‘W-I-I-I-I-I-II RELATIONSHIP OF CERTAIN FACTORS TO SUCCESSFUL CASE CLOSURE IN A CHILD GUIDANCE CLINIC Thesis for the Dogma of Ed. D. MICHIGAN STATE UNIVERSITY Harold Jay Fahs I961 This is to certify that the thesis entitled RELATIONSHIP OF CERTAIN FACTORS TO SUCCESSFUL CASE CLOSURE IN A CHILD GUIDANCE CLINIC presented by HAROLD JAY FAHS has been accepted towards fulfillment of the requirements for Ed,D degree in Education (w /I I \,~ ‘ I / , 3,.- . j ," i. I ) /“\ 51" 1 I ' ' .qMalor professor Date May 12: 1961 0—169 LIBRARY Michigan State University ABSTRACT RELATIONSHIP OF CERTAIN FACTORS TO SUCCESSFUL CASE CLOSURE IN A CHILD GUIDANCE CLINIC by Harold Jay Fahs This study is primarily concerned with the determination of what factors are most prognostic of therapy success in children seen at the.Northwest Michigan Child Guidance Clinic, located at Traverse City, Michigan. For the purpose of this investigation therapy success has been defined as a case in which, in the opinion of the counselor, the child has improved over his.condition at the time treatment started. Improvement does not have to be the result of therapy. An unsuccessful case is one which, in the opinion of the counselor, the child's condition has not improved over the time treatment started. In addition to the above purpose the researcher has attempted to (1) determine agreement between counselor judgment, parental judgment, and researcher judgment in reference to case closure; (2) determine if therapy cases classified as successful, by the counselor, have remained successful; (3) determine the type of problem which may be the "best risk" for therapy; (4) and determine if the method Harold Jay Fahs of reporting and handling information in a child guidance clinic is adequate and accurate. Five groups of referral categories were used. These categories were set up by the Michigan Department of Mental Health and consisted of conduct, habit, learning and developmental problems, functional illness, and personality problems. The period studied was eight years, from January 1, 1950 to January 1, 1958. The records of 706 child guidance referrals were examined. From this population 253 satisfied rigid requirements of record completeness. Letters were written to parents of the selected children requesting them to fill out an enclosed questionnaire. The final workable sample consisted of 215 cases. The relationship of the child's problem at time of referral to intellectual ability; duration of referred problem; parental attitude toward child; parental attitude toward therapy; counselor, parent, and researcher judgment regarding therapy outcome; and present status of case was determined by application of the chi-square method, Fisher Exact Probability Test, and percentage presentation. When the parent's judgment regarding the outcome of a case was used as the criterion of success the following factors were found to be related to successful case closure; Harold Jay Fahs age of child above nine years and four months and intelligence quotient above 100 for problems classified under the conduct category; duration of problem less than thirty months and good parental attitude toward the child for problems classified under conduct, functional illness, and learning and developmental problems. When the researcher's judgment regarding the outcome of a case was used as the criterion of success the following factors were found to be related to successful case closure: good parental attitude toward the child for referral problems classified under conduct and personality problems; duration _ of problem less than thirty months for referral problems classified under personality , functional illness, and learning and developmental problems; intelligence quotient above 100 for problems classified under learning and developmental problems; and age of child above nine years and four months for referral problems classified under the functional illness category. When the counselor's judgment regarding the outcome of a case was used as the criterion of success the following factors were found to be related to successful case closure: good parental attitude toward the child for problems class- ified under the personality category; intelligence quotient above 100 for problems classified under the learning and Harold Jay Fahs developmental category; and age of child above nine years and four months for problems classified under functional illness problems. 0f the total number of cases closed as successful, by the counselor, 47 per cent have remained successful. Fifty-three per cent of the successfully closed cases reverted back to the original referral problem. 0f the total number of cases closed as successful, by the researcher, 72 per cent have remained successful. Twenty-seven per cent have reverted back to the original problem. Of the total number of cases closed as successful, by the parent, 98 per cent have remained successful. One child reverted back to the initial referral problem. Parental judgment of case closure seems to agree more with the researcher's judgment than with counselor's judgment. Habit and personality problems seem to be the ”best risk" for therapeutic results. ‘Methods of reporting and handling information in child guidance seem to be an administrative area which might be improved. RELATIONSHIP OF CERTAIN FACTORS T0 SUCCESSFUL CASE CLOSURE IN A CHILD GUIDANCE CLINIC By Harold Jay Fahs A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR.OF EDUCATION Guidance and Personnel Services 1961 ACKNOWLEDGMENTS The author wishes particularly to thank Dr. Gregory A. Miller and Dr. Buford Stefflre for their invaluable assistance and guidance previous to and throughout the course of this research. Sincere acknowledgment is also extended to committee members Dr. Gordon Aldridge and Dr. Harry Sundwall for their helpful suggestions and encouragement. For the needed administrative permission and cooperation to carry on the proposed research the author desires to thank Miss Hazel Hardacre, Director of the Northwest Michigan Child Guidance Clinic. To his wife, Eloise Coleen Fahs, the author gives his love and indebtedness for her invaluable clerical assistance, silent encouragement, and acceptance of imposed hardships and sacrifices. To Karen and Tim dad gives his love and thanks for their acceptance and understanding of postponed fun and play. CHAPTER II. III. IV. TABLE OF CONTENTS THE NATURE OF THE PROBLEM . Introduction . Statement of the Problem . Need for the Study . Brief History of Child Guidance . Brief History of Child Guidance in Michigan . Brief History of Northwestern Michigan Child Guidance Clinic . Limitations of the Study . Definition of the Study . REVIEW OF THE LITERATURE . Introduction . Psychotherapy With Children . General Factors Related To Therapy Prediction.. Conclusion . METHODOLOGY AND PROCEDURE . Introduction . The Sample . Methods of Analysis . ‘Method of Followap . The Data . EACTORS RELATED TO CLOSURE.OUTOOME AND . . CLOSURE STABILITY. . . . n " iii PAGE 10 .12 . 15 .18 .18 . 18 ..19 .42 . 47 .47 .47 . 54 . 55 .57 .61 CHAPTER Conduct Referral Category . Habit Referral Category . Personality Referral Category . Learning and Developmental Category . Functional Illness Category . Summary . Relating the Findings To The Child Guidance Setting . . . . . Factors Related To Successful Closure . V. SUMMARY AND CONCLUSIONS . The Problem . The Findings . Implications For Further Research . BIBLIOGRAPHY . 1 APPENDIX . iv PAGE . 62 . 89 113 137 161 185 .190 . 190 192 192 .193 . 205 . 207 . 219 TABLE II. III. IV. VII. VIII. XI. XII. XIII. XIV. LIST OF TABLES PAGE NUMBER OF CASES BY TYPES OF PROBLEMS 1954- 1959 NORTHWEST MICHIGAN CHILD GUIDANCE CLINIC . . . . . . 13 CONDUCT REFERRAL CATEGORY TABLES RELATIONSHIP OF PARENT AND COUNSELOR JUDGMENT REGARDINGSUCCESSOETHERAPY. . . . . . . . . . .. 64 RELATIONSHIP OF PARENT AND RESEARCHER JUDGMENT REGARDINGSUCCESSOFTHERAPY. . . . . . . . . . .. 65 RELATIONSHIP OF RESEARCHER AND COUNSELOR JUDGMENT REGARDINGSUCCESSOFTHERAPY. . . . . . . . . . .. 66 SUCCESS OF THERAPY (As JUDGED BY THE PARENT) IN RELATIONTOAGE................... 67 SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) INRELATIONTOAGE...... .. 68 SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) INRELATTONIOAGE.._............... 69 SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION To INTELLECTUAL ABILITY . . . . . . . . . . 7O SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO INTELLECTUAL ABILITY. . . . . . . . . 71 SUCCESS OF THERAPY (ASJ JUDGED BY THE COUNSELOR) IN RELATION To INTELLECTUAL ABILITY . . -. . . . . . 72 SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATIONTO DURATION OF PROBLEM. . . . . . . . . .. 73 SUCCESS or THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO DURATION OF PROBLEM. . . . . . . . 75 SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) INRELATIONTODURATIONOFPROBLEM. . . . . . . . .. 76 RELATION OF THERAPY OUTCOME (AS JUDGED BY THE PARENT) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD . . . . . . 77 TABLE XVI. XVII. XVIII. XIX. XXI. XXII. XXIII. XXIV. XXV. XXVI. XXVII. PAGE RELATION OF THERAPY OUTCOME (AS JUDGED BY THE RESEARCHER) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD . . . . . . . . . . . . . . . . . . . . . . . 78 RELATION OF THERAPY OUTCOME (AS JUDGED BY THE COUNSELOR) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD . . . . . . . . . . . . . . . . . . . . . . . 80 OUTCOME OF CHILD'S THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO PRESENT PARENTAL ATTITUDE TOWARD THERAPY . . . . . . . . . . . . . . . . . . . . . . 81 'PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY COUNSELOR . . . . . . . . . . . . . . . . . . . . . 83 PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY RESEARCHER . . . . . . . . . . . . . . . . . . . . 85 PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY PARENT . . . . . . . . . . . . . . . . . . . . ... 87 HABIT REFERRAL CATEGORY TABLES RELATIONSHIP OF PARENT AND COUNSELOR JUDGMENT REGARDING SUCCESS OF THERAPY . . . . . . . . . . . . 89 RELATIONSHIP OF PARENT AND RESEARCHER JUDGMENT ‘ REGARDING SUCCESS OF THERAPY . . . . . . . . . . . . 91 RELATIONSHIP OF RESEARCHER AND COUNSELOR JUDGMENT REGARDING SUCCESS OF THERAPY . . . . . . . . . . . . 92 SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO AGE . . . . . . . . . . . . . . . . . . . 93 SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO AGE . . . . . . . . . . . . . . . . 94 SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO AGE . . . . . . . . . . . . . . . . . 95 O SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO INTELLECTUAL ABILITY . . . . . . . . . 96 vi TABLE XXVIII. XXIX. XXXI. XXXII. XXXIII. XXXIV. XXXVI. XXXVII. XXXVIII. XXXIX. SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO INTELLECTUAL ABILITY . ... SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO INTELLECTUAL ABILITY . . SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO DURATION OF PROBLEM . . . SUCCESS 0F THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO DURATION OF PROBLEM . . . SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO DURATION OF PROBLEM . . . . RELATION OF THERAPY OUTCOME (AS JUDGED BY THE PARENT) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD . . . . . . . . . . . . . . . . RELATION OF THERAPY OUTCOME (AS JUDGED BY THE RESEARCHER) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD . . . ... . . . . . . . . . RELATION OF THERAPY OUTCOME (AS JUDGED BY THE COUNSELOR) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD . . . . . . . . . . . . . . . . . . OUTCOME OF CHILD'S THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO PRESENT PARENTAL ATTITUDE TOWARD THERAPY . . . . . . . . . . . . . PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY COUNSELOR . PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY RESEARCHER . PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY PARENT . . . . . . . . . PERSONALITY REFERRAL CATEGORY TABLES RELATIONSHIP OF PARENT AND COUNSELOR.JUDGMENT REGARDING SUCCESS OF THERAPY . vii PAGE 97 98 99 100 101 102 103 104 105 107 109 111 114 TABLE XXXXI. XXXXII. XXXXIII. XXXXIV. XXXXV. XXXXVI. XXXXVII. XXXXVIII. XXXXIX. LI. LII. LIII. LIV. LV. PAGE RELATIONSHIP OF PARENT AND RESEARCHER JUDGMENT REGARDING SUCCESS OF THERAPY . . . . . . . . . 115 RELATIONSHIP OF RESEARCHER AND COUNSELOR JUDGMENT REGARDING SUCCESS 0F THERAPY . . . . 116 SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO ACE . . . . . . . . . . . . . 117 SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO AGE . . . . . . . . 118 SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO AGE . . . . . . . . . . . . . . 119 SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO INTELLECTUAL ABILITY . . . . . . 120 SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO INTELLECTUAL ABILITY .121 SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO INTELLECTUAL ABILITY. . . . . .122 SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO DURATION OF PROBLEM . L . . . . 123 SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO DURATION OF PROBLEM. . . . . . . 124 SUCCESS 0F THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO DURATION OF PROBLEM . . . . . . . 125 RELATION OF THERAPY OUTCOME (AS JUDGED BY THE PARENT) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD . . . . . . . . . . . . . . . . . . . . . .126 RELATION OF THERAPY OUTCOME (AS JUDGED BY THE RESEARCHER) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD . . . . . . . . . . . . . . . . . . . . . 127 RELATION OF THERAPY OUTCOME (AS JUDGED BY THE COUNSELOR) AND PARENTAL ATTITUDE TOWARD THERAPY 128 OUTCOME OF CHILD'S THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO PRESENT PARENTAL ATTITUDE TOWARD THERAPY . . . . . . . . . . . . 129 viii TABLE LVI. LVII. LVIII. PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY COUNSELOR . . . . . . . . . . . . . . . . . . PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY RESEARCHER . . . . . . . . . . . . . PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY PARENTS LEARNING and DEVELOPMENTAL REFERRAL CATEGORY TABLES LIX. LX. LXI. LXII. LXIII. LXIV. LXVI. LXVII. LXVIII. LXIX. RELATIONSHIP OF PARENT AND COUNSELOR JUDGMENT REGARDING SUCCESS OF THERAPY . . . . . . . . . RELATIONSHIP OF PARENT AND RESEARCHER JUDGMENT REGARDING SUCCESS OF THERAPY . . . . . RELATIONSHIP OF RESEARCHER AND COUNSELOR JUDGMENT REGARDING SUCCESS OF THERAPY . . . . . . . . . . SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO AGE . . . . . . . . . . . . SUCCESS OF THERAPY (As JUDGED BY THE RESEARCHER) INRELATIONTOAGE..........‘...... SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO AGE . . . . . . . . . . . . . . . SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO INTELLECTUAL ABILITY . SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO INTELLECTUAL ABILITY . . . . SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO INTELLECTUAL ABILITY . . . SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO DURATION OF PROBLEM . . . . . . SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO DURATION OF PROBLEM . . . . . SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO DURATION OF PROBLEM. . . . . . ix PAGE 131 133 135 138 139 140 141 142 143 144 145 . 146 . 147 148 . 149 TABLE LXXI. LXXII. LXXIII. LXXIV. LXXVI. LXXVII. LXXVIII. LXXIX. LXXX. LXXXI. LXXXII. LXXXIII. RELATION OF THERAPY OUTCOME (AS JUDGED BY THE PARENT) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD . . . . ... . . . . . . . . . . . . . . RELATION OF THERAPY OUTCOME (AS JUDGED BY THE RESEARCHER) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD . . . . . . . . . . . . . RELATION OF THERAPY OUTCOME (AS JUDGED BY THE COUNSELOR) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD . . . . . . . . . . . . . . . . . . OUTCOME OF CHILD'S THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO PRESENT PARENTAL ATTITUDE TOWARD THERAPY . . . . . . . . . . . . . . . . . PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY COUNSELOR . PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY RESEARCHER . PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY PARENT . FUNCTIONAL ILLNESS REFERRAL CATEGORY TABLES RELATIONSHIP OF PARENT AND COUNSELOR JUDGMENT REGARDING SUCCESS OF THERAPY . . . . . RELATIONSHIP OF PARENT AND RESEARCHER JUDGMENT REGARDING SUCCESS OF THERAPY . RELATIONSHIP OF RESEARCHER AND COUNSELOR JUDGMENT REGARDING SUCCESS OF THERAPY . SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO ACE . . . . . . . . . . . . SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO AGE . . . . . . . . . . SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) PAGE 150 151 152 153 155 157 159 162 163 164 165 . 166 IN RELATION TO AGE . . . . . . . . . . . . . . . . 167 TABLE LXXXIV. LXXXVI. LXXXVII. IXXXVIII. LXXXIX. XC. XCI. XCII. XCIII. XCIV. XCV. XCVI. XCVII. PAGE SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO INTELLECTUAL ABILITY . . . . . 168 SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO INTELLECTUAL ABILITY . . . . . . . 169 SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO INTELLECTUAL ABILITY . . 170 SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO DURATION OF PROBLEM . . . . . . . . . 171 SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO DURATION OF PROBLEM . . . . . . . .172 SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO DURATION OF PROBLEM . . . . . . . 173 RELATION OF THERAPY OUTCOME (AS JUDGED BY THE PARENT) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD . . . . . . . . . . . . . . . . . . . . . . 174 RELATION OF THERAPY OUTCOME (AS JUDGED BY THE RESEARCHER) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD . . . . . . . . . . . . . . . . . . . . . . 175 RELATION OF THERAPY OUTCOME (AS JUDGED BY THE COUNSELOR) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD . . . . . . . . . . . . . . . . . . . . . . 176 OUTCOME OF CHILD'S THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO PRESENT PARENTAL ATTITUDE TOWARD THERAPY . . . . . . . . . . . . . . . . . 177 PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY COUNSEIOR....................179 PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY RESEARCHER . . . . . . . . . . . . . . . . . . . 181 PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY PARENT . . . . . . . . . . . . . . . . . . . . . 183 SUMMARY OF RELATIONSHIPS BETWEEN SELECTED FACTORS.AND CRITERIA . . . . . . . . . . . . . . 195 x1 CHAPTER I THE NATURE OF THE PROBLEM INTRODUCTION It has been accepted for some time that the mental health of the adult is largely determined by the experien- ces of childhood.1 The present adult entry rate into mental hospitals has been variously reported as being about one adult out of every ten. If we can alleviate or prevent emotional problems in childhood it seems in order to assume that adult entry rate into our mental hospitals would be lowered. To accomplish the above purpose the State of Michigan, with the cooperation of local communities, has set up a total of eighteen child guidance clinics throughout the State of‘Michigan.2 The primary function of a child guidance clinic is the treatment of incipient mental disease or severe emotional difficulty in children. The child guidance clinics in the State of Michigan are staffed by a child guidance psychiatrist, a child guidance psychologist, and a child guidance social worker. The 1The Prevention and Early Treatment 2£_Mental and Other Personality Disturbances. (State Department of Mental ealth, 1954), p. 2. As of July 1, 1960. suggested ratio is 1:1:3 respectively. To insure that we are doing the best possible job in prevention of emotional disorders in children it is necessary that constant evaluation and research be under- taken. It is with this thought in mind that the follow- .ing study is undertaken. I. THE PROBLEM Statement of the problem. The purpose of the present study is to (1) identify common concomitants of success or failure in child therapy; (2) to determine if therapy cases classified as successful closures by a therapist have remained successful in terms of the initial referral problem; (3) to compare the initial referral problem to the problem actually found by the therapist; (4) to determine the "best risk" for therapy in terms of length of treatment and the initial referral problem; (5) to determine how successful child guidance has been in correcting the initial referral problem; and (6) to determine if there is a need to improve methods of reporting and handling information obtained in a child guidance clinic. Need for the study. One of the main crises that child guidance clinics in the State of Michigan have encountered for some time is the need for additional professional personnel. This need stems primarily from the fact that more children are being referred for treatment of emotional disorders than ever before. To keep pace with the increasing number of referred children various clinic directors have attempted to compensate for lack of professional personnel by completely terminating intake referrals on certain days of the week, assigning a burdensome caseload to the existing staff, and allowing the "open and waiting" caseload to accumulate unduly. An "open and waiting" case is one which is open, has been accepted for therapy, and is currently waiting for a therapist to arrange scheduled interviews. These methods of compensation have, however, failed to alleviate the situation arising from the pressure of community demand for service, cases that present themselves as of an emergency nature, and the desire of child guidance clinics to be of continuous service. Clinics are thus forced to build up an initial appointment list and an "open and waiting" caseload for therapy. These lists are frequently so extended that cases wait as long as twenty-four months for therapeutic assistance. Clinic public relations with schools, social agencies, the medical profession, courts, and referred families are threatened by this necessarily long "open and waiting" list. It is sometimes very difficult for parents to comprehend why they must wait for a public service which they partially support. The resulting negative kind of public relations, if allowed to gain momentum, opens the possibility of program curtailment rather than improvement. Yet of greatest importance is the fact that children who are in need of assistance are forced to forego the aid their parents seek for them. Thus, the need for the study becomes apparent. There has been only a small amount of research on the prediction of therapy outcome and therapy stability with children, and to the author's knowledge no research of this type has been done in child guidance clinics in the State of Michigan. Brief history of child guidance. The first child guidance clinics were an outgrowth of the new psychology of the "Boston Group".3 This group was comprised of William James, G. Stanley Hall, Adolph Meyer, and others of similar interests. 