sport.

Someone makes fun of him and he starts crying.
He says he can't do things.

He can't seem to sit still.

He's always playing the clown and wants everyone
to laugh at him.

He is sort of trouble.
He seems to think he's nobody.
He's the last person picked.

He always messes around and gets in trouble.

27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.

53.

H P4 +4 H H‘ Fa la H

H F1 +4 H P‘ +4 ta H H‘ he re H F4 ta H P“ re H

H

61

Hardly any boys (girls) like to play with him (her).
He wants to show off in front of kids.

I'm one of his friends.

He says he can beat everybody up.

He wiggles around.

On the playground he just stands around.

He needs attention very badly.

He'll talk out to get attention.

He's really wild.

He talks all the time.

He cries when he doesn't do something right.
He makes a lot of noise.

He is one of the kids I like.

He just can't stand anybody laughing at him.
He's the kind of kid I like.

He seems to have a chip on his shoulder.
He's really silly.

He just acts sort of babyish all the time.
He's a good friend of mine.

He cries if you hurt his feelings.

He's sort of unhappy.

He likes to pick on little kids.

He's really wild.

He will always play by himself.

He feels left out.

He's trying hard to be popular.

He tries to get attention.

54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.

69.

70.
71.

72.

H F4 +4 H H' +4 ta H H‘ F4 +4 H

[—4

62

He acts as if he's sort of a baby.

He's always acting up.

He's goofing off all the time.

He's just plain mean.

He talks to the teacher all the time.

He doesn't have very many friends.

He's not sure of himself in anything.
He's always calling peOple names.

No one plays with him.

He is sort of ignored.

He just seems sort of lost.

He cries when he doesn't know how to play.
He feels a lack of attention.

He doesn't pay attention to the teacher.
No matter what he does, its wrong.

If someone gets in his way, he shoves them
out of the way.

All the kids like him.
He's a little too sensitive to everybody.

He's not interested in anything.

THE PSYCHOLOGICAL CLINIC
OF

MICHIGAN STATE UNIVERSITY
PROBLEM LIST*

NAME(S) OF RESPONSIBLE ADULT(S)
COMPLETING THIS FORM

 

DATE ' CHILD'S NAME Age

 

 

DIRECTIONS

This is a list of problems that children often have and need
help for. Pick out the problems or difficulties that the
child has.

Read every line on the list, without skipping any, and draw a
line under any problems that the child has which trouble you.
For example, if you are quite worried about the child's lack
of eating, underline the first item, like this, "1. Eats too
little." If you are concerned about your child's behav1or,
such as running away from home without permission, you would
underline number 73, like this, "Runs away from home."

 

After you have gone through all the problems on pages 2, 3,
and 4, please turn to page 5 and answer the remaining questions.

It is necessary that you fill in this list and return it as
soon as possible. It will probably take no longer than thirty
minutes to finish, and will help give us an accurate picture
of the child and of your concerns.

*Adapted from the Problem List of the Children's Psychiatric
Center, Inc., Eatontown, N. J., developed by Theodore Leventhal,
Ph.D., and Gary E. Stollak, Ph.D.

63

Directions:
have.
that describe your child.
1. Eats too little 37,
2. Eats too much 38.
3. Not eating the right food 39,
4. Drools 4o,
5. Frequently wets bed at night 41.
6. Frequently not dry during 42.
day
7. Constipated 43.
8. Soils self 44.
9. Gets lower grades in school 45.
than should
10. Afraid of tests 46.
ll. Afraid of going to school 47.
12. Refuses to go to school 48.
13. Does not talk plainly, poor 49.
pronunciation 50.
14. Stutters 51.
15. Uses baby-talk
16. Stammers 52.
17. Shy with other children 53.
18. Too few friends 54.
19. Feels inferior to other 55.
children
20. Picked on by children 56.
21. Feels unattractive
22. Feels too short 57.
23. Feels too large in size
24. Feels inadequate about a 58.
handicap or deformity 59.
60.
25. Worries too much about health
26. Very nervous, tense 61.
27. Fear of animals
28. Afraid of high places 62.
63.
29. Sad, unhappy too often 64.
30. Cries too easily
31. Feels helpless 65.
32. Blames self too much 23.
33. Gets into trouble 68.
34. Destroys property of others
35. Steals

36.