3 Adolph Meyer, "Thirty-five Years of Psychiatry In the United States and Our Present Outlook," American Journal .2; orthOPaychiatry,8:9, July, 1928. These men represented a union of psychology and psychiatry, both of which disciplines, under their influence, became humanistic. To James, mind was an active moving power, and all of its manifestations were of importance. Invididuality, initiative, and freedom were to James the main desire. Hall was an ardent geneticist and much given to "instinct feelings" over rationality. Meyers, on the other hand, had long been interested in the developmental processes, especially as pertaining to the psychoses, and was strongly against theoretical systems and abstractions of any sort. The development of child guidance was thus dependent upon the emergence of a set of hypotheses about human behavior and its disorders which were neither physiologi- cal nor fatalistic. Basically the 'Boston Group‘ believed that a human being is a living whole and not a sum of elements or a mysteriously split organism composed of mind and body. From this concept of human conduct a theory about mental disorders and their orgins logically followed. These disorders were now regarded as being, for the most part, maladjustments of personality rather than diseases of the nervous system. It was Meyer's viewpoint that predominated throughout this era and it was his theories that underlaid the practices of the first child guidance clinics. The Juvenile Psychopathic Institute in Chicago, now Illinois Institute for Juvenile Research, is generally credited with being the first child guidance clinic. The Institute was founded in 1909.. In 1912 the Boston Psychopathic Hospital was established and put under the direction of men who shared the Meyerian point of view. A year later the Phipps Psychiatric Clinic in Baltimore was opened. Children were accepted as out-patients in both of the above clinics. Shortly afterward the National Committee for Mental Hygiene undertook surveys of school children and found many had behavior problems that called for study and treatment. By 1921 a fairly large number of clinics for children were in existence. These clinics, however, were mostly attached to mental hospitals, courts, schools, social agencies and colleges. Only a few of the early clinics had the characteristics of the later child guidance clinics. The peculiarity of child guidance clinics (first established in 1922 under the name as demonstrations by the National Committee for Mental Hygiene of the Commonwealth Fund) is that they offered psychiatric treatment to children and social casework service to parents simul- taneously. They also included a psychologist on the 'clinic team' who administered psychological examinations and often aided in treatment if necessary. The psychiatric treatment offered children during this era was commonly referred to as psychotherapy. Psychotherapy was developed to be a controlled, not a controlling, process and when directed toward a child was to be used in an effort to modify the child's attitudes, to assist him to work out emotional conflicts, and to help him attain a more adult and mature attitude toward situations and individuals with whom he came in contact. It was assumed that the patient consciously involved himself to some degree in the therapeutic process and that transference was used as the chief medium of treatment. Therapy did not endeavor to make a person conform to harsh and depriving conditions nor to become as normal or mature as the theoretically 'average' person could be. Therapy did desire to allow a person to achieve a more adequate use of all his faculties within his own capabilities. Therapy was especially important to children since whenever pressure from without could be modified or inhibitions removed, the forces of growth were on the side of the therapist. Psychotherapy offered adults differs from child psychotherapy due to the incomplete personality organ- ization of the child. The most outstanding characteristic of the child is that of a weak ego organization and a limited ability to manipulate inner impulses and external demands. A second difference, a direct outgrowth from the above, is a basically narcissistic character; hence self indulgence and feelings of omnipotence. A third distinction is the nearness to the surface of the unconscious, often causing children to act out and Speak about matters that are embarrassing to an older person. The closeness of the unconscious to the surface of the child's consciousness can also be attributed to the incomplete super-ego development. Brief history 2: child guidance in Michigan. By 1923 the interest in work with children stimulated the State Hospital Commission of the State of Michigan to establish the authority to set up child guidance clinics, but lack of appropriations made it impossible for such clinics to be organized. In 1944 the State Hospital Commission was abolished and the State Department of Mental Health was created in its place. Financial assistance was brought forth in 1929 when Senator James Couzens donated $10,000,000. This money was donated with the stipulation that it be spent within a twenty- five year period of time. At a later date $2,100,000 was added to the above amount. In 1930 the Children's Fund entered the field of child guidance and took as its first step the task of training graduate students in social work. In 1937 the Children's Fund combined with the Michigan State Hospital Commission to launch the present program in mental health. A child guidance clinic was set up at Traverse City to work with the local state hospital staff. The foundation gave $11,000 to demonstrate the clinics in Michigan. William H. Kelly, M. D., currently the assistant director of the Department of Mental Health, was the first child guidance psychiatrist in the State of Michigan. The second child guidance psychiatrist was Norman Westlund, M. D., currently the director of the Saginaw Valley Child Guidance Clinic and the attending child guidance psychiatrist to the Northwest Michigan Child Guidance Clinic. At the present time advisory boards, composed of local people actively interested in the development of and the continued support of the clinic, work with the Department of Mental Health and the clinic in matters of policy and finance of the clinic. This effort, in collaboration with the state's monetary support, supplies the necessary funds for operating. At this time the state is providing approximately 53 per cent of the total operating funds for clinic Operations. The ultimate goal is a 50-50 sharing of costs between the State of Michigan 10 and the local community in which the clinic is established. Michigan's Child Guidance Program currently costs the state and the community about $1,317,000 a year. As of the middle of the fiscal year ending June 30, 1960, there were eighteen child guidance clinics in the State of Michigan and sixteen branch offices. A branch off- ice is set up within a relatively small geographic area other than where the clinic is located. Its primary func- tion is to give additional local clinic service where a full clinic is not justified or feasible. The local community contributes by supplying a professional worker and office facility for a full-time or part-time oper- ation. The branch office is supervised by and augmented by occasional visits of other staff members from the clinic area. Brief history gprorthwest Michigan Child Guidance Clinic. James Decker Munson Hospital, in Traverse City, Michigan, was selected as a place where the Children's Fund of Michigan could give the best service available to children who lived in the northern portion of the lower peninsula. Initially James Decker Munson Hospital was a general hospital belonging to the Traverse City State Hospital, an institution for the mentally ill. At a 11 later period Munson Hospital was legally separated from Traverse City State Hospital and came to be owned by the Traverse City community with a separate board of trustees. In the spring of 1936 the name of the children's section of the new medical facility became the Central Michigan Children's Clinic. The first pediatrician of the children's section was Mark F. Osterlin, M. D., now deceased. In the year 1937 the Child Guidance Division of the Children's Fund sent a psychiatric social worker to initiate child guidance work in the area. This was a departure from the usual procedure because the worker was Inot under the supervision of a psychiatrist but correlated her activities with the pediatrician. Psychiatric and psychological consultation service was made available to the Child Guidance Division by the Traverse City State Hospital Staff. Miss Hazel Hardacre is the third psychiatric social worker to funCtion in the child guidance pro- gram in this clinic. Miss Hardacre arrived in 1938 and is still working in this capacity. In 1954, when the Children's Fund ceased to exist, the clinic was taken over by the Michigan Department of Mental Health. The name 12 of the clinic was changed to the Northwest Michigan Child Guidance Clinic and placed under the directorship of Miss Hardacre. The child guidance clinic staff consisted of one child guidance social worker in the summer of 1937. Short- ly after, because of the expanding request for service, it was necessary to increase the staff. Two additional child guidance social workers were engaged on a full-time basis and given the additional responsibility of setting of branch offices in Mason and Wexford counties. In 1955 a psycholo- gist was employed and in 1957 an additional psychologist brought the staff total to five. An attending psychiatrist reviews selected cases at periodic intervals and is available at all times for cases which require immediate expert psychiatric consultation. The attending psychiatrist is available to the clinic from the Saginaw Valley Child Guidance Clinic. In 1958 the third branch clinic of the Northwest Michigan Child Guidance Clinic was opened in Alpena, Michigan. Past, present, and future growth of the Northwest Michigan Child Guidance Clinic is quite evident. Table I shows the number of cases and types of problems seen at the clinic during the years 1954- 1958. Limitations gf the study. The limitations of the study include the following points. 13 TABLE I NUMBER OF CASES BY TYPES OF PROBLEMS 1954-1959 NORTHWEST MICHIGAN CHILD GUIDANCE CLINIC Type of Problem Year Conduct Habit Persona 1 ity Learning 6: Funct ions 1 Other Tots 1 Developmental Illness 1954 35 2 29 57 29 1 153 1955 56 12 25 133 18 1 244 1956 66 8 33 155 . ll 2 275 1957 115 7 23 209 10 1 365 1958 133 16 20 206 10 0 375 1959 101 32 18 133 19 145 448 Total 506 77 148 893 97 150 1860 The above table begins in the year 1954 due to the fact that records are not available prior to this date. The table is extended to 1959 to include the last statistical summary. 14 1. The entire sample of subjects was drawn from the files of the Northwest Michigan Child Guidance Clinic at Traverse City. The sample represents cases which have accumulated over a seventeen county area. 2. The analysis of the referred cases will be confined to the years 1950-1957. 3. The sample used in this study is the caseload of five therapists, none of whom follows any one school of therapy. 4. Statistical prediction from the obtained data may be classified as a limitation due to the fact that prediction for individuals is based on group data. It is thus important to make an intensive analysis of each child to determine the personality and environmental make-up which has classified him as a child guidance referral. 5. The records used in this study were compiled with varying degrees of proficiency and may, in some cases, be incomplete or inaccurate. Material included in the case record is often quite subjective. 6. The variables used in this study are not the only variables that could, or should, be explored. The variables used are the ones selected by the author that seemed to be the most fitting for investigation of the ' problem. 15 II. DEFINITION OF TERMS USED The terms used in this study are terms used in the child guidance clinics in the State of Michigan. Due to administrative policy the terms do not necessarily apply to other child guidance clinics located in different states. Definitions taken directly from the Michigan Department of Mental Health will be starred.4 *Child guidance clinic. A child guidance clinic is an out-patient clinic for children up to seventeen years of age which is staffed by a child guidance psychiatrist, child guidance social worker, and a child guidance psychologist. The function of the child guidance clinic is the alleviation and prevention of mental disorders in children. Child guidance psycholggist. A child guidance psychologist is a person trained to adminster and interpret psychological tests for children and is capable of carrying on psychotherapy with children under the supervision of a child guidance psychiatrist, and is adequately trained in the area of psychology. 4 Michigan Department of Mental Health, Child Guidance Clinic Statistical Manual. (Lansing: Research Section, 1958), pp. 2-9. 16 Child gyidance social worker. The child guidance social worker functions as an integral member of the clinical team in the child guidance setting, contributing to diagnosis and treatment of psychosocial factors related to the situation of stress for which the child patient has been referred.5 *Open case. A case is classified as open following the interview(s) with the child and/or the parent or responsible agent during which it has been established that the case is appropriate for clinic service. *Reopened case. Any case opened for service which has previously been an open case at any state child guidance clinic is classified as a reopened case. All cases transferred to another clinic will be closed by the original clinic and reported as reopened by the receiving clinic. *Successful closure. A successful closure is a case in which it is the opinion of the therapist that the child has improved over his condition at the time treatment started, regardless of whether or not this improvement is thought to be related to therapy. 5Definition suggested by the School of Social Work, Michigan State University. 17 *Unsuccessful closure. An unsuccessful closure is a closed case in which, in the opinion of the therapist, the child's condition has not improved over the time treatment started. Psychotherapy. Psychotherapy is a planned and systematic application of psychological facts and theories to the alleviation of a large variety of human ailments and disturbances. Psychotherapy and counseling are used synonymously.6 Psychotherapist. Psychotherapist, as used in this study, refers to a person actively engaged in supervised psychotherapy with children. The term psychotherapist, therapist, and counselor are used synonymously. In Chapter I the researcher has identified the purpose of the present study, given a brief history of child guidance, a brief history of the Northwest Michigan Child Guidance Clinic. In addition, the limitations of the study and definition of terms have been defined. Chapter II will give a review of the literature pertaining to prediction of therapy outcome in child guidance. 6D. E. Fisher, The'Meaning and Practice gf Psycho- therapy (New York: MacMillan Co., 1950), p. 9. CHAPTER II REVIEW OF THE LITERATURE INTRODUCTION Much has been written in regard to the prediction of therapy outcome and factors entering into the success and failure of psychotherapy. The greatest percentage of this material however deals primarily with adults rather than with children. This chapter will mention several studies that deal with adult population but the majority of the literature will be in reference to children and the prediction of therapy outcome in child guidance. Psychotherapy With Children The literature on psychotherapy with children is still limited and available authoritative texts are few in number. Furthermore, psychotherapeutic methods and processes in work with children have not up to the pre- sent been clearly systematized and fully described. Every psychotherapist of experience is painfully aware of the amount of time wasted by carrying on therapy with cases which are unsuitable for such treatment. The greatest loss of time and effort is brought about by 18 19 selecting the child for psychotherapy on the basis of only one or two factors. For example, to select a child for psychotherapy on the child's motivation or the need of a mother figure would be entirely erroneous. It is necessary that the task of selection be approached from an open minded standpoint and that we be honest in our judgment of which cases can be completely cured, which can be helped to be more independent, and which do not have the slightest chance to benefit from psychotherapy. To accomplish this it is necessary that all factors which may affect treatment outcome be investigated previous to case acceptance or case goal setting. As Rees says, "Through psychotherapy we may sometimes hope to cure, more often to relieve, and always to support."1 General Factors Related To Therapy Prediction Factors which are related to therapy prediction have been investigated from a very general viewpoint to specific variables. Katzeneleogen has suggested that failure and success in psychotherapy is determined by: (1) the nature of the illness; (2) the time that is available for psychiatric assistance; and (3) the patient's mode of living both inside and outside the family. He 1 J. R. Rees, Modern Practice l§_2§ychological Medicine (London:Butterworth and Company, 1949), p. 381. 20 feels that if the biological and psychological needs of the individual are not gratified, treatment effectiveness is greatly impaired.2 Psychologic deprivation in early childhood has been investigated increasingly during the past twenty-seven years. The great majority of these investigations have convincingly demonstrated conspiodous deviations in both intellectual and emotional response when deprivation in childhood is evidenced. Goldfarb regards the family as a psychological climate which as such determines the person- ality development of the child.3 Beck states that various factors should be considered in relation to therapy prediction. Ego strength, capacity for relationship, capacity for insight, desire to be helped, quantity of conscious anxiety, quantity of repressed host- ility, intelligence, and time available are all valuable criteria in determining whether or not therapy should be undertaken.4 2 Soloman Katzeneleogen, Analyging Psychotherapy (Philosophical Library Inc., 1958) p. 97. 3 William Goldfarb, Emotional and Intellectual Conseguences‘gf Psychological Deprivation $3 Infancy (New York:Grune and Stratton, 1955), pp. 105-118. Bertram M. Beck, Short Term Therapy IQ AB Author- itative Setting (Family Service Association of America, 1946) p. 66. 21 Ingham and Love indicate greater favorability of prognosis with specific factors.5 They are somewhat in agreement with Beck and state that age is an important factor when thinking in terms of treatment, the main generalization of age being that the older a person is the less likely he is to be adaptable to therapy procedure. They also discuss intelligence as a predictive factor but arrive at the loosely formulated statement that, "The more intelligence a person has the better chance for success in therapy, prognosis improves with intellectual ability, and different types of therapy go with very dull normal individuals and mental defectives." Ingham and Love also feel that flexibility, or the ability of a person to change conditions to meet his needs, is a fortunate asset in determining therapy outcome. They feel that previously attempted therapy may detract from the likelihood of success but does not necessarily preclude it.6 Behavior maladjustments are notoriously discouraging but sometimes not impossible to deal with successfully. The psychoneurotics as a rule are easier to treat. Disturbance causing most psychosomatic manifestations and the other psychoneuroses including the anxiety state, Harrington V. Ingham and Leonora Love, The Process 2: Psychotherapy (New York: MCGraw-Hill Book Co. Inc., 1954) pp- 147-148. 61bid., p. 157. 22 depression, and hysteria are far more likely to show improvement. Dunner points out the following factors that have been assessed as favorable assets in predicting therapy outcome: 1. High intellectual ability. 2. Ability to relate to others on a verbal level. 3. Young age at time of referral. 4. Average or above achievement before illness. 5. Sudden onset of problem. 6. Onset of problem due to external conflict. 7. Insight. 8. Seeking psychotherapy on own initiative. The Institute For Juvenile Research selects cases for treatment on a rather loose basis but has produced successful treatment in many instances. However, the successful cases may quite possibly contain many of the factors which other authors have mentioned as criteria for successful prediction. The Institute selects child 7Eugene E. Levitt, "The Results of Psychotherapy With Children: An Evaluation," Journal 22 Consultigg Psychology, 21;l89-l96, 1957. 8Ada Dunner, "Aspects.g§ Prognosis For Patients Referred for Psychotherapyd" Journal American Medical Esmen's Association, 11:203, 1956. 23 guidance cases on the supposition that the case is apparently treatable; (2) that resources seem available for treatment and the carrying out of recommendations; and (3) the problem is an important one to the community.9 Cameron in his book, General ngchotherapy Dynamics and Procedures, feels that the best cases for successful therapy are the early behavioral disturbances in children which represent a response to current stress. The anxiety states, provided they have not been extensively organized, also respond reasonably well. While a few psychopathic states seem to reapond more spontaneously, they are definitely in the minority. Another important criterion of successful case prediction is motivation. The fact, however, that a person comes to a child guidance clinic requesting assistance by no means signifies that he wants assistance, or that he will continue in therapy. Intelligence is described as a factor that does not determine whether or not psychotherapy can be carried out but rather dictates the kind of psychotherapy which should be used. A person with low or below average intelligence will probably respond better to directive, social, or the 9Institute For Juvenile Research, Child Guidance Procedures (New Yorszhe Appleton Century, 1936), p. 36. 24 simpler forms of group psychotherapy. The more intelli- gent person will derive more benefit from the nondirec- tive school. Age and duration of the problem are not strict components in themselves, yet the odds for success are in favor of the younger person and the shorter the duration of the problem. A case that has had a long duration will be more likely to be unsuccessful than succ- essful. Previous assistance from a child guidance clinic does not mean positive failure but is a discouraging factor when one is attempting to predict therapy outcome. Cameron also feels that in the matter of case selection one must se- lect on the basis of several criteria and that the criteria must be suited to a given technique or set of techniques. Thus the criteria may change according to the therapist hand- ling the case, a factor which suggests that each child guid- ance worker know the techniques of therapy used by the other staff members when assignment of case for treatment 10 occurs. Specific Studies Related To Therapy Prediction Research has produced many interesting facts D. E. Cameron, General Psychotherapy Dynamics 32d Procedures (New Yorkzcrune and Stratton, 1950) pp. 43-65. 25 concerning Specific variables and their relationship to therapy prediction. Bennett, in a study undertaken by the staff of the Rochester Guidance Center involving 200 experimental subjects from three to eighteen years of age, reports that prediction of therapy outcome depends upon the thoroughness of the diagnosis. Younger children are most amenable to treatment when the problem refers primarily to family experience. When distrust or distress revolves around the child's status in a social group, or reaches the point of ungovernable conduct, the outcome of therapy is not favorable. Children included in the study were functioning in the normal range of intelligence. Boys outnumbered the girls two to one, and half of the 11 group were younger than thirteen. Cunningham, Westerman, and Fischoff, in a follow-up study of children seen at the Children's Center of Metropolitan Detroit found that out of 420 children girls made a better adjustment than boys. The "only" child, possibly because of lack of sibling competition, seemed to have responded well to treatment and was making the best adjustment at home. The oldest child in the family made the pooreSt adjustment. From the standpoint 11 Chester C. Bennett, and Carl R. Rogers, "Predicting the Outcomes of Treatment," American Journal 9f Orthopsychiatry, 11:210-219, 1944. 