64

Lies

Below is a list of problems that children often
Read each one and draw a line under those

Bites nails

Picks nose

Pulls out hair
Always late, dawdles

Puts everything to mouth

Difficulty falling asleep
or sleeping

Sleeps too much

Troubled, restless sleep

Diarrhea, frequent bowel
movements

Holds urine

Too much gas

Excessive masturbation

Slow in reading

Cannot keep mind on studies

Does not pay attention to
teachers

Restless in class

Slow in learning to talk

Asthma

Headaches for no physical
reason

Stomach cramps, aches, too
often

Feels different from other
children

Too easily led

Left out by children own age

Never chosen as a leader

Is self-conscious about own
body

"Big-shot"

Gets angry too easily

Cruel to animals

Will not stay home alone
Fear of darkness

Fear of death

Panics when afraid

69.
70.
71.
72.

73.
74.

75.
76.

77.
78.
79.
80.

81.
82.
83.
84.

85.
86.

87.
88.

89.

90.
91.
92.

93.
94.
95.
96.

97.
98.
99.

100.

101.
102.
103.
104.

65

Too easily discouraged
Gloomy about the future
No interests

Has no character

Runs away from home

Sets fires, plays too much
with matches

Traffic offender

Breaks promises

Breath holding
Thumb sucking

Bad table manners
Untidy

Has bad dreams

Sleepwalks

Has nightmares, night terrors
Talks in sleep

Touches or plays with sex
organ when should not

"Peeps," looks at people
when undressing

Exposes self excessively

A masculine girl ("tomboy")

Coaching, tutoring does not
help in school work

Afraid to speak up in class

A "bookworm"

Does not get along with
teacher

Nausea, vomiting
Eczema

Hives

Ulcers

Picks wrong kind of friends

Fights too much with children

Can't keep up with kids of
own age

Spends too much time with
friends

Cruel to peOple
Blows his or her top
Sulks, pouts

Gripes too much

105.
106.

107.
108.

109.
110.
111.
112.

113.
114.

115.
116.

117.
118.
119.

120.

121.
122.

123.
124.

125.
126.
127.
128.

129.

‘130.

131.
132.

133.
134.
135.

136.
137.
138.
139.

Fear-ridden child
Unusual fears (describe)

 

Has peculiar ideas
Gets very confused

A passive child
Too meek

A "clinging vine"
No self-confidence

Does not do chores

Takes advantages of
people

Disobeys parents

Not close to parents

Schratches self a lot

Picks skin

Swears, uses dirty
language

Unable to keep to a time
schedule

Uses hands in poorly co-
ordinated way

Restless, can't stay in
one place

Clumsy in using legs

Non-athletic

She is "boy crazy"
Menstrual difficulties

A feminine boy ("sissy")
She has had sex relations

Truants

Does not like to go to
school

Does not spend enough
time in study

Not interested in books

Colitis

Fainting, dizziness

Loss of feeling in part
of body

Dislikes other children
Withdraws from children
Jealous of friends
Bossy with friends

140.
141.
142.
143.

144.
145.

146.
147.

148.
149.
150.
151.

152.
153.

154.
155.

156.

157.
158.

159.

160.
161.
162.
163.

164.
165.
166.

167.

168.
169.
170.
171.

172.
173.
174.
175.