26 of diagnosis, children diagnosed as psychoneurotic and having transient situational disorders showed the most favorable results.12 Parental attitude studies have presented themselves quite frequently in the literature. A study undertaken by Dukette points out that Catholic parents who seem to minimize the services of the clinic refer children who pre- sent more serious problems than do average child guidance referrals. These children are not to be classified as unsuccessful cases to work with but present a higher ratio of unsuccessful closures. Another feature of importance is the unusually high rate of adolescents included in this group.13 Hartin brings forth essentially the same material as Dukette in a study carried on at the Brooks County Guidance Institute in Pennsylvania. Attitudes of parents were studied in forty-seven cases. As a rule parents who came with attitudes that were favorable toward establishing a treat- ment relationship remained interested in treatment, but the clinic staff found it difficult to change or modify the 2 James M. Cunningham and others, "A Follow-up Study of Patients Seen In The Psychiatric Clinic for Children," American Journal 23 0rthopsychiatry,26: 602-610, 1956 13 Rita Dukette, "Attitudes of A Group of Catholic Parents Toward Child Guidance Treatment," Smith College Studies EB Social Work, 10: 102, 1939-1940. 27 attitudes of those who did not want the clinic's help. A few more than half of the parents left the clinic with the same attitudes with which they had come. This information would seem to have valuable implications if the referred child identifies with the attitude of one or both parents.14 The outcome of a study by Herkimer states that the initial attitude of parents toward a child guidance clinic cannot be used as a shortcut to prognosis. Rather the clues of treatability of parents and children lie within the more fundamental areas of the real feelings of the parent toward himself and his child.15 Additional comments of interest, when dealing with attitudes, are found in the study undertaken by Wilson. This study showed that when the attitudes of both parents and child are favorable toward treatment, there is a great likelihood that the case will be continued and that the child's adjustment will improve. If the attitudes of both parents are unfavorable, and for the most part unmodifiable, 14 . Ruth E. Hartin, "Parents attitudes Toward Child Guidance Treatment," Smith College Studies 13 Social Work, 10:103, 1939-1940. 15Jesse K. Herkimer, "The Relation Between Parents Attitudes For Coming To A Child Guidance Clinic and The Outcome of Treatment," Smith College Studies i3 Social Work, 10:103, 1939-1940. 28 little can be accomplished by the clinic. In some instances in which the child does not want help from the clinic, help to the parents in dealing with the situation more effectively may aid in the child's adjustment. Sometimes, when the child's pattern of behavior is very deep-seated, the study brings forth the feeling that there will be no response to treatment regardless of the desire for help on the part of either the child or the parent.16 Kleinman feels that intellectual ability should not be used as a basis for selection of a child for treatment. She feels that the less gifted benefits no more nor less from treatment than the superior child. Unless otherwise indicated a child guidance clinic should accept the dull normal on the same basis as any other child for treatment.17 A study undertaken by Glassman also points out that psychotherapy in child guidance clinics appears to be successful with children of dull normal intelligence as well as with those who are above average. Few children with intelligence quotients below eighty however, are given 16Ruth Anna Wilson, "Effects of Attitudes Toward Child Guidance Treatment and Its Outcome," Smith College Studies 12 Social Work, 18 & 19: 131-132, 1947-1948. 17Frances Z. Kleinman, "Intellegence As A Factor In Child Guidance Treatment," Smith Collegg Studies 13 Social Work, 20:114-115, 1949-1950. 29 direct treatment. Elliot feels that successful treatment seems to be dependent upon the parent's real sense of need for help, capacity to understand symptomatic behavior, ability to effectively carry out treatment suggestions and willing- ness to have their own problems studied in So far as they relate to the patient's problems. She also feels that. unsuccessful treatment goes along with distant location - thus lack of parental cooperation.19 Bonnet, in a study involving sixty child guidance cases, states that success or failure bears no statistical relationship to sex, age, or quality of school work. Comparison of cases in regard to physical classification showed that case failure occurred more frequently in children having marked sensory defect, glandular disturbances, and marked general over-development. Factors in the home situation related to success or failure showed little difference; composition of family, social contacts of the 18Lillian Glassman, "Is Dull Normal Intelligence a Contra-Indication For Therapy?", Smith Collggg Studies lg Social Work, 13:275-298, 1943. 19Mary Elliot, ”A Study of Factors Associated With Success Or Failure In Treatment of Child Guidance Clinic Patients". (Unpublished Master's thesis, Smith College, Northampton, Massachusetts, 1931), pp. 13-21. 30 family, source of referral, or size of family.20 thjntire, in a study involving thirty school referral cases, states that the most successful closures were girls between the ages of six through ten. In this particular study the most successful closures had superior intellectual ability. There seemed to be no relationship between the economic status of the family or the marital adjustment of the parents.21 Peterson concludes, through a study of fifty cases from the Providence, Rhode Island, Child Guidance Clinic, that two-thirds of the fifteen cases that were failures were children whose parents were openly rejecting. The cases which had the least success were those which the parents were convinced that the problem had a physical basis. Cases which were helped the most were cases in which the parents sincerely desired help from the child guidance 22 clinic for themselves or for their children. A study of seventy-nine adolescent children treated by 0Esther Bonnett, "A Comparison of Patients Successfully Adjusted With Those Unimproved At Close of Treatment". (Unpublished Master's thesis, Smith College, Northampton, Massachusetts, 1931), pp. 10-56. 21Virginia Macintire, "Factors Relating To Treatment Outcome In A Child Guidance Clinic,"Smith Collegg Studies 33 Social Work, 18:131-132, 1947-1948. 22Electra Peterson, "Prognostic Clues In The First Interview In Child Guidance,"Smith Collegg Studies 32 Social Work, 18 & 19:133-134, 1947-1948. 31 the psychiatrists of two child guidance clinics was under- taken by Allbright and Gambrell. They attempted to answer two questions: (1) Are adolescents less amenable to treatment than children of other ages? (2) Can the chance of their being successfully treated be predicted at all accurately from a consideration of their personality traits? The fact that at each clinic all the children were treated by a single psychiatrist was considered some control over treatment variation. It was found that thirty-nine per cent of the children were successfully treated, twenty- six per cent made some progress, and thirty-five per cent did not respond to treatment at all. A comparison of these percentages with others reported for unselected groups of child guidance referrals led to the conclusions that adolescents differ very little from other children in their response to child guidance treatment. With regard to the second question, it was found that a sur- prisingly accurate estimate of the probable results of treatment could be made from a study of certain person- ality traits. If the adolescents confined'their aggres- sion to certain areas, or were timid and retiring, and if they responded to aggression by renewing their attack or by giving way to annoyance and temper, the probab- ility of being helped by psychiatric treatment was 32 very high. On the other hand, if adolescents tended to avoid frustrating situations, they were unlikely to be aided by treatment unless they gave evidence in some area of having initiative and being able to assume responsibilities. If the adolescent was extremely aggressive and hostile in almost all situations the chance of successful treatment was slight. Only two out of fourteen such children were classified as successfully closed.23 Quite prominent in the prediction of therapy outcome is the lack of professional'skill in treatment methods. The proportion of cases in which the child fails to continue treatment probably is quite high. Feldman's study suggests that unsuccessful case closures often come about by improper case work methods, including the transfer of a case to a different worker. She also suggests that failure of the child to continue treatment is often due to the parent's attitudes toward them and toward treatment as well.24 In a study by Maberly in Britain of 500 children, it was pointed out that age was not an important factor in 23Sue Allbright, and Helen Gambrell, "Personality Traits As Criteria For the Psychiatric Treatment of Adolescents C'Smith College Studies in Social Work, 9:1-26, 1938. 24 Edith Feldman, "Why Children Discontinue Child Guidance Treatment," Smith College Studies 12_Social Work, 10:27-28, 1933-1939. 33 determining success of treatment. There was also no hear- ing on the child's ordinal position in the family and successful or unsuccessful closure. Children of average intellectual ability responded best to treatment. This group was followed by children of above average intellectual ability. Age had more to do with successful closure than intellectual ability. A child of fourteen responded better to treatment than a child of six with the same intellectual ability.25 Hofstein in his study states that the ability to profit from treatment depends on various factors. He feels that cultural differences, involvement of parents, and purpose and goals of treatment should all be taken into account when considering children for treatment. If the above mentioned factors are not favorable the possibility of unsuccessful therapy outcome is increased.26 Davis in her master's thesis attempted to ascertain what factors may be related to varying degrees of success in the treatment of patients referred to a child guidance clinic and to show by means of a follow-up investigation to 25 Alan Maberly, "After Results of Child Guidance: A Follow-UP of 500 Children Treated At The Travistock Clinic, 1921-1934," British Medical Journal, 1:1130-1134, 1939. 26Saul Hofstein, "Social Factors In Assessing Treat- ability in Child Guidance," Children, 4:48-53, 1957. 34 what extent the child maintained the rating of success which he was given at the close of treatment. The sample consis- ted of sixty-five cases from the Judge Baker Child Guidance Clinic in Boston, Massachusetts. The following conclusions were drawn: 1. Sex is unrelated to social adjustment. 2. Neither age nor intelligence were found to be related to adjustment whether at the end of treatment or at the time of follow-up. No differences of importance were found when physical condition, nativity, economic status, and marital status were considered. 3. Partial or absolute failures occurred where there was extreme lack of affection. 4. Length and intensity of treatment bore no relation to the outcome of the case. 5. Intangible aspects of family life play a very important part in the outcome of therapy.27 Hylan's study was concerned with a comparison of treatment in adjusted and non-adjusted cases in an attempt to ascertain whether the psychiatric interpretations which give rise to treatment recommendations, the kind and number of recommendations themselves, or the inclination 2 7Ellen E. Davis, "Factors Related To The Outcome of Treatment In A Child Guidance Clinic33'(Unpublished Master's thesis, Smith College, Northampton, Massachusetts, 1934) pp. 72-75. 35 of parents to carry out treatment recommendations offer any basis for the prediction of successful treatment. It was found that: l. The kind and number of recommendations offer no index as to the probability of success in the treatment of cases. 2. In the adjusted group 58 per cent of the parents cooperated in carrying out suggestions as to more adequate ways of handling the children's problems, while only seven per cent cooperated in the non-adjusted group. This is a significant difference and suggests that coop- eration of parents is associated with success in the ad- justment of cases. 3. Cooperation on the part of the child is associated with success in the adjustment of cases. 4. Chances of successful adjustment is fairly good if the child is cooperative even though the parent 28 is not. Maslen in a follow-up study of sixty-five patients fbund that the trend toward successful closure increased when the children were under eleven years of age, of high intellectual ability, in good physical condition, and came 28Mary Champlin Hylan, "A Study of Factors Associated With Success or Failure In The Treatment of Child Guidance Clinic Patients,"(Unpublished Master's thesis, Smith College, Northampton, Massachusetts, 1932), pp. 39-43. 36 from harmonious homes. The amount of treatment and type of case are relatively unimportant determinants when measuring successful case closure. The best risk is the case in which the child is of high intellectual ability and the parents are willing to accept advice. .MacGregor's study attempted to determine whether certain objective factors related to the patient and to his environment have significant bearing on his adjustment following treatment. The sample consisted of 297 closed cases which were given treatment service at the Institute for Child Guidance, New York City. Conclusions were as follows: Boys showed a tendency to respond more favorably 1. to treatment than girls. 2. There was consistent, though slight, increase of successful treatment with increase in age. 3. More success in treatment was obtained with higher intellectual ratings. 4. The intermediate child in the family seemed to respond more favorably to treatment, although the size of the family and the home group with whom the child lived seemed to bear little relationship to adjustment. 29.Albertina Aida Maslen, ”A Study of Factors Associated With Success or Failure In Treatment of Child Guidance Clinic Patients,"(Unpublished Master's thesis, Smith College, Northampton, Mhssachusetts, 1932), pp. 26-28. 37 5. The source of the referral appeared to have no relationship to final adjustment.30 In a study done by Leslie it was shown that success in treatment had no bearing on intellectual ability, number of school terms repeated, or physical condition of the referred child.31 The Institute of Juvenile Research, an agency of the Department of Public Welfare, State of Illinois, undertook a three year-study to evaluate the effect of psychotherapy. The Institute sees anywhere from 800 to 1,000 child patients diagnostically in its Chicago clinic, and accepts for treatment about 200 to 300 of these cases, all that the available number of therapists permits. Both parents and children may be seen in therapy, depending upon the individual case, and treatment is carried out by psychiatrists, psychologists, and social workers. The basic design of the study was to compare the present psychological adjustment of a sampling of cases treated at 3O Madeline Leitch MacGregor, "The Relation Between De- gree of Adjustment and Certain Objective Traits of The Patients". (Unpublished Master's thesis, Smith College, Northampton, Massachusetts, 1931), pp. 22-24. 31Myrtle Leslie, "A Study of Factors Associated With Success or Failure In Treatment of Child Guidance Patients," (Unpublished Master's thesis, Smith College, Northampton, Massachusetts, 1932), pp. 40-41. 38 the Institute of Juvenile Research during the period 1944 to 1954, inclusive, with a suitable control group. The experhmental groups consisted of 237 children. The control group consisted of ninety-three children and 69 per cent of the cases were males. The data of this study indicates that there is no difference at follow-up between adjustments made by treated and untreated child patients.32 The above information corroborates a recent survey conducted by Levitt of thirty-seven investigations of the efficacy of psychotherapy with children.33 Therapy prediction through the use of psychometrics has been very limited. Literature pertaining to the prediction of therapy outcome through the use of psycho- metrics in a child guidance clinic is meagre. Most of the studies dealing with adult prediction make use of the Rorschach Personality Test and the Minnesota Multiphasic Personality Inventory. Other instruments have been used 32Eugene E. Levitt and others, "A Follow-Up Evaluation Of Cases Treated At A Community Child Guidance Clinic," American Journal 9f Orthopsychiatry, 29:337-349, 1959. 33 E. E. Levitt, "The Results of Psychotherapy With Children: An Evaluation,H Journal Consultigg Psychology, 21:189-196, 1957. 39 but to a lesser extent. Siegel made use of the Rorschach Personality Test for diagnostic and prognostic purposes in child guidance. In addition the instrument was used to measure the effective- ness of therapy. It was felt that significant and predic- tive trends could be measured by the presence of certain traits in the personality structure. Rogers and Hammond in their study of 109 unselected veterans attempted to predict the success of treatment by means of the Rorschach Personality Test. The psychologists did not make better than chance predictions about the outcome of treatment under three separate methods of treating the Rorschach protocol. Rogers in an earlier study attempted to predict contin- uation of adult therapy by use of the Rorschach Personality Test. The results were negative.36 34 Miriam C. Siegel, "The Diagnostic and Prognostic Validity of The Rorschach Test In A Child Guidance Clinic," American Journal 2; Orthopsychiatgy, 18:113-119, 1948. 5Lawerence S. Rogers, and Kenneth R. Hammond, "Pred- iction of The Results of Therapy By Means of The Rorschach Test,fl'Journa1 Consulting Psychology, 17:8-15, 1953. 36Lawerence S. Rogers, and others, "Predicting Contin- uation In Therapy by Means of The Rorschach Test,fl'Journal ngsulting Psyghology, 15:368-371, 1951. 4O Auld and Eron made use of the Rorschach Personality Test to predict whether or not adult patients would continue psychotherapy. Their sample group consisted of thirty-three patients in the psychiatric out-patient clinic at the New Haven Hospital. Two-thirds of the patients were diagnosed as neurotic and the remaining one-third diagnosed as suf- fering from psychosis or character or behavioral disorders. Their prediction as to continuance of therapy was correct on 69 per cent of the subjects. Gibby in his study states that the Rorschach Personality Test identifies the poor therapeutic risk as those with limited productivity, few content categories, lack of reference to sexual and other topics, little color response, and preference for good form response. Interpreted in the conventional manner, the above types of responses indicate that the patient is overly deliberate, does not talk much, has a tendency to stick to safe sub- jects when he does talk and centers his emotional reaction on card content.38 The Minnesota Multiphasic Personality Inventory was 37Frank Auld Jr., and Leonard Eron, "The Use of The Rorschach Scores To Predict Whether Patients Will Continue Psychotherapy," Journal Consulting Psychology, 17:104-109, 1953. 38 Robert Gibby, and Bernard Stotsky, "Prediction of Duration of Therapy From The Rorschach Test," Journal 2: Consulting Psycholdgy, 348-354, 1953. 41 used by Wiert to predict response to psychotherapy. A total of 535 adult hospital patients was used in this study with reference to the Ego Strength Scale of the Minnesota Multiphasic Personality Inventory. He concluded that this scale was a good predictive instrument. Future samples proved that selected patients did show improvement but the use of the test did not point out all the patients that responded well to psychotherapy.39 Barron points out that considerable caution should be exercised when using the Ego Strength Scale. It should certainly not serve as the only basis in which to accept a case for treatment.40 The Wechsler-Bellevue as a predictor of continuation in psychotherapy was used in a study by Hiler. His study was carried out in the Veterans Administration Mental Hygiene Clinic at Detroit, Michigan. His sample consisted of 216 patients; 133 of whom were given the Wechsler- Bellevue. A comparison was made of the performance of patients who remained in treatment and those who terminated prematurely. Patients who remained in treatment scored 39Robert E. Wiert, "Further Validation of The Ego Strength Scale,'VJournal 3; Consulting Psychology, 19-444, 1955. 0 Frank Barron, "An Ego Strength Scale Which Predicts Response To Psychotherapy," Journal 2; Consultigg Psychology, 17: 327-333, 1953. 42 significantly higher in intellectual ability the difference being greater for the Verbal Scale than for the Performance Scale. With total intelligence held constant, the patients who remained in treatment did significantly better than the terminators on the Similarities subtest, a finding which is perhaps due to a greater ability to perceive relation- ships. Also, with total intelligence held constant the patient who remained in treatment did relatively less well on the Digit Span and Digit Symbol subtests. These subtests are very much affected by emotional disturbances and there- fore these results probably indicated a greater degree of anxiety on the part of the patients who remained in treatment which perhaps served to motivate them to continue treatment."1 CONCLUSION From the above studies it is quite apparent that many authorities have arrived at various conclusions regarding the relationship of specific factors to therapy prediction.. The author will attempt to combine those factors which are generally in agreement in predicting therapy out- come, those factors which seem to have no agreement in 41 E. Wisley Hiler, "Wechsler-Bellevue As A Predictor Of Continuation In Psychotherapy J'Journal‘gf Clinical Psychology, 17:192-194, 1958. 