66

Always wants revenge
Irritable child
Very sarcastic
Teases excessively

Daydreams a lot

Hears or sees things that
are not there

Extremely poor judgment

Does strange things.
Specify

 

"Spineless," no "guts"

Cannot make own decisions

Gets too excited

Does not try to correct bad
habits

Too stubborn with parents

Continual demanding of gifts,
new things

Over-obedient at home

Wants too much attention
from parents

Loses own possessions
frequently

Careless with own appearance

Careless with clothes and
belongings

Selfish, won't share

Jerky movements

Lazy, apathetic, no energy
Head banging

Paralyzed

He is "girl crazy"

Abnormal sex acts

No interest in opposite sex
though old enough

Always thinking about sex

Below average in intelligence
Does not complete work

Poor memory

Unsure of self in school

Hurts self too often

Neglects own health and safety

Has had a number of accidents
Threatens suicide

176.
177.
178.

179.

180.
181.
182.
183.

184.
185.

186.
187.

188.
189.
190.
191.
192.
193.
194.
195.
196.
197.
198.
199.
200.
201.
202.
203.
204.
205.

206.

207.

Difficulties with children
of opposite sex

Plays too much with younger
children

Bossy with brother(s)
and/or sister(s)

Jealous of brother(s)
and/or sister(s)

Does not express anger
Threatens homicide
Attempted homicide
Carries dangerous weapons

"Out of this world"

Preoccupied with own
thoughts

Talks about going crazy

Does not notice
surroundings

Loses temper

Makes hasty decisions

Is erratic, unpredictable
No control over emotions

Distrusts, suspicious of
parents

Fights back, talks back to
elders

Too dependent upon mother,
father

Inconsiderate of parents

Cannot handle money as well
as should

Smokes

Drinks

Gambles

Moves too slowly

Has twitches

Rocks all the time

Bumps into furniture,
trips, etc.

Prudish and embarrassed by
talk about sex

Unsure of how to act with
opposite sex

Does not know enough about
sex

Has been sexually molested

208.
209.

210.
211.
212.
213.
214.
215.
216.
217.
218.
219.
220.
221.
222.
223.
224.
225.
226.
227.
228.
229.
230.
231.

232.
233.

234.
235.

236.
237.

67

Watches T.V. all the time

Trouble adjusting to a new
school

Tries to get attention in
class

Too many absences from school

Has attempted to kill self
Lets self be used by others
Makes fool of self

Wants to get punished

Fights brother(s) and/or
sister(s) too much

Clings to brother(s) and/or
sister(s)

No love for brother(s) and/
or sister(s)

Hateful

Gets people angry, provokes
"Brat"

Bully

Is having, or will have a ner—
vous breakdown

Gets completely out of control

Talks to self

Laughs for no reason

Too cautious

Never shows feelings

Drives car too fast

Will do anything for thrills

Over-sensitive to criticism
from parents

Spoiled, runs household

A pest at home

Too fussy about cleanliness,
neatness

Does not take care of per-
sonal hygiene

Does not feed self well

Behind other children on
dressing self

68

Are there problems you are concerned about that were not men-
tioned? If so, list:

Write down the number(s) of the problem(s) (if any) that you
consider to be very serious problems. If none, write "none."

How long did it take you to complete the check list?
Do you think it gives an accurate picture of your child's dif-
ficulties? If not, what are your criticisms?

 

Write a general description of what you feel the child's per-
sonality is:

What are the child's best attributes?

 

Rating Scales

Name of Person being Rated

 

Name of Rater

 

Date Rated

 

69

70

AWARENESS OF SELF

 

The aware child knows how he feels,
what he thinks, and what he is doing.
Although he is conscious of himself,
he is not self-conscious, insecure

or embarrassed. This awareness

does not produce anxiety. He accepts
and can acknowledge how he really
feels, thinks, and acts.

 

RATING
Very aware; always conscious of his feelings, wishes,
fears, and the meaning of his behavior (positive or
negative).

Most of the time aware, ready to acknowledge what he

 

feels, thinks, and does. Only occasionally uses denial.
Often aware of his feelings, thoughts and behavior,
and willing to recognize them as such. However, often
reacts without awareness or uses denial.

Usually unconscious or unaware of himself; denies his

 

real feelings and thoughts, and cannot recognize his
own actions for what they are.

Unconscious; full of denial, completely unable to

 

recognize his true feelings, thoughts, or behavior.

 

ACTIONS JUSTIFYING RATING

70

CONSIDERATENESS

 

The considerate child cares about
the well-being of others. He ad-
justs his behavior in ways that
are thoughtful and beneficial to
others.

 

RATING

Extremely considerate. Always thoughtful and spon-

 

taneously concerned with the other person's welfare.

Very considerate. Most of the time he is thought-

 

ful and deals constructively with others.

Somewhat considerate, but sometimes inconsiderate

 

about what is good for another person.

Seldom considers the well-being of other people.

 

Only rarely takes into account what others may feel.
Tends to be thoughtless, indifferent.

Rarely considers the other person. Tends to pursue

 

his behavior no matter how it may affect the other
person.

 

ACTIONS JUSTIFYING RATING

71

EAGERNESS

 

The eager child likes to try new
things or take on a new problem.
He is eager to overcome, to engage,
and to try to master a new problem.

 

RATING

Loves challenge; eager to try anything that is new.

 

Delights in testing his ability.

Frequently seeks out and meets new and challenging

 

situations. Shows little hesitancy.

Often rises to challenge what is presented to him,

 

but does not seek out challenging situations of
his own. Shows some hesitancy.

Tends to shy away from challenges much of the time,

 

but will deal with them when encouraged.

Almost always shies away from challenge. Requires

 

a great deal of encouragement, before he reluctantly
tries.

ACTIONS JUSTIFYING RATING

72

EFFECTIVENESS

 

The effective child copes appropri—
ately. He readily tries and is
successful in his efforts to im-
plement his own desires or to meet
the external demands of the environ-
ment.

 

RATING

Very effective. Always deals appropriately and suc-
cessfully with his inner needs and external demands.
Always meets and responds effectively to a problem
situation.

Mostly effective. Typically gets his needs met and

 

handles challenge successfully.

Moderately effective. Often successful, but often

 

fails to get his needs met or to cope with problems
with success.

Mostly ineffective. But occasionally successful in

 

his efforts.

Rarely succeeds in his efforts. Inadequate.

 

Ineffective.

ACTIONS JUSTIFYING RATING

73

FLEXIBILITY

 

The flexible child can shift his
viewpoint or behavior in accord-
ance with new information or new
demands of the peOple. He is
adaptive, but shifts because of
conviction rather than because of
passively submitting to persuasion.
When changing he continues with the
same degree of interest and involve-
ment.

 

RATING

Very flexible. Adapts readily and easily to new

 

information and demands. Participation continues
with undiminished interest.

Very frequently flexible. Most of the time adapts

 

although shows some tendency to persist even in the
face of new information or new expectations.

Reasonably flexible, but often clings to his original

 

viewpoint or behavior.

At times flexible, but usually unable to adapt to

 

new information or demands.

Rigid. Very unresponsive to new information or

 

demands. Cannot shift.

ACTIONS JUSTIFYING RATING

74

INTERPERSONAL COMPREHENSION

This trait assesses the child's
understanding of how one person's
behavior causes approval or dis-
approval of that behavior in
another person.

 

RATING

Very high comprehension. Child almost always re-

 

cognizes the effect of any given behavior.

Usually comprehends what the second person's re-

 

action will be to the first person's behavior.

Sometimes perceives the interpersonal effects, but

 

just as often fails to comprehend how one person's
behavior effects another person's attitude.

Seldom comprehends interpersonal interaction.

 

Usually at a loss in being able to see how one
person's behavior effects another person's reaction.

Virtually no comprehension of how a person's be-

 

havior causes attitudes in other people. Almost
always fails to comprehend the interaction.