43 predicting therapy outcome and the factors which give evidence of probable therapy outcome. The general conclusion regarding age of the subject and therapy outcome is that age of the child is of no significance. Adolescents have responded to therapy equally well as children of six years of age or older. The main difference seems to lie not in the age level but in the intensity and duration of the presented problem. Intellectual ability does not seem to be a significant factor in predicting therapy outcome. Children of below average intellectual ability, average intellectual ability, and above average intellectual ability have been reported to respond equally well in therapeutic sessions. The type of psychotherapy offered seems to be more important than the intellectual level of the child. Various authors have suggested that direct therapy be given to children who are functioning below dull normal intelligence. The more intelligent child seems to derive more benefit from the non-directive school of therapy. Parental attitude toward the clinic and toward the child suggests evidence of the direction of case closure. Parents who maintain a healthy climate within the home and are sincerely interested in the clinic function lend support to the probability that case closure will be 44 successful. The real feelings of the parent toward himself and child are seemingly more important than the marital adjustment within the home. If previous therapy has been attempted with a child the probability is that additional therapy will result in failure. Although boys outnumber girls in the majority of the studies the data suggest that sex is not a determining factor in therapy prediction. Literature pertaining to specific diagnostic classi- fications in child guidance presents too meagre a picture to form positive conclusions. It is suggested, however, that failure in therapy will result most generally with children classified as behavior maladjustments and psychopathic deviates. Favorable treatment seems to coincide with a relatively quick onset of problem due to external conflict and current stress. The use of psychometrics for prediction of therapy outcome has been exceedingly meagre in child guidance. The majority of the literature pertains to adults and the use of the Rorschach Personality Test and the Minnesota Multiphasic Personality Inventory. Although test results provide a valuable contribution toward therapy prediction they are not to be used as the sole or determining factor. 45 Past studies have shown that various factors are of more value in prediction of therapy outcome than others. The researcher proposes to advance the comprehension of the subject through the following: 1. By separating referral problems into distinctive categories it may be possible to demonstrate that the studied factors effect specific referral categories in various degrees. 2. Due to the fact that the population studied is classified as rural urban, the obtained information has particular interest to child guidance clinics in a rural setting. Such a study has never been undertaken in the State of Michigan. 3. The cases used in this study have been seen on a therapeutic basis by five therapists, all of whom are still employed by the Northwest Michigan Child Guidance Clinic. In addition to the low number of therapists involved the availability of therapists for discussion of records has added validity to date which otherwise may have been misinterpreted. Chapter II has presented a review of the literature pertaining to the prediction of therapy outcome in child guidance. The following chapter will outline the method of sample selection, the method of case analysis, and the method of 46 follow-up. In addition the researcher will present the predictive factors, as used in this study, in relation to successful and unsuccessful case closure. CHAPTER III METHODOLOGY AND PROCEDURE INTRODUCTION In this study an attempt is made to determine the significance of various items in relation to common child guidance referral categories, the stability of successful closures, and the evaluation of specific child guidance practices. For approximately fifty years investigators inter- ested in the emotional develOpment of children have made an attempt to predict the behavior of an individual under a given set of circumstances. Out of their research numerous convictions have appeared stating that it is possible to predict how children can or will, react when confronted with a given problem situation. The degree to which a child reacts to a problem and the degree of adjustment is still somewhat of a debatable question. It is this uncertainty in the final adjustment of children which has led the researcher to believe that much can be done in evaluating child guidance procedures. The Sample Method 2; Selection. The population for this study 47 48 consisted of 706 child guidance referrals seen at the Northwest Michigan Child Guidance Clinic located at Traverse City, Michigan. The cases chosen for the study sample were selected in the belief that a complete study of the child is necessary for a proper understanding of the problems presented by him. In all cases a history and an individual study, including psychiatric, physical, and psychological examination, were necessary. It was the researcher's feeling that no part of the study could be dispensed with if proper research outcome of the case was to result. The cases selected had all of the follow- ing characteristics: 1. A case was selected for study if it had been seen on a treatment or therapy basis. Cases that were given diagnosis only or psychological testing only were not used in the original selection. These cases were omitted due to the fact that a referral interview was at times unnecessary for a case classified as diagnosis only, thus making the record incomplete. 2. A case was selected for study if it contained a complete social case history. A social case history was classified as complete if it contained adequate information on the medical history, developmental history, duration of referred problem, social history, psychological datqb and some identifying information pertaining to the children's parents. 49 3. A case was selected for study if it was classi- fied at the time of referral as falling in one of the following categories:1 A. Conduct Disorder. Conduct disorders cover a wide range of misconduct from minor misbehavior to grave delinquency. Such conditions may exist chiefly in the home, in the school, or in the community. The term "conduct disorder" is not generally applied to very young children. Examples of conduct disorder, as used in this study, include: 1. Truancy. 2. Fighting and quarreling. 3. DisobedienCe. 4. Untruthfulness. 5. Stealing. 6. Forgery. 7. Setting fires. 8. Destruction of property. 9. Sex offenses. 10. Delinquency. B. Habit Disorder. Habit disorders are particularly prevalent during the pre-school period, 1 Sanger Brown and others, Outline §2£.£§£ Psychiatric Classification‘gf Problgg Children (Lapeer Home and Training School Print Ship, 1945, pp. 3-4.) 50 although they occur at all ages. Habit disorders are often minor and transient in character in young children. In older children habit disorders may be more permanent. Examples of habit disorders, as used in this study, include: 1. Nail biting. 2. Thumb sucking. 3. Nocturnal and diurnal enuresis. 4. Masturbation. 5. Habit spasms. C. Personality Problems. Children in many instances display personality disorders of a nature which have come to be considered indicative of poor mental health. These disorders, if they tend to become exaggerated, later assume the characteristics of actual mental disease signs and symptoms. Examples of personality problems, as used in this study, include: I. Seclusive states. ,/ 2. Depressed states. 3. Suicidal threats and attempts. 4. Day dreaming. 5. Feelings of indadequacy. 6. Shyness. 7. Fears of normal activities. 51 D. Learning and Developmental Problems. Learn- ing and developmental problems are particularly prevalent during the ages four through ten. They are usually assoc— iated with school problems but some include delayed matur- ational problems of speech, walking, and coordination. The types of disabilities included in this category are associa- ted with both average and below average intellectual abil- ity. Examples of learning and developmental problems, as used in this study include: 1. Poor schoolwork. 2. Problems associated with dull normal or borderline intelligence. 3. Special mental disabilities. a. In writing. b. In reading. c. In arithmetic. 4. Developmental patterns below age expec- tancy when the child has average intellectual ability. E. Functional Illness. A functional ill- ness problem is a behavior disorder which takes on the characteristic of a physical condition, even though there is no direct relation between the two. Examples of functional illness problems, as used in this study, include: 1. Headaches. 2. Skin disorders. 52 3. Vomiting. 4. Fainting 5. Convulsions The total sample used in this study represents cases drawn from a seventeen county area.2 The seventeen county area is the allotted territory for the Northwest Michigan Child Guidance Clinic. The area division is governed by the Michigan Department of Mental Health. The area covered by the study varies from walking distance to the Northwest Michigan Child Guidance Clinic to 138 miles away; the most distant point being the area served by the North- west Michigan Child Guidance Branch Office located in Alp- ena,‘Michigan. In selecting the cases from the case files many referrals were bypassed either because the records were inadequate or because some cases would not be classified as adults. Other conditions such as lack of case notes, incomplete social history, and lack of psychological data forced the rejection of some cases. The final sample of workable cases consisted of 253 drawn from the years 1950- 1957. These years were chosen to allow adequate sample size representation and to permit at least two years to elapse to show outcome of.treatment. There were additional 2 See Appendix A.for map giving description of seventeen county area. 53 factors that were unique with this period. (1) The director of the Northwest Michigan Child Guidance Clinic remained the same during this period. (2) All cases used in the sample represent the therapeutic effort of five therapists, all of whom are still employed at the Northwest Michigan Child Guidance Clinic. Thirty-eight cases were omitted from the workable sample because of failure of the families to cooperate (31) and the impossibility of locating them by mail, telephone, through relatives, or personal contact (7). The returned questionnaire narrowed the working sample from 253 to 215.3 This figure represents all cases class- ified as usable with the exception of three cases which were omitted because they were cases of two therapists no longer on the staff of the Northwest Michigan Child Guidance Clinic, thus keeping the number of therapists to five instead of sev- en. Of the 215 workable cases the number of females totaled seventy-four. The males totaled 141. This proportion is in keeping with the reported state statistical summary which shows that boys are referred approximately twice as often as girls. In the successful closure group there were 156 cases. The unsuccessful closure group consisted of fifty-nine cases. This classification was determined 38cc Appendix B for sample questionnaire. 54 by the case closure of the therapist. In an attempt to test the authenticity of this classification the researcher set up a board of three professional workers, two child gui- dance psychologists and a child guidance social worker, to judge the classification of the closure from social history, case notes, psychological data, psychiatric interview if held, duration of problem and attitude of parent toward child. Methods 2; Analysis: The case record of each individual child containing case history, psychological data, referral problem, counselor found problem, therapy notes, and other pertinent information was examined. This -information was recorded on individual information sheets. The record sheets were classified according to referral problem and sorted into successful and unsuccessful closure groups. From each group tables were constructed to present the reported data. Due to the many comparisons involved: agreement of parent judgment and counselor judgment; agreement of parent judgment and researcher's judgment; significance of closure in relation to age; significance of intellectual ability in relation to closure; signifi- cance of duration of problem and closure; significance of parenteral attitude toward therapy and case closure; sig- nificance of parental attitude toward child - the most 4 See Appendix B for sample of individual information sheet. 55 practicable way of handling the material seemed to be by machine tabulation. Data that was most applicable to "Mistic", the electronic calculator at Michigan State University, was punched on tape and processed. The data were treated by the application of the chi-square method of analysis. The chi-square method enabled the researcher to establish significance betweentzhe various factors studied and success or failure in therapy outcome. Data not applicable to the chi-square method were treated either by Fisher's Test of Exact Probability or percentage presentation. Method 2; Followigp. Due to the number of years covered in this study it was necessary to be prepared for the lack of correct address information. To reduce the number of postal returns the author attempted to establish the most recent mailing address list by: (a) locating directories for the communities that listed the names by street address and phone; (b) checking with the respective county agent when in doubt of the given address; (c) checking with the local physician; (d) checking with all private agencies who may have had contact with the family; (3) checking with the courts and police of each local community; and finally, (f) checking with the Armed Forces for servicemen who had been stationed at military 56 bases in the studied area and had later been transferred. The initial form letter was forwarded requesting that the attached follow-up questionnaire be completed.5 The first attempt to contact the parent of the referred child was relatively successful. Out of the total initial contacts seven were returned for incorrect address. The researcher attempted to relocate these people but was unsuccessful. After waiting for an arbitrary period of five weeks for follow-up returns the researcher sent a second request to the parents who had not responded.6 The parents who were within a twenty-five mile radius were contacted by phone and asked to complete the form if they had no personal objection to doing so. Many of the parents felt they did not desire to complete the form letter, and conversation with the parents revealed fear that the form would be filed in the child's clinic folder on a permanent basis, that the information would be held against the child, and that a return might "hurt the feelings" of the thera- pist or clinic administration. The remaining nonresponders were sent a third letter of request, and some were contacted by phone. On five 5 See Appendix B for initial introductory letter. See Appendix B for second follow-up request. 57 occasions the parent requested a personal interview to evaluate each question on the questionnaire with the researcher. The researcher set up the requested interview at the child guidance clinic. In all cases the parent seemed insecure and quite negative toward the clinic in gen- eral. This feeling was evident even though the therapist had classified some of the case closures as successful. Referrals were returned from such distant points as Guam, California, and Florida. The replies from Guam and California were from military personnel who had been transferred from local military bases. The replies from Florida were from members of the teaching profession who had transferred from the local school system to school systems in Florida. Eighty-five per cent of the questionnaires were ultimately returned. The Data To make possible the prediction of successful or unsuccessful case closures information is needed that will help distinguish between children most likely to succeed in therapy and those who will terminate in an unsuccessful case closure. The main hypothesis in this study is that certain information variables will 58 be associated with successful closures and other infor- mation variables with unsuccessful case closures. The main difficulty will be to dichotomize the various factors that operate to produce the particular closure. In an effort to separate the present variables that operate toward successful or unsuccessful closures it was felt that each referral problem.must be placed in a specific referral category. To do this the researcher used the referral category set up by the Michigan Depart- ment of Mental Health. In each referral category it would thus be possible to see how each predictive factor affected that particular classification. The predictive factors used were selected from staff discussion concerning factors of importance in successful treatment, past studies, and the researcher's own feeling toward the problem. The predictive factors used in this study in rela- tion to successful and unsuccessful closures in specific categories were as follows: 1. Age at time of referral. 2. Duration of problem before initial referral. 3. Intellectual ability of referred child. 4. Parental attitude toward child. 59 5. Parental attitude toward clinic. In addition to the above list the researcher has attempted to form generalized constructive comments from the returned data and an analysis of the case records. The generalized constructive comments concern the following points. 1. Therapy success with reopened cases. 2. Therapy success with cases which are trans- ferred from one worker to another 3. Agreement of the therapist and the parent re- garding the success of the therapy. 4. Recurrence of referred problem after closure. 5. Incidence of new problems after case closure. 6. Types of problems most commonly referred. 7. Referred problem and counselor-found problem. The data used in this study have no bearing on the school of therapy or type of counseling used. It is not the intention of this study to evaluate counseling or psychotherapy or best therapeutic procedure. As stated above, most of the predictive factors are of an objective nature. In those instances in which subjectiveness necessarily enters in; the researcher, child guidance social worker and child guidance psychologist have shared judgment. This method has been adopted to insure greater consistency. 60 Chapter III has presented the methodology and procedure as used in this study. The following chapter will discuss the analysis of various factors used by the researcher in attempting to predict therapy outcome. CHAPTER IV FACTORS RELATED TO CLOSURE OUTCOME AND CIOSURE STABILITY This chapter is devoted to an analysis of the factors used by the researcher in predicting successful case closures and is approached from the standpoint that the various factors used may effect the studied referral categories in a somewhat different manner. Stating the above in an alternate manner one might say that sex, age, or duration of referred problem may effect a conduct pro- blem differently than a learning and developmental problem. The researcher hypothesized that children who had the following characteristics were poor risks in a thera- peutic situation: 1. Chronological age above twelve. 2. Intellectual quotient below eighty. 3. Parents with a negative attitude toward them. 4. Parents with a negative attitude toward therapy. 5. A problem which had persisted over thirty months. 6. Therapy in which their case was transferred 61 62 from one worker to another. 7. Therapy in which their case was closed and then reopened. 8. Broken, emotionally unstable, or unhappy home. 9. Therapy characterized by lack of thoroughness of the social intake interview and lack of completeness in the psychological data gathered previous to staffing of the case. The researcher feels that due to the small amount of knowledge concerning prediction of therapy outcome in child guidance work errors resulting in the rejection of the null hypotheses were less dangerous than errors confirming it and therefore the probability level of significance was established at the five per cent level. The tables which follow and explanation and discussion of each table summarize the findings concerning the variables which were studied in reference to each specific referral category. Conduct referral category. The first category to be discussed will be the conduct category. Conduct disorders cover a wide range of misconduct from minor misbehavior to grave delinquency. Examples of conduct 63 disorders include stealing, fighting, destruction of property, and disobedience. 64 Conduct Referral Category TABLE II RELATIONSHIP OF PARENT AND COUNSELOR JUDGMENT REGARDING SUCCESS OF THERAPY Parental . Cases Judged Successful Cases Judged Unsuccess- Totals Judgment By Counselor ful By Counselor 9.1 Parent Judged 10 3 13 Successful Parent Judged 28 ll 39 Unsuccessful Totals 38 14 52 p=.564 (Fisher Exact Probability) Not Significant ‘ k Table II presents parental agreement with counselor judgment. The relationships found are not statistically significant. The data indicate that parental judgment is unrelated to counselor judgment when dealing with conduct problems. It would seem however that the parent is somewhat less optimistic than is the counselor regarding the success of cases. 65 Conduct Referral Category TABLE III RELATIONSHIP OF PARENT AND RESEARCHER JUDGMENT REGARDING SUCCESS OF THERAPY Parental Cases Judged Successful Judgment By Researcher ful Cases Judged Unsuccess- Totals By Researcher Parent Judged Successful Parent Judged Unsuccessful Totals p=.026 (Fisher Exact Probability) 13 22 4 13 26 39 30 52 Significant Table III presents parental agreement with researcher's judgment regarding the success of cases. The findings are significant at the level chosen for this study. The data indicated that parental judgment is related to researcher's judgment in regard to success of therapy. This finding refers to the conduct category. 66 Conduct Referral Category TABLE IV RELATIONSHIP OF RESEARCHER AND COUNSELOR JUDGMENT REGARDING SUCCESS OF THERAPY Researcher's Cases Judged Successful Cases Judged Unsuccess- Totals Judgment By Counselor ful By Counselor Researcher Judged 22 O 22 Successful Researcher Judged Unsuccessful 16 14 30 Totals 38 14 52 p=Less than .001 (Fisher Exact Probability) Significant Table IV presents researcher's and counselor's judgment regarding the success of cases. The findings are significant at the level chosen for this study. The data indicate that research judgment is related to counselor judgment in regard to success of therapy. This finding refers to the conduct category. 67 Conduct Referral Category TABLE V SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO AGE Closure Below Median Above Median Totals Classification Age Age Successful Closure 3 10 13 Unsuccessful Closure 21 18 39 Totals 24 28 52 p-.016 (Fisher Exact Probability) Significant When considering the prediction of therapy outcome, as judged by the parent, in relation to age of referred child the obtained exact probability value is of statistical significance. This finding applies to the conduct category. Success of therapy, as perceived by the parent, is related to the age of the child in that the older child seems more apt to profit from therapy. The median age of the children in the conduct referral category was nine years and five months. SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) 68 Conduct Referral TABLE VI Category IN RELATION TO ACE Closure Below Median Above Median Totals Classification Age Age Successful Closure 11 ll 22 Unsuccessful Closure 14 16 30 . Totals 25 27 52 x2=2.433 p= Greater than .100 Not Significant The relationship between success of therapy, as judged by the researcher, and the age of the referred child is of no statistical significance. conduct category. conduct category was nine years and five months. This finding applies to the The median age of the children in the 69 Conduct Referral Category TABLE VII SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO AGE Closure Below Median Above Median Totals Classification Age Age Successful Closure 21 17 38 Unsuccessful Closure 6 8 14 Totals 27 25 52 x2=.23l p= Greater than .50 Not Significant When considering the outcome of therapy, as judged by the counselor, in relation to the age of the referred child the obtained exact probability value is of no statistical significance. This finding applies to the conduct category. Success of counseling, as perceived by the counselor, is not related to the age of the child. The median age of the children in the conduct referral category was nine years and five months. 70 Conduct Referral Category TABLE VIII SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO INTELLECTUAL ABILITY Closure Cases Below Cases Above Totals Classification Median I.Q. Median I.Q. Successful Closure 2 11 13 Unsuccessful Closure 19 20 39 Totals 21 31 52 p=.032 (Fisher Exact Probability) Significant Table VIII shows the relation of therapy outcome, as judged by the parent, to intellectual ability of the child. The obtained exact probability is of statistical significance. The finding applies to the conduct category. The intellectual ability of the child is positively related in this sample to the parent's perception of the success of therapy. The median intellectual quotient of conduct cases was 96. 71 Conduct Referral Category TABLE IX SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO INTELLECTUAL ABILITY Closure Cases Below Cases Above , Totals Classification Median I.Q. Median I.Q. Successful Closure 8 14 22 Unsuccessful Closure 17 13 30 Totals 25 27 52 x2=l.360 p= Greater than .20 Not Significant Table IX presents the relation of therapy outcome, as judged by the researcher, to intellectual ability of the child. The obtained probability is of no statistical signi- ficance. This finding applies to the conduct category. The intellectual ability of the children in this sample is not related to the researcher's judgment of success in therapy. The median intellectual quotient of conduct cases was 96. 72 Conduct Referral Category TABLE X SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO INTELLECTUAL ABILITY Closure Cases Below Cases Above Totals Classification Median I.Q. Median I.Q. Successful Closure 21 17 38 Unsuccessful Closure 4 10 14 Totals 25 27 52 p=.084 (Fisher Exact Probability) Not Significant The obtained exact probability of Table X is of no statistical significance. This finding indicates there is no significant relationship between success of therapy as judged by the counselor, and intellectual ability of the child. This finding applies to the conduct category. The median intellectual quotient of conduct cases was 96. 73 Conduct Referral Category TABLE XI SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO DURATION OF PROBLEM Closure Duration of Problem Totals Classification 30 Months or Less More Than 30 Months Successful Closure 12 l 13 Unsuccessful Closure 11 28 39 Totals 23 29 52 p= Less than .001 (Fisher Exact Probability) Significant Table XI shows the relation of counseling outcome, as judged by the parent, to the duration of the problem. The duration of the problem which occasioned the referral was taken from the social worker's intake referral sheet. The obtained exact probability value is significant at the level chosen for use in this study. This finding applies to the conduct referral category. Case success is related 74 to the duration of the problem in that cases in which the problem has persisted for more than 30 months before therapy are more apt to result in outcomes judged by the parent as unsuccessful than are cases where the problem has been of a shorter duration. 75 Conduct Referral Category TABLE XII SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO DURATION OF PROBLEM Closure Duration of Problem Classification 30 Months or Less More Than 30 Months Totals Successful Closure 16 6 22 Unsuccessful Closure 7 23 30 Totals 23 29 52 x2=1.431 p= Greater than .20 Not Significant The obtained probability of Table XII is of no statistical significance. Case success, as judged by the researcher, is not related to the duration of the problem. The duration of the problem which occasioned the referral was taken from the social worker's intake referral sheet. This finding applies to the conduct referral category. 76 Conduct Referral Category TABLE XIII SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO DURATION OF PROBLEM Closure Duration of Problem Classification . 30 Months or Less More Than 30 Months Totals Successful Closure 20 18 38 Unsuccessful Closure 3 ll 14 Totals 23 29 52 p=.040 (Fisher Exact Probability) Not Significant Table XIII shows the relation of counseling outcome, as judged by the counselor, to the duration of the problem. The duration of the problem which occasioned the referral was taken from the social worker's intake referral sheet. The obtained exact probability is statistically significant. Case success, as judged by the counselor, is inversely related to the duration of the problem. This finding refers to the conduct referral category. 77 Conduct Referral Category TABLE XIV RELATION OF THERAPY OUTCOME (AS JUDGED BY THE PARENT) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD Closure Parental Attitude Parental Attitude Totals Classification Poor Good Successful Closure 3 10 13 Unsuccessful Closure 34 5 39 Totals 37 15 52 p= Less than .001 (Fisher Exact Probability) Significant Table XIV points out that success of closure, as judged by the parent, is related to the parent's attitude toward the child. It would seem that poor parental attitude toward the child is positively related to unsuccessful case closures, as perceived by the parent. This finding refers to the conduct category. Poor parental attitude was measured by evidence of parental rejection, hostility, and marital diffi- culty. This factor was recorded if it had been given orally by the referring agent or if clinically interpreted by the counselor. 78 Conduct Referral Category TABLE XV RELATION OF THERAPY OUTCOME (AS JUDGED BY THE RESEARCHER) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD Closure Parental Attitude Parental Attitude Totals Classification Poor Good Successful Closure 0 22 22 Unsuccessful Closure 10 20 30 Tota ls 10 ' 42 52 p=.001 (Fisher Exact Probability) Significant The obtained exact probability of Table XV suggests that success of closure, as judged by the researcher, is related to the parent's attitude toward the child. Poor parental attitude toward the child, as judged by the re- searcher, is positively related to unsuccessful case closures. This finding applies to the conduct category. Poor parental attitude was measured by evidence of parental This factor rejection, hostility and marital difficulty. was recorded if it had been given orally by the referring 79 agent or if clinically interpreted by the counselor. 8O Conduct Referral Category TABLE XVI RELATION OF THERAPY OUTCOME (AS JUDGED BY THE COUNSELOR) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD Closure Parental Attitude Parental Attitude Totals Classification Poor ' Good Successful Closure 6 32 38 Unsuccessful Closure 9 5 14 Totals 15 37 52 2 x =2.069 p= Greater than .10 Not Significant Table XVI points out that success of closure, as judged by the counselor, is not related to the parent's attitude toward the child. Poor parental attitude is not significantly related to unsuccessful closures. This finding refers to the conduct category. Poor parental attitude was measured by evidence of parental rejection, hostility and marital difficulty. This factor was recorded if it had been given orally by the referring agent or if clinically interpreted by the counselor. 81 Conduct Referral Category TABLE XVII OUTCOME OF CHILD'S THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO PRESENT PARENTAL ATTITUDE TOWARD THERAPY Closure Parental Reply Parental Reply Parental Reply Classification to Question 6 to Question 7 to Question 10 No Some Great No Yes No Yes Help Help Help Successful Closure l 2 10 l 12 2 ll Unsuccessful Closure 12 21 6 18 21 13 26 Totals 13 23 16 19 33 15 37 Question Six = Assistance given to child at child guidance, in Traverse City, was of Great He1p____ Some Help____ No He1p____s Question Seven = Do you feel that you have a better under- standing of the problem, for which the child was referred, as a result of assistance received from the child guidance clinic located in Traverse City? Yes No Question Ten = Would you refer additional children who are having a behavior problem to a child guidance clinic? Yes No 82 Table XVII shows the relationship of present parental attitude toward therapy which has been conducted with their child. Question six, seven, and ten from the questionnaire were used for this purpose. Approximately 44 per cent of the parents reported that they received some help; 31 per cent stated they received no help. A better understanding of the problem was reported by 63 per cent while 37 per cent reported they were not offered a better understanding of the problem by the counselor. A total of 71 per cent of the parents stated they would refer additional children to the clinic for assistance. 83 Conduct Referral Category TABLE XVIII PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY COUNSELOR Cases Presenting New Problems Cases Reverting To Original Problem 26 14 Cases Remaining Successful In Terms Of Initial Referral Problem 12 9 Total Number of Successful Case Closures 38 23 Table XVIII points out the number of successful case closures, as judged by the counselor, where the problem has not returned and the number who have reverted to the original problem. Table XVIII also shows the number of new problems presented in each category. This table refers to conduct problems. The above information was gathered from question four (Has past problem, or problems, disappeared? Yes____ No____Partially____) and question five (Have additional behavior difficulties occUrred since child was last seen at the child guidance clinic in Traverse City? Yes___;No____ If so, state problem) of the questionnaire. Due to the fact that a successful closure is classified by the State Department of Mental Health as one showing improvement, regardless of ...—___ 84 degree or from what source, the term partially improved as used in question four is classified as a case that has remained successful. In some cases however, this classification is in error due to the fact that complete success in therapy has re- verted to partial or minimal success. Out of the thirty-eight cases closed as successful twelve, or 32 per cent, have remained successful in terms of the initial referral problem. Of the thirty-eight successful closures twenty-three are reported as having new problems. The twelve cases which remained success- ful in terms of the original problem have developed new prob- lems in nine instances. Of the twenty-six who reverted to the original problem fourteen have presented new problems. 85 Conduct Referral Category TABLE XIX PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY RESEARCHER Cases Presenting New Problems Cases Reverting To Original Problems 12 8 Cases Remaining Successful In Terms of Initial Referral Problem 10 2 Total Number of Successful Case Closures 22 10 Table XIX points out the number of successful case closures, as judged by the researcher, where the problem has not returned and the number who have reverted to the ori- ginal referral problem. Table XIX a1So shows the number of new problems presented in each category. This table refers to conduct problems. The above information was gathered from question four (Has past problem, or problems, disa- ppeared? Yes____ No____ Partially____) and question five (Have additional behavior difficulties occurred since child was last seen at the child guidance clinic in Traverse City? Yes No . If so, state problem) of the questionnaire. Due to the fact that a successful closure is classified by the State Department of Mental Health as one showing impro- vement, regardless of degree or from what source, the term 86 partially improved as used in question four is classified as a case that has remained successful. In some cases however, this classification is in error due to the fact that complete success in therapy has reverted to partial or minimal success. Of the twenty-two cases judged as successful, by the researcher, ten, or 46 per cent, have remained successful in terms of the initial referral problem. Of the twenty-two successful closures ten are reported as having new problems. The ten cases which remained successful in terms of the original problem have developed new problems in two instances. Of the twelve who reverted to the original problem eight have presented new problems. 87 Conduct Referral Category TABLE XX PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY PARENT Cases Presenting New Problems Cases Reverting To Original Problem 0 0 Cases Remaining Successful In Terms of Initial Referral Problem 13 2 Total Number of Successful Case Closures l3 2 The above table shows the number of successful case closures, as perceived by the parent, where the problem has not returned and the number who have reverted to the original referral problem. Table XX also shows the number of new pro- blems presented in each category. This table refers to con- duct problems. The above information was gathered from ques- tion four (Has past problem, or problems, disappeared? Yes No Partially ) and question five (Have addi- tional behavior difficulties occurred since child was last seen at the child guidance clinic in Traverse City? Yea____ Nq____. If so, state problem) of the questionnaire. Due to the fact that a successful closure is classified by the State Department of Mental Health as one showing improvement, 88 regardless of degree or from what source, the term partially improved as used in question four is classified as a case that has remained successful. In some cases however, this classification is in error due to the fact that complete success in therapy has reverted to partial or minimal succ- ess. Of the fifty-two conduct cases thirteen were judged as successful by the parent. In terms of the initial refer- ral problem 100 per cent of the successful closures have re- mained successful. The thirteen cases which remained success- ful in terms of the initial problem developed new problems in two instances. 89 Habit referral category. The following tables and presented comparisons are applicable only to the habit re- ferral category. They are to be interpreted in the same manner as those classified under the conduct referral category. Habit disorders are often minor and transient in character but occur at all ages. Examples of habit disorders include nail biting, thumb sucking, masturbation, and habit spasms. Habit Referral Category TABLE XXI RELATIONSHIP OF PARENT AND COUNSELOR JUDGMENT REGARDING SUCCESS OF THERAPY Parental Cases Judged Successful Cases Judged Unsuccessful Totals Judgment By Counselor By Counselor k Parent Judged Successful 5 0 5 Parent Judged Unsuccessful 9 8 17 Totals 14 8 22 P= .076 (Fisher Exact Probability) Not Significant 90 Table XXI presents parental agreement with counselor judgment. The differences found are not statistically significant. The data indicate that parental judgment is not statistically related to counselor judgment when deal- ing with habit problems. It would seem that the parent is somewhat less optimistic than the counselor regarding the outcome of therapy. 91 Habit Referral Category TABLE XXII RELATIONSHIP OF PARENT AND RESEARCHER JUDGMENT REGARDING SUCCESS OF THERAPY Parental Cases Judged Successful Cases Judged Unsuccessful Totals Judgment By Researcher By Researcher Parent Judged Successful 4 1 5 Parent Judged Unsuccessful 3 14 17 Totals 7 15 22 p=.020 (Fisher Exact Probability) Significant Table XXII presents parental agreement with researcher's judgment regarding the success of cases. The relationship is significant at the level chosen for this study. The data indicate that parental judgment is related to research judgment in regard to success of therapy. This finding refers to the habit category. 92 Habit Referral Category TABLE XXIII RELATIONSHIP OF RESEARCHER AND COUNSELOR JUDGMENT REGARDING SUCCESS OF THERAPY Researcher's Cases Judged Successful Cases Judged Unsuccess- Totals Judgment By Counselor ful By Counselor Researcher Judged Successful 7 0 7 Researcher Judged Unsuccessful 7 8 15 Totals 14 8 22 p=.019 (Fisher Exact Probability) Significant Table XXIII presents counselor agreement with researc- her's judgment regarding the success of cases. The relation- ship is significant at the level chosen for this study. The data indicate that research judgment is related to coun- selor judgment in regard to success of therapy. This finding refers to the habit category. 93 Habit Referral Category TABLE XXIV SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO AGE Closure Below Median Above Median Totals Classification Age Age Successful Closure 3 2 S Unsuccessful Closure 8 9 17 Totals 11 ll 22 p=.500 (Fisher Exact Probability) Not Significant When considering the prediction of therapy outcome, as judged by the parent, in relation to the age of the referr- ed child the obtained exact probability value of Table XXIV is of no statistical significance. This finding applies to the habit category. The median age of the children in the habit referral category was nine years and nine months. Success of counseling, as perceived by the parent, does not seem to be re- lated to the age of the child. 94 Habit Referral Category TABLE XXV SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO AGE Closure Below Median Above Median Totals Classification Age Age Successful Closure 4 3 7 Unsuccessful Closure 7 8 15 Totals 11 ll 22 p=.508 (Fisher Exact Probability) Not Significant When considering the prediction of therapy outcome, as judged by the researcher, in relation to age of referred child the obtained exact probability value of Table XXV is of no statistical significance. This finding applies to the habit category. The median age of the children in the habit referral category was nine years and nine months. Success of counseling, as perceived by the researcher, does not seem to be related to the age of the child. SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) 95 Habit Referral Category TABLE XXVI IN RELATION TO AGE Closure Below Median Above Median Totals Classification Age Age Successful Closure 7 7 14 Unsuccessful Closure 3 5 8 Totals 10 12 22 p=.448 (Fisher Exact Probability) Not Significant Success of therapy, as judged by the counselor, in relation to age of referred child is of no statistical significance. Success of counseling, as perceived by the counselor, is not related to the age of the child. This finding applies to the habit category. The median age of the children in the habit category was nine years and nine months. 96 Habit Referral Category TABLE XXVII SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO INTELLECTUAL ABILITY Closure Cases Below Cases Above Totals Classification Median I.Q. Median I.Q. Successful Closure 3 2 S Unsuccessful Closure 5 12 17 Totals 8 14 22 p=.231 (Fisher Exact Probability) Not Significant Table XXVII shows the relation of therapy outcome, as judged by the parent, to intellectual ability of the child. The obtained exact probability is of no statistical signifi- cance. This finding applies to the habit category. The data indicate that success in therapy, as perceived by the parent, is unrelated to intellectual ability of the child. The median intellectual quotient of children in the habit category was 107. Habit Referral Category TABLE XXVIII SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO INTELLECTUAL ABILITY Closure Cases Below Cases Above Totals Classification Median I.Q. Median I.Q. Successful Closure 4 3 7 Unsuccessful Closure 4 11 15 Totals 8 14 22 p=.l75 (Fisher Exact Probability) Not Significant Table XXVIII shows the relation of therapy outcome, as judged by the researcher, to intellectual ability of the child. ficance. The obtained probability is of no statistical signi- This finding applies to the habit category. The in- tellectual ability of the child is not related in this sample to the researcher's judgment of the success of therapy. The median intellectual quotient of habit cases was 107. Habit Referral Category TABLE XXIX SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO INTELLECTUAL ABILITY Closure Cases Below Cases Above Totals Classification Median I.Q. Median I.Q. Successful Closure 6 8 14 Unsuccessful Closure 3 5 8 Totals 9 13 22 p=.569 (Fisher Exact Probability) Not Significant no statistical significance. The obtained exact probability of Table XXIX is of This finding indicates there is no significant relation between success of therapy, as judged by the counselor, and intellectual ability of the child. This finding applies to the habit category. The median intellectual quotient of habit cases was 107. 99 Habit Referral Category TABLE XXX SUCCESS OF THERAPY (AS JUDGED BYTPHE PARENT) IN RELATION TO DURATION OF PROBLEM Closure Duration of Problem Totals Classification 30 Months or less More Than 30 Months Successful Closure 3 2 5 Unsuccessful Closure 3 14 17 Totals 6 16 22 p=.100 (Fisher Exact Probability) Not Significant Table XXX shows the relation of counseling outcome, as judged by the parent, to the duration of the problem. The duration of the problem which occasioned the referral was taken from the social worker's intake referral sheet. The relationships found are not statistically significant. This finding applies to the habit referral category and suggests that case success, as judged by the parent, is unrelated to the duration of the problem. 100 Habit Referral Category TABLE XXXI SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO DURATION OF PROBLEM Closure Duration of Problem Totals Classification 30 Months or Less More Than 30 Months Successful Closure 3 4 7 Unsuccessful Closure 3 12 15 Totals 6 16 22 p=.864 (Fisher Exact Probability) Not Significant The obtained probability of Table XXXI is of no statistical significance. Case success, as judged by the researcher, is not related to the duration of the problem. The duration of the problem which occasioned the referral was taken from the social worker's intake referral sheet. This finding applies to the habit referral category. 101 Habit Referral Category TABLE XXXII SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION '10 DURATION OF PROBLEM Closure Duration of Problem Totals Classification 30 Months or Less More Than 30 Months Successful Closure Unsuccessful Closure Totals 4 10 14 2 6 8 6 16 22 p=.585 (Fisher Exact Probability) Not Significant Table XXXII shows the relation of counseling outcome, as judged by the counselor, to the duration of the problem. The duration of the problem which occasioned the referral was taken from the social worker's intake referral sheet. The obtained exact probability is not significant. Case success, as judged by the counselor, is not related to the duration of the problem. This finding refers to the habit referral category. 102 Habit Referral Category TABLE XXXIII RELATION OF THERAPY OUTCOME (AS JUDGED BY THE PARENT) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD Closure Parental Attitude Parental Attitude Totals Classification Poor Good Successful Closure 2 3 5 Unsuccessful Closure 6 ll 17 Totals 8 14 22 p=.767 (Fisher Exact Probability) Not Significant Table XXXIII points out that success of closure is unrelated to the parent's attitude toward the child. This finding refers to the habit category. The relation- ships found are not statistically significant. 103 Habit Referral Category TABLE XXXIV RELATION OF THERAPY OUTCOME (AS JUDGED BY THE RESEARCHER) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD Closure Parental Attitude Parental Attitude Totals Classification Poor Good Successful Closure 1 6 7 Unsuccessful Closure 2 13 15 Totals 3 19 22 p=.755 (Fisher Exact Probability) Not Significant The obtained exact probability, of Table XXXIV sug- gests that success of closure, as judged by the researcher, is not related to the parent's attitude toward the child. Poor parental attitude, as perceived by the researcher, is not significantly related to unsuccessful closures. This was measured by evidence of parental rejection, hostility, and marital difficulty. This factor was recorded if it had been given orally by the referring agent or if clinically interpreted by the counselor. 