 

ACTIONS JUSTIFYING RATING

75

SELF CONFIDENCE

 

The confident child believes that
he is able and behaves with a calm
assured manner. He is self-
assured and realistic when coping
with new challenges.

 

RATING

Realistically very confident. Approaches challenge

 

with assurance. Possible failure does not deter
action.

Confident most of the time with realistic challenges.

 

Only mild caution with unfamiliar tasks.

While often confident, in many instances is unsure

 

of his ability to cope with realistic challenge.

Some degree of confidence with familiar things, but

 

often expects to meet with failure with challenge.

Virtually no self-confidence. Unable or unwilling

 

to try. Almost always behaves as though he expects
to fail with new challenges.

 

ACTIONS JUSTIFYING RATING

76

SENSITIVITY TO OTHERS

 

The sensitive child is aware and
concerned about the welfare of
other people. He readily ascer-
tains what the other person is
feeling and what would be in their
best interest.

 

RATING

Acutely aware and concerned about people's feelings

 

and reactions.

Most of the time aware and concerned about how

 

others are truly feeling and reacting.

Often aware and concerned, but in many instances

 

seems unaware and relatively unconcerned about
other people's feelings and reactions.

Usually unaware and disinterested in what other

 

people are feeling, but can recognize what is
going on in others when it is directly called to
his attention.

Insensitive and unconcerned as to what is going

 

on in and with other people. Deals with them as
though they were devoid of feelings.

 

ACTIONS JUSTIFYING RATING

77

SPONTANEITY

 

The spontaneous child is natural.
His acceptance of himself is high
and permits freedom of expression.
He is uninhibited, but not dramatic
or exhibitionistic.

 

RATING

Always highly spontaneous. Very natural and free in

 

his expressions.

Very often spontaneous. Most of the time reacts

 

freely and naturally, but on occasion is inhibited.

Usually spontaneous. While he frequently expresses

 

himself naturally he is inhibited on many occasions.

Shows spontaneity on occasion, but more often in-

 

hibited, constricted, and stilted in his response.

Many strong inhibitions, very constricted. Almost

 

never spontaneous; not natural.

 

ACTIONS JUSTIFYING RATING

78

STABILITY

 

The stable child is emotionally
balanced. He remains composed
in the face of stressful events.
He remains involved and does not
find it necessary to shift his
direction.

 

RATING

Very stable. Not easily upset by change or dis-

 

appointment.

Usually stable. Accepts and adjusts well to

 

changing circumstances, but occasionally loses his
calmness and direction.

Moderately stable. Often retains his equilibrium,

 

but rather easily upset and loses his direction.

Sometimes shows stability, calm and direction, but

 

frequently is upset and loses his bearings when
circumstances change.

Unstable. Shows little capacity to accommodate to

 

change. Excitable or immobilized by new demands.

ACTIONS JUSTIFYING RATING

79

TOLERANCE

 

The tolerant child recognizes and
accepts individual differences.

He accepts and gives full regard
to others who have different feel-
ings, thoughts, and reactions than
his own. But he does not neces-
sarily approve or yield to their
influence.

RATING

Extremely tolerant. Understands and accepts dif-

 

ferences as natural. Tolerates a very broad
spectrum of feeling, thoughts, and behavior in
others.

Reasonably tolerant about individual differences.

 

Mildly tolerant, but tends to not accept certain

 

natural variations.

Usually intolerant. Tends to regard people who

 

differ from him as being unacceptable, even wrong.

Very intolerant. His way of feeling, thinking,

 

and reacting is the only way that he can accept.
People who are different are completely unaccept-
able. Very narrow.