104 Habit Referral Category TABLE XXXV RELATION OF THERAPY OUTCOME (AS JUDGED BY THE COUNSELOR) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD Closure Parental Attitude Parental Attitude Totals Classification Poor Good Successful Closure l 13 14 Unsuccessful Closure 2 6 8 Totals 3 19 22 p=.286 (Fisher Exact Probability) Not Significant Table XXXV points out that success of closure, as judged by the counselor, is not related to the parent's attitude toward the child. Poor parental attitude, as perceived by the counselor, is not significantly related to unsuccessful closures. This finding refers to the habit category. Poor parental attitude was measured by evidence of parental rejection, hostility, and marital difficulty. This factor was recorded if it had been given orally by the referring agent or if clinically interpreted by the counselor. 105 Habit Referral Category TABLE XXXVI OUTCOME OF CHILD'S THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO PRESENT PARENTAL ATTITUDE TOWARD THERAPY Parental Reply Parental Reply Parental Reply Closure Classification To Question 6 To Question 7 To Question 10 No Some Great No Yes No Yes Help Help Help ' Successful Closure 0 1 4 1 4 O 5 Unsuccessful Closure 8 6 3 8 9 1 16 Totals 8 7 7 9 13 1 21 Question Six = Assistance given to child at child guidance clinic in Traverse City, was of Great Help Some Help No Help . Question Seven = Do you feel that you have a better understand- ing of the problem, for which the child was referred, as a re- sult of assistance received from the child guidance clinic lo- cated in Traverse City? Yes No Question Ten ving a behavior problem to a child guidance clinic? Yes No = Would you refer additional children who are ha- 106 Table XXXVI shows the relationship of present parental attitude toward the therapy which was conducted with their child. Question six, seven, and ten were used from the follow-up questionnaire for this purpose. Approximately 32 per cent of the parents felt that they had received great help from the clinic; 32 per cent received some help; and 36 per cent received no help. A better understanding of the problem was reported by 59 per cent while 41 per cent stated they did not have a better understanding of the pro- blem. A total of 95 per cent felt they would refer additional children to the clinic for counseling. 107 Habit Referral Category TABLE XXXVII PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY COUNSELOR Cases Presenting New Problems Cases Reverting To Original Problem 8 0 Cases Remaining Successful In Terms Of Initial Referral Problem 6 4 Total Number of Successful Case Closures 14 Table XXXVII points out the number of successful case closures where the problem has not returned and the num- ber who have reverted to the original referral problem. Table XXXVII also shows the number of new problems presented in each category. This table refers to habit problems. The above infor- mation was gathered from question four (Has past problem, or problems, disappeared?) and question five (Have additional behavior difficulties occurred since child was last seen at the child guidance clinic in Traverse City?) of the questionn- aire. 0f the twenty-two habit cases fourteen were closed as successful by the counselor. In terms of the initial referral problem 43 per cent have remained successful. Approximately 57 per cent have reverted to the original referral problem. ‘- 108 The six cases which remained successful in terms of the original referral problem have developed new problems in four instances. ..w a..- ...—.quflo‘e: .. 109 Habit Referral Category TABLE XXXVIII PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY RESEARCHER Cases Presenting New Problems Cases Reverting To Original Problem 2 0 Cases Remaining Successful In Terms of Initial Referral Problem 5 2 7 2 Total Number of Successful Case Closures The above table shows the number of successful case closures, as judged by the researcher, where the problem has not returned and the number who have reverted to the original referral problem. Table XXXVIII also shows the number of new problems presented in each category. This table refers to habit problems. The above information was gathered from question four (Has past problem, or problems, disappeared?) and question five (Have additional behavior difficulties occurred since child was last seen at the child guidance clinic in Traverse City?) of the question- Of the twenty-two habit cases the researcher judged naire. seven as successful. Five of the seven successful closures, or 71 per cent, have remained successful. 110 Approximately 29 per cent have reverted to the original referral problem. The five cases which remained successful in terms of the original referr- al problem have developed new problems in two instan- C68. 111 Habit Referral Problem TABLE XXXIX PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY PARENT Cases Presenting New Problems Cases Reverting to Original Problem 0 0 Cases Remaining Successful In Terms of Initial Referral Problem 5 2 Total Number of Successful Case Closures 5 2 Table XXXIX points out the number of successful case closures, as judged by the parent, where the problem has not returned and the number who have reverted to the ori- ginal problem. Table XXXIX also shows the number of new problems presented in each category. This table refers to habit problems. The above information was gathered from question four (Has past problem, or problems, disappeared? Yes No Partially ) and question five (Have additional behavior difficulties occurred since child was last seen at the child guidance clinic in Traverse City? Yes No If so, state problem.) of the questionnaire. Due to the fact that a successful closure is classified by the State 112 Department of Mental Health as one showing improvement, regardless of degree or from what source, the term partially improved as used in question four is classified as a case that has remained successful. In some cases however, this classification is in error due to the fact that complete success in therapy has reverted to partial or minimal success. Of the twenty-two habit cases five were judged as successful by the parent. In terms of the initial referral problem 100 per cent of the successful closures have remained successful. The five cases which remained successful in terms of the initial referral pro- blem developed new problems in two instances. 113 Personality referral category. The following tables and presented comparisons are applicable only to the personality referral category. They are to be interpreted in the same manner as previous tables and presentations. Personality disorders, if they tend to become exaggerated, later assume the characteristics of actual mental disease signs and symptoms. Examples of personality problems, as used in this study, include shyness, fears of normal activities, seclusive states, and suicidal threats and (attempts. 114 Personality Referral Category TABLE XXXX RELATIONSHIP OF PARENT AND COUNSELOR JUDGMENT REGARDING SUCCESS OF THERAPY no-.. .- .....s-c cup—.1 Parental Cases Judged Successful Cases Judged Unsuccess- Totals Judgment By Counselor ful By Counselor Parent Judged Successful 33 4 37 Parent Judged Unsuccessful 27 16 43 Totals 60 20 80 p=.005 (Fisher Exact Probability) Significant Table XXXX presents parental agreement with research judgment regarding the success of cases. The findings are significant at the level chosen for this study. The data indicate that parental judgment is related to counselor judgment in regard to success of therapy. This finding refers to the personality category. 115 Personality Referral Category TABLE XXXXI RELATIONSHIP OF PARENT AND RESEARCHER JUDGMENT REGARDING SUCCESS OF THERAPY Parental Cases Judged Successful Cases Judged Unsuccess- Totals Judgment By Researcher ful By Researcher Parent Judged Successful 26 11 37 Parent Judged Unsuccessful 11 32 43 Totals 37 43 80 x2= 1.936 p= Greater than .10 Not Significant Table XXXXI presents parental agreement with res- earcher's judgment regarding the success of cases. The findings are not significant at the level chosen for this study. The data indicate that parental judgment is unre- lated to research judgment in regard to success of therapy. This finding refers to the personality category. 116 Personality Referral Category TABLE XXXXII RELATIONSHIP OF RESEARCHER AND COUNSELOR JUDGMENT REGARDING SUCCESS OF THERAPY Researcher's Cases Judged Successful Cases Judged Unsuccess- Totals Judgment By Counselor ful By Counselor Researcher Judged Successful 36 l 37 Researcher Judged Unsuccessful 24 19 43 Totals 60 20 80 p= Less than .001 (Fisher Exact Probability) Significant Table XXXXII presents researcher's and counselor's judgment regarding the success of cases. The relationship is significant at the level chosen for this study. The data indicate that research judgment is related to counselor judg- ment in regard to success of therapy. This finding refers to the personality category. 117 Personality Referral Category TABLE XXXXIII SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO AGE . Closure Below Median Above Median Totals Classification Age Age Successful Closure l8 19 37 Unsuccessful Closure 22 21 43 Totals 40 40 80 x2=1.160 p= Greater than .20 Not Significant When considering the prediction of therapy outcome, as judged by the parent, in relation tot:he age of the referred child the researcher finds the obtained chi-square value of no statistical significance. This finding app- lies to the personality category. The median age of child- ren in the personality category was eight years and two months. 118 Personality Referral Category TABLE XXXXIV SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO AGE Closure Below Median Above Median Totals Classification Age Age Successful Closure 20 17 37 Unsuccessful Closure 18 25 43 Totals 38 42 8O x2=.757 p= Greater than .30 Not Significant Success of therapy, as judged by the researcher, in relation to age of referred child is of no statistical sig- nificance. This finding applies to the personality category. Success of counseling, as viewed by the researcher, is not related to the age of the child. The median age of the chil- dren in the personality category was eight years and two months. 119 Personality Referral Category TABLE XXXXV SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO ACE Closure Below Median Above Median Totals Classification Age Age Successful Closure 29 31 6O Unsuccessful Closure 6 14 20 Totals 35 45 80 x2=1.376 p= Greater than .20 Not Significant When considering the outcome of therapy, as judged by the counselor, in relation to age of referred child the ob- tained exact probability is of no statistical significance. This finding applies to the personality category. Success of counseling, as perceived by the counselor, is not related to the age of the child. The median age of the children in the personality referral category was eight years and two months. 120 Personality Referral Category TABLE XXXXVI SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO INTELLECTUAL ABILITY Closure Cases Below Cases Above Totals Classification Median I.Q. Median I.Q. Successful Closure 15 22 37 Unsuccessful Closure 24 19 43 Totals 39 41 80 x2=.895 p= Greater than .30 Not Significant Table XXXXVI presents the relation of therapy outcome, as judged by the parent, to intellectual ability of the child. The obtained chi-square value is of no statistical significance. This finding applies to the personality category. The findings indicate that intellectual ability is unrelated to success in therapy as judged by the parent. The median intellectual quo- tient of the personality category was 107. 121 Personality Referral Category TABLE XXXXVII SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO INTELLECTUAL ABILITY Closure Cases Below Cases Above Totals Classification Median I.Q. Median I.Q. Successful Closure 19 18 37 Unsuccessful Closure 20 23 43 Totals 39 41 80 x2=.043 p= Greater than .80 Not Significant Table XXXXVII illustrates the relation of therapy outcome, as judged by the researcher, to intellectual ability of the child. The obtained probability is of no statistical significance. This finding applies to the personality cate- gory. The intellectual ability of the children in this sample is not related to the researcher's judgment of success in ther- apy. The median intellectual quotient of personality cases was 107. 122 Personality Referral Category TABLE XXXXVIII SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO INTELLECTUAL ABILITY Closure Cases Below Cases Above Totals Classification Median I.Q. Median I.Q. Successful Closure 25 35 60 Unsuccessful Closure l4 6 20 Totals 39 41 80 x2=3.752 p= Greater than .05 Not Significant The obtained exact probability of Table XXXXVIII is of no statistical significance. This finding indicates there is no significant relationship between success of therapy, as judged by the counselor, and intellectual ability of the child. This finding applies to the person- ality category. The median intellectual quotient of person- ality cases was 107. 123 Personality Referral Category TABLE XXXXIX SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO DURATION OF PROBLEM Closure Duration of Classification 30 Months or Less Problem Totals More Than 30 Months ' Successful Closure 31 Unsuccessful Closure 11 Totals 42 x2= 2.476 p= Greater than .10 Not Significant 6 37 32 43 38 80 Table XXXXIX shows the relation of counseling outcome to the duration of the problem. The duration of the problem which occasioned the referral was taken fromthe social worker's intake referral sheet. not statistically significant. The differences found are This finding applies to the personality category and suggests that case success, as judged by the parent, is unrelated to the duration of the problem. 124 Personality Referral Category TABLE'L SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO DURATION OF PROBLEM Closure Duration of Problem Totals Classification 30 Months or Less More Than 30 Months Successful Closure 30 7 37 Unsuccessful Closure 12 31 43 Totals 42 38 80 x2= 20.467 p= Less than .01 Significant The obtained probability of Table L is statistically significant. Case success, as judged by the researcher, is significantly related in this sample to the duration of the problem so that children who had a problem for more than thirty months are less apt to be helped by therapy. The dur- ation of the problem which occasioned the referral was taken from the social worker‘s intake referral sheet. This finding applies to the personality category. 125 Personality Referral Category TABLE LI SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO DURATION OF PROBLEM Closure Duration of Problem Totals Classification 30 Months or Less More Than 30 Months Successful Closure 35 25 60 Unsuccessful Closure 7 13 20 Totals 42 38 8O 2 X = 2.406 p= Greater than .10 Not Significant Table LI shows the relation of counseling outcome, as judged by the counselor, to the duration of the problem. The duration of the problem which occasioned the referral was taken from the social worker's intake referral sheet. The obtained exact probability is insignificant. success, as judged by the counselor, is not significantly related to the duration of the problem. fers to the personality category. This finding re- 126 Personality Referral Category TABLE LII RELATION OF THERAPY OUTCOME (AS JUDGED BY THE PARENT) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD Closure Parental Attitude Parental Attitude Totals Classification Poor Good Successful Closure 10 27 37 Unsuccessful Closure 31 12 43 Totals 41 39 80 x2= 1.441 p= Greater than .20 Not Significant Table LII points out that success of closure, as judged by the parent, is unrelated to the parent's attitude toward the child. This finding refers to the personality category. The relationships found are not statistically significant. 127 Personality Referral Category TABLE LIII RELATION OF THERAPY OUTCOME (AS JUDGED BY THE RESEARCHER) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD Closure Parental Attitude Parental Attitude Totals Classification Poor Good Successful Closure 2 35 37 Unsuccessful Closure 39 4 43 Totals 41 39 8O p= Less than .001 (Fisher Exact Probability) Significant Table LIII points out that success of closure, as judged by the researcher, is significantly related to the parent's attitude toward the child. It would seem that poor parental attitude toward the child is positively re- lated to unsuccessful case closures as perceived by the researcher. This finding refers to the personality cate- gory. Poor parental attitude was measured by evidence of parental rejection, hostility, and marital difficulty. This factor was recorded if it had been given orally by the refer- ring agent or if clinically interpreted by the counselor. 128 Personality Referral Category TABLE LIV RELATION OF THERAPY OUTCOME (AS JUDGED BY THE COUNSELOR) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD Closure Parental Attitude Parental Attitude Totals Classification Poor Good Successful Closure l 59 6O Unsuccessful Closure 4 16 20 Totals 5 75 8O p= .012 (Fisher Exact Probability) Significant Table LIV points out that success of closure, as judged by the counselor, is significantly related to the parent's attitude toward the child. Poor parental attitude is signifi- cantly and positively related to unsuccessful closures. This finding refers to the personality category. Poor parental atti- tude was measured by evidence of parental rejection, hostility, and marital difficulty. This factor was recorded if it had been given orally by the referring agent or if clinically int- erpreted by the counselor. 129 Personality Referral Category TABLE LV OUTCOME OF CHILD'S THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO PRESENT PARENTAL ATTITUDE TOWARD THERAPY Closure Parental Reply Parental Reply Parental Reply Classification To Question 6 To Question 7 To Question 10 No Some Great No Yes No Yes Help Help Help Successful Closure O 12 25 12 25 10 37 Unsuccessful Closure 17 22 4 23 20 14 29 Totals 17 34 29 35 45 14 66 Question Six = Assistance given to child at child guidance clinic, in Traverse City, was of Great Help Some Help No Help , Question Seven = Do you feel that you have a better understan- ding of the problem, for which the child was referred, as a result of assistance received from the child guidance clinic located at Traverse City? Yes No Question Ten = Would you refer additional children who are having a behavior problem to a child guidance clinic? Yes No 130 Table LV shows the relationship of present parental attitude toward therapy which has been conducted with their child. Questions six, seven, and ten were used from the follow-up questionnaire for this purpose. Approximately 36 per cent of the parents felt that they had received great help from the clinic; 43 per cent received some help; and 21 per cent received no help. A better understanding of the problem was reported by 56 per cent of the parents. It is interesting to note that regardless of how much help was given to the child, both in understanding the problem and diminishing the symptoms of the problem, 82 per cent of the parents stated they would refer additional children to the clinic for counseling. 131 Personality Referral Category TABLE LVI PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY COUNSELOR Cases Presenting New Problems Cases Reverting To Original Problem 27 8 Cases Remaining Successful In Terms of Initial Referral Problem 33 5 60 13 Total Number of Successful Case Closures Table LVI points out the number of successful case clo- sures where the problem has not returned and the number who have reverted to the original referral problem. Table LVI also shows the number of new problems presented in each cate- gory. This table refers to personality problems. The above information was gathered from question four (Has past problem, or problems, disappeared?) and question five (Have additional behavior difficulties occurred since child was last seen at the child guidance clinic in Traverse City?) of the questionnaire. Of the eighty personality cases sixty were closed as successful by the counselor. In terms of the original referral problem 55 per cent of the successful closures have remained successful. Approximately 45 per cent have reverted to the original referral 132 problem. The twenty-seven cases reverting to the initial re- ferral problem developed new problems in eight instances. The thirty-three cases which remained successful in terms of the initial referral problem developed new problems in five instances. 133 Personality Referral Category TABLE LVII PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY RESEARCHER Cases Presenting New Problems Cases Reverting To Original Problem 9 1 Cases Remaining successful In Terms Of Initial Referral Problem 28 2 Total Number of Successful Case Closures 37 3 The above table shows the number of successful case closures, as judged by the researcher, where the problem has not returned and the number who have reverted to the original referral problem. Table LVII also shows the number of new problems presented in each category. This table refers to personality problems. The above information was gathered from question four (Has past problem, or problems, disappeared? Yes No Partially ) and question five (Have addition- al behavior difficulties occurred since child was last seen at the child guidance clinic in Traverse City? Yes No If so, state problem) of the questionnaire. Due to the fact that a successful closure is classified by the State Department of Mental Health as one showing improvement, regardless of 134 degree or from what source, the term partially improved as used in question four is classified as a case that has remained successful. In some cases however, this classification is in error due to the fact that complete success in therapy has reverted to partial or minimal success. Of the eighty person- ality cases thirty-seven were judged, by the researcher, as successful. In terms of the initial referral problem twenty- eight, or 76 per cent, of the successful closures have rem- ained successful. Approximately twenty-four per cent have reverted to the original referral problem. The nine cases reverting to the initial referral problem developed new problems in only one instance. The twenty-eight cases which remained successful in terms of the initial referral problem developed new problems in two instances. 135 Personality Referral Category TABLE LVIII PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY PARENTS Cases‘Presenting New Problems Cases Reverting To Original Problem 1 0 Cases Remaining Successful In Terms of Initial Referral Problem 36 5 Total Number of Successful Case Closures 37 5 Table LVIII points out the number of successful case closures, as judged by the parent, where the problem has not returned and the number who have reverted to the original referral problem. Table LVIII also shows the number of new problems presented in each category. This table refers to personality problems. The above informa- tion was gathered from question four (Has past problem, or problems, disappeared? Yes No Partially____) and question five (Have additional behavior difficulties occurred since child was last seen at the child guidance clinic in Traverse City? Yes____ No____. If so, state problem.) of the questionnaire. Due to the fact that a 136 successful closure is classified by the State Department of Mental Health as one showing improvement, regardless of degree or from what source, the term partially improved as used in question four is classified as a case that has remained successful. In some cases however, this classi- fication is in error due to the fact that complete suc- cess in therapy has reverted to partial or minimal success. Of the eighty personality cases thirty-seven were judged as successful by the parent. In terms of the initial referral problem thirty-six, or 97 per cent, of the successful closures have remained successful. Only one case reverted to the origi- nal referral problem. Of the thirty-six cases which remained successful five developed new problems. 137 Learning and developmental referral category. The following tables and presented comparisons are applicable only to the learning and developmental referral category. They are to be interpreted in the same manner as previous tables and presentations. Learning and developmental pro- blems are particularly prevalent during the ages four through ten. They are usually associated with school problems but may include delayed maturational problems of speech, walking, and coordination. Examples of learning and developmental problems, as used in this study, include: poor schoolwork, developmental patterns below age expectancy, and problems associated with dull normal or borderline intelligence. 138 Learning and Developmental Category TABLE LIX RELATIONSHIP OF PARENT AND COUNSELOR JUDGMENT REGARDING SUCCESS OF THERAPY Parental Cases Judged Successful Cases Judged Unsuccess- Totals Judgment By Counselor ful By Counselor Parent Judged Successful 7 1 8 Parent Judged Unsuccessful 14 8 22 Totals 21 9 3O p=.179 (Fisher Exact Probability) Not Significant Table LIX presents parental agreement with counselor judgment. The differences found are not statistically significant. The data indicate that parental judgment is unrelated to counselor judgment when dealing with learning and developmental problems. It would seem that the parent is somewhat less optimistic than is the coun- selor regarding the success of cases. 139 Learning and Developmental Category TABLE LX RELATIONSHIP OF PARENT AND RESEARCHER JUDGMENT REGARDING SUCCESS OF THERAPY Parental Cases Judged Successful Cases Judged Unsuccess- Totals Judgment By Researcher ful By Researcher Parent Judged Successful 7 l 8 Parent Judged Unsuccessful 3 19 22 Totals 10 20 30 p=.004 (Fisher Exact Probability) Significant Table LX presents parental agreement with researcher's judgment regarding the success of cases. The findings are significant at the level chosen for this study. The findings indicate that parental judgment is related to researcher's judgment in regard to success of therapy. This finding app- lies to the learning and developmental category. 140 Learning and Developmental Category TABLE LXI RELATIONSHIP OF RESEARCHER AND COUNSELOR JUDGMENT REGARDING SUCCESS OF THERAPY Researcher's Cases Judged Successful Cases Judged Unsuccess- Totals Judgment By Counselor ful By Counselor Researcher Judged Successful 9 1 10 Researcher Judged Unsuccessful 12 8 20 Totals 21 9 30 p=.089 (Fisher Exact Probability) Not Significant Table LXI presents researcher's and counselor's judg- ment regarding the success of cases. The findings are not significant at the level chosen for this study. The data indi- cate that research judgment is not significantly related to counselor judgment in regard to success of therapy. This find- ing refers to the learning and developmental category. 141 Learning and Developmental Category TABLE LXII SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO AGE Closure Below Median Above Median Totals Classification Age Age Successful Closure 5 3 8 Unsuccessful Closure 10 12 22 Totals 15 15 30 p=.34l (Fisher Exact Probability) Not Significant When considering the prediction of therapy outcome, as judged by the parent, in relation to age of referred child, the researcher finds the obtained exact probability of no statistical significance. This finding applies to the learn- ing and developmental category. Age does not seem to be re- lated to success of therapy, as judged by the parent. The median age of children in the learning and developmental category was nine years and two months. 142 Learning and Developmental Category TABLE LXIII SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO AGE Closure Below Median Above Median Totals Classification Age Age Successful Closure 7 3 10 Unsuccessful Closure 10 10 20 Totals 17 13 30 p=.267 (Fisher Exact Probability) Not Significant Success of therapy, as judged by the researcher, in relation to age of referred child is of no statistical significance. This finding applies to the learning and de- velopmental category. Success of therapy, as viewed by the researcher, is not significantly related to the age of the child. The median age of the children in the learning and developmental category was nine years and two months. 143 Learning and Developmental Category TABLE LXIV SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO ACE Closure Below Median Above Median Totals Classification Age Age Successful Closure 10 ll 21 Unsuccessful Closure 6 3 9 Totals 16 14 3O P= .271 (Fisher Exact Probability) Not Significant When considering the outcome of therapy, as judged by the counselor, in relation to age of referred child the obtained probability level is of no statistical significance. This finding applies to the learning and developmental cate- gory. Success of counseling, as perceived by the counselor, is not related to the age of the child. The median age of the children in the learning and developmental category was nine years and two months. 144 Learning and Developmental Category TABLE LXV SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO INTELLECTUAL ABILITY Closure ' Cases Below Cases Above Totals Classification Median I.Q. Median I.Q. Successful Closure 1 7 8 Unsuccessful Closure 15 7 22 Totals l6 14 3O p=.009 (Fisher Exact Probability) Significant Table LXV illustrates the relation of therapy outcome to intellectual ability of the child. The obtained exact pro- bability is of statistical significance. This finding applies to the learning and developmental category. The findings in- dicate that intellectual ability of the child is related to success in therapy as judged by the parent. The median int- ellectual quotient for this sample was 106. The brighter child is more apt to have his therapy judged successful by his parent than is the duller child. 145 Learning and Developmental Category TABLE XLVI SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO INTELLECTUAL ABILITY Closure Cases Below Cases Above Totals Classification Median I.Q. Median I.Q. Successful Closure 2 8 10 Unsuccessful Closure l4 6 20 Totals l6 14 3O p=.012 (Fisher Exact Probability) Significant Table LXVI illustrates the relation of therapy outcome as judged by the researcher, to intellectual ability of the child. The obtained probability is of statistical significance. This finding applies to the learning and developmental cate- gory. The intellectual ability of the child in this sample is positively related to the researcher's judgment of succ- ess in therapy. The median intellectual quotient of learn- ing and develOpmental cases was 106. 146 Learning and Developmental Category TABLE LXVII SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO INTELLECTUAL ABILITY Closure Cases Below Gases Above Totals Classification Median I.Q. Median I.Q. Successful Closure 8 13 21 Unsuccessful Closure 6 3 9 Totals 14 16 3O p=.035 (Fisher Exact Probability) Significant The obtained exact probability level of Table LXVII is of statistical significance. This finding indicates there is a significant and positive relationship between success of therapy, as judged by the counselor, and intell- ectual ability of the child. This finding applies to the learning and developmental category. The median intell- ectual quotient of the learning and developmental cate- gory was 106. 147 Learning and Developmental Category TABLE LXVIII SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO DURATION OF PROBLEM Closure Duration of Problem Classification 30 Months or Less More Than 30 Months Totals Successful Closure 7 1 8 Unsuccessful Closure 6 16 22 Totals 13 17 3O p=.005 (Fisher Exact Probability) Significant Table LXVIII shows the relation of counseling outcome to the duration of the problem. The duration of the problem which occasioned the referral was taken from the social work- er's intake referral sheet. The differences found are stat- istically significant. This finding applies to the learning and developmental category and suggests that case success, as perceived by the parent, is related inversely to the duration of the problem. 148 Learning and Developmental Category TABLE LXIX SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO DURATION OF PROBLEM Closure Duration of Problem Classification 30 Months or Less More Than 30 Months Totals Successful Closure 9 1 10 Unsuccessful Closure 4 16 20 Totals 13 17 30 p= Less than .001 (Fisher Exact Probability) Significant. The obtained probability-of Table LXIX is of statistical significance. Case success, as judged by the researcher, is related inversely in this sample to the duration of the problem. The duration of the problem which occasioned the referral was taken from the social worker's intake referral sheet. the learning and developmental category. This finding applies to 149 Learning and Developmental Category TABLE LXX SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO DURATION OF PROBLEM Closure Duration of Problem Totals Classification 30 Months or Less More Than 30 Months Successful Closure 10 11 21 Unsuccessful Closure 3 6 9 Totals l3 17 30 p=.502 (Fisher Exact Probability) Not Significant Table LXX shows the relation of counseling outcome, as judged by the counselor, to the duration of the problem. The duration of the problem which occasioned the referral was taken from the social worker's intake referral sheet. The obtained exact probability is not significant. Case success, as judged by the counselor, is not related in this sample to the duration of the problem. This finding refers to the learning and developmental category. 150 Learning and Developmental Category TABLE LXXI RELATION OF THERAPY OUTCOME (AS JUDGED BY THE PARENT) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD Closure Parental Attitude Parental Attitude Totals Classification Poor Good Successful Closure l 7 8 Unsuccessful Closure l3 9 22 Totals l4 16 30 p=.03 (Fisher Exact Probability) Significant Table LXXI points out that success of closure is related to the parent's attitude toward the child. This finding applies to the learning and developmental category. Poor parental attitude toward the child is positively related to unsuccessful case closures. 151 Learning and Developmental Category TABLE LXXII RELATION OF THERAPY OUTCOME (AS JUDGED BY THE RESEARCHER) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD Closure Parental Attitude Parental Attitude Totals Classification Poor Good Successful Closure O 10 10 Unsuccessful Closure O 20 20 Totals 0 30 30 p=1.00 (Fisher Exact Probability) Not Significant Table LXXII suggests that success of closure, as judged by the researcher, is not related to the parent's attitude toward the child. This finding refers to the learning and developmental category. Poor parental atti- tude was measured by evidence of parental rejection, host- ility, and marital difficulty. This factor was recorded if it had been given orally by the referring agent or if clinically interpreted by the counselor. 152 Learning and Developmental Category TABLE LXXIII RELATION OF THERAPY OUTCOME (AS JUDGED BY THE COUNSELOR) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD Closure Parental Attitude Parental Attitude Totals Classification Poor Good Successful Closure O 21 21 Unsuccessful Closure O 9 9 Totals 0 3O 3O p=l.00 (Fisher Exact Probability) Not Significant Table LXXIII suggests that success of closure, as judged by the counselor, is not related to the parent's attitude toward the child. This finding refers to the learning and developmental category. Poor parental atti- tude was measured by evidence of parental rejection, host- ility, and marital difficulty. This factor was recorded if it had been given orally by the referring agent or if clinically interpreted by the counselor. 153 Learning and Developmental Category TABLE LXXIV OUTCOME OF CHILD'S THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO PRESENT PARENTAL ATTITUDE TOWARD THERAPY Closure . Parental Reply Parental Reply Parental Reply Classification To Question 6 To Question 7 To Question 10 No Some Great No Yes No Yes Help Help Help Successful Closure O 2 6 5 3 O 8 Unsuccessful Closure 8 12 2 l4 8 4 18 Totals 8 14 8 19 ll 4 26 Question Six = Assistance given to child at child guidance clinic, in Traverse City, was of Great Help____ Some Help____ No Help____. Question Seven = Do you feel that you have a better under- standing of the problem, for which the child was referred, as a result of assistance received from the child guidance clinic located in Traverse City? Yes No Question Ten a Would you refer additional children who are hav- ing a behavior problem to a child guidance clinic? Yes No 154 Table LXXIV shows the relationship of present parental attitude toward therapy which has been conducted with their child. Questions six, seven, and ten were used from the follow-up questionnaire for this purpose. Approximately 27 per cent of the parents felt that they had received great help from the clinic; 46 per cent received some help; and 27 per cent felt that they had received no assistance. A better understanding of the problem was reported by 37 per cent of the parents while 63 per cent did not feel that they had received assistance in understanding the child's problem at time of closure. Approximately 87 per cent stated they would refer additional children to the clinic. 155 Learning and Developmental Category TABLE LXXV PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY COUNSELOR New Problems Presented Cases Reverting To Original Problem 12 2 Cases Remaining Successful In terms of Initial Referral Problem 9 2 Total Number of Successful Case Closures 21 4 Table LXXV points out the number of successful case closures where the problem has not returned and the number who have reverted to the original referral problem. Table LXXV also shows the number of new problems presented in each category. This table refers to learning and develop- mental problems. The above information was gathered from question four (Has past problem, or problems, disappeared?) and question five (Have additional behavior difficulties occurred since child was last seen at the child guidance clinic in Traverse City?) of the questionnaire. Of the thirty cases twenty-one were closed as successful by the counselor. In terms of the original problem 43 per cent have remained successful. Approximately 57 per cent have 156 reverted to the original referral problem. Two children in each category have presented new problems. 157 Learning and Levelopmental Problems TABLE LXXVI PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY RESEARCHER Cases Presenting New Problems Cases Reverting To Original Problem 2 0 Cases Remaining Successful In Terms of Initial Referral Problem 8 2 Total Number of Successful Case Closures 10 2 The above table shows the number of successful case closures, as judged by the researcher, where the problem has not returned and the number who have reverted to the original referral problem. Table LXXVI also shows the num- ber of new problems presented in each category. This table refers to learning and developmental problems. The above information was gathered from question four (Has past pro- blem, or problems, disappeared? Yes_____No_____Partially;___,) and question five (Have additional behavior difficulties occurred since child was last seen at the child guidance clinic in Traverse City? Yes_____Nq____. If so, state problem) of the questionnaire. Due to the fact that a 158 successful closure is classified by the State Department of Mental Health as one showing improvement, regardless of degree or from what source, the term partially improved as used in question four is classified as a case that has remained successful. In some cases however, this class- ification is in error due to the fact that complete success in therapy has reverted to partial or minimal success. Of the thirty cases in the learning and develop- mental category ten were judged as successful by the researcher. In terms of the initial referral problem eight, or 80 per cent, have remained successful. Approx- imately 20 per cent have reverted to the original referral problem. The eight cases which remained successful in terms of the initial referral problem developed new pro- blems in two instances. 159 Learning and Developmental Category TABLE LXXVII PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY PARENT Cases Presenting New Problems Cases Reverting To Original Problem 0 0 Cases Remaining Successful In Terms of Initial Referral Problem 8 1 Total Number of Successful Case Closures 8 1 Table LXXVII points out the number of successful case closures, as judged by the parent, where the problem has not returned and the number who have reverted to the original referral problem. Table LXXVII also shows the number of new problems presented in each category. This table refers to learning and developmental problems. The above information was gathered from question four (Has past problem, or problems, disappeared? Yes____ No____ Partially;___) and question five (Have additional behavior difficulties oc- curred since child was last seen at the child guidance cli- nic in Traverse City? Yes____ No____. If so, state problem) of the questionnaire. Due to the fact that a successful clo- sure is classified by the State Department of Mental Health 160 as one showing improvement, regardless of degree or from what source, the term partially improved as used in ques- tion four is classified as a case that has remained succ- essful. In some cases however, this classification is in error due to the fact that complete success in therapy has reverted to partial or minimal success. Of the thirty learning and developmental cases eight were judged as suc- cessful by the parent. In terms of the initial referral problem all of the successful closures remained successful. The eight cases which remained successful in terms of the in- itial referral problem developed new problems in only one instance. 161 Functional illness referral category. 'The following tables and presented comparisons are applicable to the functional illness category. They are to be interpreted in the same manner as previous tables and presentations. A functional illness problem is a behavior disorder which takes on the characteristic of a physical condition, even though there is no direct relation between the two. Examples of functional illness problems, as used in this study, include headaches, skin disorders, vomiting, faint- ing, and convulsions. 162 Functional Illness Category TABLE LXXVIII RELATIONSHIP OF PARENT AND COUNSELOR JUDGMENT REGARDING SUCCESS OF THERAPY Parental Cases Judged Successful Cases Judged Unsuccess- Totals Judgment By Counselor ful By Counselor Parent Judged Successful 15 1 16 Parent Judged Unsuccessful 8 7 15 Totals 23 8 31 p= .01 (Fisher Exact Probability) Significant Table LXXVIII presents parental agreement with coun- selor judgment. The findings are significant at the level chosen for this study. The findings indicate that parental judgment is related to counselor judgment in regard to suc- cess of therapy with cases in the functional illness category. 163 Functional Illness Category TABLE LXXIX RELATIONSHIP OF PARENT AND RESEARCHER JUDGMENT REGARDING SUCCESS OF THERAPY Parental Cases Judged Successful Cases Judged Unsuccess- Totals Judgment By Researcher ful By Researcher Parent Judged Successful 15 1 16 Parent Judged Unsuccessful O 15 15 Totals 15 16 31 p= .01 (Fisher Exact Probability) Significant Table LXXIX presents parental agreement with resear- cher's judgment regarding the success of cases. The rela- tionship is significant at the level chosen for this study. The findings indicate that parental judgment is related to researcher judgment when dealing with functional illness problems. 164 Functional Illness Category TABLE LXXX RELATIONSHIP OF RESEARCHER AND COUNSELOR JUDGMENT REGARDING SUCCESS OF THERAPY Researcher Cases Judged Successful Cases Judged Unsuccess- Totals Judgment By Counselor ful By Counselor Researcher Judged Successful 14 1 15 Researcher Judged Unsuccessful 9 7 16 Totals 23 8 31 p= .002 (Fisher Exact Probability) Significant Table LXXX presents researcher's and counselor's judgment regarding the success of cases. The relationship is significant at the level chosen for this study. The data indicate that research judgment is related to counselor judgment in regard to success of therapy. This finding refers to the functional illness category. 165 Functional Illness Category TABLE LXXXI SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO AGE Closure Below Median Above Median Totals Classification Age Age Successful Closure 10 6 l6 Unsuccessful Closure 5 10 15 Totals 15 16 31 x2= 2.092 p= Greater than .10 Not Significant When considering the prediction of therapy outcome, as judged by the parent, in relation to age of referred child the researcher finds the obtained chi-square value of no statistical significance. This finding applies to the functional illness category. The age of the child does not seem to be related to success of therapy as perceived by the parent. The median age of the children in the func- tional illness category was nine years and nine months. 166 Functional Illness Category TABLE LXXXII SUCCESS OF THERAPY ( AS JUDGED BY THE RESEARCHER) IN RELATION TO AGE Closure Below Median Above Median Totals Classification Age , Age Successful Closure l3 2 15 Unsuccessful Closure 6 10 16 Totals 19 12 31 p= .006 (Fisher Exact Probability) Significant Success of therapy, as judged by the researcher, in relation to age of referred child is statistically significant. This finding applies to the functional ill- ness category. Success of counseling, as viewed by the researcher, is negatively related to the age of the child. The median age of the children in the functional illness category was nine years and nine months. 167 Functional Illness Category TABLE LXXXIII SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO AGE Closure Below'Median Above Median Totals Classification Age Age Successful Closure l6 7 23 Unsuccessful Closure 2 6 8 Totals 18 13 31 p= .036 (Fisher Exact Probability) Significant When considering the outcome of therapy, as judged by the counselor, in relation to age of referred child the obtained exact probability is statistically significant. This finding applies to the functional illness category. Success of counseling, as perceived by the counselor, is negatively related in this sample to the age of the child. The median age of the children in the functional illness category was nine years and nine months. 168 Functional Illness Category TABLE LXXXIV SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO INTELLECTUAL ABILITY Closure Cases Below Cases Above Totals Classification Median I.Q. Median I.Q. Successful Closure 5 11 16 Unsuccessful Closure 8 7 15 Totals 13 18 31 x2= .736 p= Greater than .30 Not Significant Table LXXXIV shows the relation of therapy outcome to intellectual ability of the child. The ob- tained chi-square value is of no statistical significance. This finding applies to the functional illness category. The data indicate that intellectual ability of the child is unrelated to success in therapy as judged by the parent. The median intellectual quotient of children in the functional illness category was 103. 