 

ACTIONS JUSTIFYING RATING

APPENDIX B

SCORING SYSTEM FOR INSTRUMENTS

80

Scoring System for Instruments

Children's Behavior Checklist—
Classification by Item Number

 

 

 

 

Desirable Undesirable
(Positive) (Negative) Descriptive Relationship
13 3 40 1 29
15 5 42 2 39
18 6 43 4 41
70 7 44 12 45
8 46 25
9 47 31
10 48 36
ll 49 52
14 50 58
16 51 66
17 53
19 54
20 55
21 56
22 57
23 59
24 60
26 61
27 62
28 63
30 64
32 65
33 57
34 68
35 69
37 71
38 72

Only the negative items will be used to formulate the composite
negative behavior score.

Successful Outcome:
I. Negative behavior score points derived from the undesirable
characteristics classification decrease.

PROBLEM LIST
Successful Outcome:
1. Number of items marked decrease

II. Number of additional items mentioned decrease

III. Number of items marked as "very serious"
decrease

IV. Number of negative attributes in the general
description of the child's personality
decrease

B-P RATING SCALES
Successful Outcome:

I. Rating on any scale of "l" or "2" increases

81

APPENDIX C

SCORING SCHEME FOR CHILDREN'S
COMPOSITE NEGATIVE BEHAVIOR SCORE

SCORING SCHEME FOR

CHILDREN'S COMPOSITE NEGATIVE BEHAVIOR SCORE

Children's Behavior Checklist:
For the undesirable behaviors (54 items)
Score one point for each rating of "3"

Score two points for each rating of "4"

Problem List:
For each item marked score one point

For each item marked as "very serious" score an
additional one point

For each additional item score one point
For each negative attribute listed in the description of

the child's personality score one point

B-P Rating Scales:
For each scale rated as "2" score one point

For each scale rated as "1" score two points

82

APPENDIX D

CHILDREN'S COMPOSITE NEGATIVE BEHAVIOR SCORES

Children's Composite

Play Therapy Group

 

Child
Child
Child
Child
Human
Child
Child
Child
Child
Human
Child
Child
Child

Child

1

2*

3*

4*

Develppment Therapy Group I
5

6*

7

8

Development Therapy GrouppII
9*

10*

ll

12

Control Gropp

 

Child

Child

13*

14

* Clinic referred children

83

Pre-Test

69
40
133

55

20
33

12

53
61
10

68

106

37

Negative Behavior Scores

Post-Test

 

62
47
121

50

11

16

56
52
10

56

81

37

 

APPENDIX E

COMPARISON OF THE CLINIC REFERRED CHILDREN OF THIS
STUDY WITH THE REST OF THE TOTAL CLINIC REFERRED
CHILD POPULATION AT THE M.S.U. PSYCHOLOGICAL CLINIC

Comparison of the Clinic Referred Children of this study with
the rest of the Total Clinic Referred Child Population* at the
M.S.U. Psychological Clinic.

 

The Total
Experimental Clinic Population
Sample (N=6) Less the

Experimental Sample (N=22)

 

Child's Characteristics

 

Age M=8.5 M=7.5
u=8.3 u=7.8
Grade M=3.5 =2
u=3.3 u=2.4
Sex 83% M 68% M
17% F 32% F
Race 83% White 91% White
17% Non-White 9% Non-White
Previous Treatment 0% Yes 32% Yes
100% No 68% No
Number of Siblings M=2.5 =2
u=2.7 u=2.5

Referral Problem

 

Academic 17% 18%
Interpersonal 67% - 50%
Intrapsychic 17% 27%
Other 0% 5%

84

85

Experimental
Sample (N=6)

Type of Parents

 

Natural 17%
By Adoption 17%
One Step-Parent 50%
One or more Missing 17%

Socio-Economic Status

 

of Family
Lower Class 33%
Lower Middle Class 50%
Upper Middle Class 17%

The Total
Clinic Population
Less the
Experimental Sample (N=22)

68%
9%
5%

18%

18%
32%

50%

*Those children referred solely for diagnostic evaluation
or whose parents upon initial contact requested family therapy
or where no descriptive data could be located were eliminated

from this comparison.

ll
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