169 Functional Illness Category TABLE LXXXV SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO INTELLECTUAL ABILITY Closure Cases Below Cases Above Totals Classification Median I.Q. Median I.Q. Successful Closure 5 10 15 Unsuccessful Closure 5 11 16 Totals 10 21 ' 31 p= .074 (Fisher Exact Probability) Not Significant Table LXXXV shows the relation of therapy outcome, as judged by the researcher, to intellectual ability of the child. The obtained probability is of no statistical significance. This finding applies to the functional ill- ness category. The intellectual ability of the children in this sample is not related to the researcher's judgment of success in therapy. The median intellectual quotient of children in the functional illness category was 103. 170 Functional Illness Category TABLE LXXXVI SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO INTELLECTUAL ABILITY Closure Cases Below Cases Above Totals Classification Median I.Q. Median I.Q. Successful Closure 7 16 23 Unsuccessful Closure 3 5 8 Totals 10 21 31 p= .742 (Fisher Exact Probability) Not Significant The obtained exact probability of Table LXXXVI is of no statistical significance. This finding indicates there is no significant relationship between success of therapy, as judged by the counselor, and intellectual ab- ility of the child. This finding applies to the functional illness category. The median intellectual quotient of chil- dren in the functional illness category was 103. 171 Functional Illness Category TABLE LXXXVII SUCCESS OF THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO DURATION OF PROBLEM Closure Duration of Problem Totals Classification 30 Months or Less More Than 30 Months Successful Closure 12 4 16 Unsuccessful Closure 5 V 10 15 Totals 17 14 31 p= .024 (Fisher Exact Probability) Significant Table LXXXVII shows the relation of counseling out- come to the duration of the problem. The duration of the problem which occasioned the referral was taken from the social worker's intake referral sheet. The relationships found are statistically significant. This finding applies to the functional illness category and suggests that case success, as judged by the parent, is inversely related to the duration of the problem. 172 Functional Illness Category TABLE LXXXVIII SUCCESS OF THERAPY (AS JUDGED BY THE RESEARCHER) IN RELATION TO DURATION OF PROBLEM Closure Duration of Problem Totals Classification 30 Months or Less More Than 30 Months Successful Closure 15 0 15 Unsuccessful Closure 2 - l4 16 Totals 17 14 31 p= Less than .001 (Fisher Exact Probability) Significant The obtained probability of Table LXXXVIII is of statistical significance. Case success, as judged by the researcher, is inversely related in this sample to the du- ration of the problem. The duration of the problem which occasioned the referral was taken from the social worker's intake referral sheet. This finding applies to the func- tional illness category. 173 Functional Illness Category TABLE LXXXIX SUCCESS OF THERAPY (AS JUDGED BY THE COUNSELOR) IN RELATION TO DURATION OF PROBLEM Closure Duration of Problem Totals Classification 30 Months or Less More Than 30 Months Successful Closure ll 12 23 Unsuccessful Closure 6 2 8 Totals 17 14 31 p= .177 (Fisher Exact Probability) Not Significant Table LXXXIX shows the relation of counseling out- come, as judged by the counselor, to the duration of the problem. The duration of the problem which occasioned the referral was taken from the social worker's intake referral sheet. The obtained exact probability is not significant. Case success, as judged by the counselor, is not related to the duration of the problem. This finding refers to the functional illness category. 174 TABLE XC RELATION OF THERAPY OUTCOME (AS JUDGED BY THE PARENT) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD Closure Parental Attitude Parental Attitude Totals Classification Poor Good Successful Closure 4 12 16 Unsuccessful Closure 9 6 15 Totals 13 18 31 p= .043 (Fisher Exact Probability) Significant Table XC points out that success of closure, as per- ceived by the parent, is related to the parent's attitude toward the child. This finding applies to the functional illness category. It would seem that poor parental atti- tude toward the child is positively related to unsuccessful case closure as judged by the parent. 175 Functional Illness Category TABLE XCI RELATION OF THERAPY OUTCOME (AS JUDGED BY THE RESEARCHER) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD Closure Parental Attitude Parental Attitude Totals Classification Poor Good Successful Closure l 14 15 Unsuccessful Closure l 15 16 Totals 2 29 31 p= 1.326 (Fisher Exact Probability) Not Significant Table XCI points out that success of closure, as judged by the researcher, is not significantly related to the parent's attitude toward the child.' This finding applies to the func- tional illness category. Poor parental attitude was measured by evidence of parental rejection, hostility, and marital difficulty. This fact was recorded if it had been given oral- ly by the referring agent or if clinically interpreted by the counselor. 176 Functional Illness Category TABLE XCII RELATION OF THERAPY OUTCOME (AS JUDGED BY THE COUNSELOR) AND PARENTAL ATTITUDE TOWARD REFERRED CHILD Closure Parental Attitude Parental Attitude Totals Classification Poor Good Successful Closure l 22 23 Unsuccessful Closure l . 7 8 Totals 2 29 31 p= .576 (Fisher Exact Probability) Not Significant Table XCII points out that success of closure, as judged by the counselor, is not significantly related to the parent's attitude toward the child. This finding refers to the functional illness category. Poor parental attitude was measured by parental rejection, hostility, and marital dif- ficulty. This factor was recorded if it had been given oral- ly by the referring agent or if clinically interpreted by the counselor. 177 Functional Illness Category TABLE XCIII OUTCOME OF CHILD'S THERAPY (AS JUDGED BY THE PARENT) IN RELATION TO PRESENT PARENTAL ATTITUDE TOWARD THERAPY Closure Parental Reply Parental Reply Parental Reply Classification To Question 6 To Question 7 To Question 10 No Some Great No Yes No Yes Help Help Help Successful Closure 0 5 ll 7 9 0 l6 Unsuccessful Closure 6 7 2 9 6 3 12 Totals 6 12 l3 16 15 3 28 Question Six = Assistance given to child at child guidance clinic, in Traverse City, was of Great Help Some Help No Help . Question Seven = Do you feel that you have a better under- standing of the problem, for which the child was referred, as a result of assistance received from the child guidance clinic located in Traverse City? Yes No Question Ten = Would you refer additional children who are hav- ing a behavior problem to a child guidance clinic? Yes No 178 Table XCIII shows the relationship of present par- ental attitude toward therapy which has been conducted with their child. Question six, seven, and ten from the follow-up questionnaire were used for this purpose. Approximately 42 per cent of the parents felt they had received great help; 39 per cent received some help; and 19 per cent received no help. A better understanding of the problem was reported by 44 per cent of the parents. It is interesting to note that regardless of how much help was given to the child 90 per cent of the parents stated they would re- fer other children to the clinic for counseling. 179 Functional Illness Category TABLE XCIV PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY COUNSELOR Cases Presenting New Problems Cases Reverting to Original Problem 9 5 Cases Remaining Successful In Terms of Initial Referral Problem 14 3 Total Number of Successful Case Closures 23 8 Table XCIV points out the number of successful case closures where the problem has not returned and the number who have reverted to the original referral problem. Table XCIV also shows the number of new problems presented in each category. This table refers to functional illness problems. The above information was gathered from question four (Has past problem, or problems, disappeared?) and question five (Have additional behavior difficulties occur- red since child was last seen at the child guidance clinic in Traverse City?) of the questionnaire. Of the thirty- one functional illness cases twenty-three were closed as successful by the counselor. In terms of the original re- ferral problem 61 per cent of the successful closures have remained successful. Approximately 39 per cent have reverted 180 to the original referral problem. The nine cases reverting to the original referral problem developed new problems in five instances. The fourteen cases which remained success- ful in terms of the initial referral problem developed new problems in three instances. 181 Functional Illness Category TABLE XCV PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY RESEARCHER Cases Presenting New Problems Cases Reverting To Original Problem 0 0 Cases Remaining Successful In Terms Of Initial Referral Problem 15 2 Total Number of Successful Case Closures 15 2 The above table shows the number of successful case closures, as judged by the researcher, where the problem has not returned and the number who have reverted to the original referral problem. Table XCV also shows the number of new pro- blems presented in each category. This table refers to func- tional illness problems. The above information was gathered from question four (Has past problems, or problems, disappea- red? Yes____ No____ Partially;___) and question five (Have additional behavior difficulties occurred since child was last seen at the child guidance clinic in Traverse City? Yes No . If 80, state problem) of the questionnaire. Due to the fact that a successful closure is classified by the State Department of Mental Health as one showing improve- 182 ment, regardless of degree or from what source, the term partially improved as used in question four is classified as a case that has remained successful. In some cases how- ever, this classification is in error due to the fact that complete success in therapy has reverted to partial or mini- mal success. Of the thirty-one functional illness cases fifteen were judged as successful by the researcher. In terms of the initial referral problem all of the cases jud- ged as successful by the researcher remained successful. The fifteen cases which remained successful in terms of the initial referral problem developed new problems in two instances. 183 Functional Illness Category TABLE XCVI PRESENT STATUS OF CASES JUDGED SUCCESSFUL BY PARENT Cases Presenting New Problems Cases Reverting To Original Problem 0 0 Cases Remaining Successful In Terms of Initial Referral Problem 16 _ 2 Total Number of Successful Case Closures l6 2 Table XCVI points out the number of successful case closures, as judged by the parent, where the problem has not returned and the number who have reverted to the original referral problem. Table XCVI also shows the number of new problems presented in each category. This table refers to functional illness problems. The above information was gath- ered from question four (Has past problem, or problems, disap- peared? Yes____ No____ Partially____) and question five (Have additional behavior difficulties occurred since child was last seen at the child guidance clinic in Traverse City? Yes No . If so, state problem) of the questionnaire. Due to the fact that a successful case closure is classified by the State Department of Mental Health as one showing im- provement, regardless of degree or from what source, the 184 term partially improved as used in question four is classi- fied as a case that has remained successful. In some cases however, this classification is in error due to the fact that complete success in therapy has reverted to partial or minimal success. Of the thirty-one functional illness cases sixteen were judged as successful by the parent. In terms of the initial referral problem all of the succ- essful closures, as judged by the parent, have remained successful. The fifteen cases which remained successful in terms of the initial referral problem developed new pro- blems in two instances. 185 Summary The relationship between a successful and an unsuccess- ful case closure was analyzed in reference to four factors. The factors were (1) age; (2) duration of referred pro- blem; (3) intellectual ability; and (4) parental attitude toward child. In addition to the above analyses the researcher attempted to measure (1) agreement of parent judgment with counselor's judgment and researcher's judgment; (2) agreement of counselor's judgment and researcher's judgment; (3) present parental attitude toward therapy as related to outcome of therapy; (4) number of cases that have remained successful in terms of the initial referral problem; (5) number of ca- ses that have reverted to the original referral problem; and (6) number of cases that have presented new problems. When considering prediction of success through the use of the above four factors, in reference to the five referral categories, the chi-square method of analysis and the Fisher Exact Probability Test showed: 1. Researcher and counselor judged a‘tas a pre- dictive factor in relation to the functional illness cate- gory. Both parent and researcher felt the younger child was more apt to benefit from therapy than the older child. When considering the conduct category the parent judged age as a predictive factor and felt that the older 186 child was more apt to benefit from therapy than younger child. Age was not judged as a significant predictive fac- tor by parent, researcher, or counselor in relation to habit, personality, or learning and deve10pmental categories. 2. Intellectual ability was of no statistical significance for problems classified as habit problems, personality problems, and functional illness problems. Parent, researcher, and counselor judged intelligence as a significant predictive factor in relation to the learning and developmental category. Intelligence was judged as a significant factor by the parent in relation to the conduct category. Where intellectual ability was considered a predictive factor5the brighter children were shown as more apt to pro- fit from therapy. 3. Duration of problem and success in therapy was found to be significantly related, by parent and researcher, to learning and developmental problems and functional ill- ness problems. The researcher also considered duration of problem as a significant predictive factory when used in re- ference to the personality category. Counselor and parent also considered duration of problem a predictive factor for conduct problems. Duration of problem was not judged as a significant 187 predictive factor by parent, researcher, or counselor in relation to habit problems. Where duration of problem was considered a significant predictive factor the children who had problems that had per- sisted for less than thirty months were shown as more apt to profit from therapy. 4. Parental attitude toward the child in relation to prediction of therapy outcome was significantly related, by the parent, to conduct problems, learning and developmental problems, and functional illness problems. The researcher considered parental attitude a predictive factor in ref- ence to conduct problems and personality problems. The coun- selor felt parental attitude was a predictive factor when uSed only in reference to personality problems. Parent, researcher, and counselor felt that parental attitude toward the child was not significant when used in reference to habit problems. Poor parental attitude toward the child was shown to be positively related to unsuccessful case closure where parental attitude was considered a significant predictive factor. From the data gathered throughout the parents of refer- red children it is apparent that present parental attitude toward therapy is an item worth analyzing rather closely. Approximately 34 per cent of the parents stated their chil- dren had received great help from the clinic. Approximately 188 26 per cent of the parents felt that their children had received no help. Some help was reported by 40 per cent of the parents. A better understanding of the child's problem was reported by 52 per cent of the parents. Approximately 48 per cent of the parents felt they did not have a better grasp of the child's problem upon termination of therapy. It is interesting to note that regardless of the amount of assistance the parent felt he had received at the clinic or the degree of understanding of the referred problem 84 per cent of the parents said they would refer other chil- dren for counseling assistance. Of the total number of cases judged as successful by the counselor 47 per cent have remained successful, while 53 per cent have reverted back to the original problem. Over half of the total cases the counselor considered successfully closed are no longer classified as successful by the parent. Fifty-two children of the 156 successful clo- sures have developed new problems. Of the total number of cases closed as successful by the researcher 72 per cent have remained successful, while 27 per cent have reverted been to the original problem. Of the ninety-one cases judged as successfully closed by the researcher.seventeen have developed new problems. Over half the total cases considered successfully closed by the re- 189 searcher were classified by the parent as remaining success- fully closed. The parent judged seventy-nine cases as successfully closed. Of these seventy-nine the parent classified seventy- eight as remaining successfully closed. Twelve of the seventy- nine children successfully closed by the parent have developed new problems. The relationship of parental judgment and counselor judgment regarding success of therapy is somewhat conflicting. Counselor judgment and parental judgment were related only when dealing with personality and functional illness problems. Counselor and parent seemed to disagree on the success of closure in the remaining three categories. Parental judgment and researcher judgment regarding success of therapy related in all categories except those refer- rals classified under personality problems. It would seem that parental judgment of successful closures are more closely rela- ted to researcher's judgment than to counselor’s judgment. Researcher's judgment and counselor's judgment were related when dealing with conduct problems, habit problems, personality problems, and functional illness problems. Coun- selor and researcher seemed to disagree on the success of clo- sure in reference to learning and developmental problems. Parent, counselor, and researcher were in agreement in reference to the closure of problems classified under |. 190 the functional illness category. RELATING THE FINDINGS TO THE CHILD GUIDANCE SETTING It is possible now, from the analyses provided by the foregoing chapters, to construct a composite picture of some of the factors related to therapy outcome and closure stability. Certain factors are associated gener— ally with successful or unsuccessful closure while additio- nal factors need to be looked at in reference to closure stability. For those who desire to utilize the findings the type of area from which the total sample was drawn must be taken into consideration. The area studied would be clas- sified as rural urban, small city and refined farm area, and may not offer the type of children and problems pres- ented in a metropolitan district. FACTORS RELATED TO SUCCESSFUL CLOSURE What factors are related most definitely to predic- tion of successful counseling outcome? Only factors with a level of confidence at or beyond the five per cent level of confidence have been used in drawing the composite pic- ture. When considering case selection for successful outcome 191 it would seem that referrals presenting habit problems have the least number of variables to statistically satisfy. All four of the tested variables (1) age, (2) duration of refer- red problem, (3) intellectual ability, and (4) parental att- itude toward referred child, were found to be related to suc- cess in a statistically non-significant manner. It is inter- esting to note however that parents report 57 per cent of the successful closures, in the habit category, reverting back to the original referral problem. The group which seems to have the next best chance of success in a therapeutic situation are those with personality problems. For this category duration under thirty months and a good parental attitude toward the child were found to be statistically significant by researcher or counselor. The remaining factors, age and intellectual ability, were not found to be statistically significant by parent, researcher, or counselor. CHAPTER V SUMMARY AND CONCLUSIONS The Problem The determination of what factors are most useful in predicting therapy success with children, the stability of successful therapeutic closures, and an evaluation of specific child guidance practices is a most difficult task. The mat- erial gathered previously consists mostly of data which have been loosely formulated and applied to children who have not been categorized according to specific referral problems. Such data has been used by most child guidance clinics in attempting to arrive at conclusions regarding treatment and clinic practices. The problem of this study was (1) to select and to analyze some factors hypothesized to be related to suc- cessful therapy closure; (2) to determine if therapy ca- ses classified as successful by a counselor have remained successful; (3) to compare the initial referral problem to the problem actually found by the counselor; (4) to determine the "best risk" for therapy in terms of length of treatment and the initial referral problem; (5) to de- termine how successful child guidance has been in correc- ting the initial referral problem; and (6) to determine if there is a need to improve methods of reporting and 192 193 handling information obtained in a child guidance clinic. Because the school age population and the public awareness of emotional problems in children has increased during the past several years it is understandable that the child guidance clinics in the State of Michigan have become overburdened. The increase in children being referred to child guidance clinics much outweighs the increase in pro- fessional staff. The public's concern with emotional pro- blems of children has become more acute each year for the past several years. Child guidance clinics are adding more professional service, new clinics are being established, and communities are demanding legislation leading to more and more service. If negative public Opinion of the present program is allowed to gain momentum, it may curtail the im- provement of this situation. It is necessary that some method of sorting be attempted to enable clinics to determine which child will benefit most from therapeutic interviews. The main hypothesis of this study is that there are relationships between specific characteristics of the re- ferred child and his actual problem.as classified which de- termines the probability of successful counseling. The Findings The analysis of the factors studied in relation to successful or unsuccessful case closure resulted in a number of findings. 194 1. At or beyond the five per cent level of con- fidence the following factdrs appeared to be significantly related by parent, counselor, or researcher, to successful case closure; intellectual ability above 100 for referral problems classified under the learning and developmental category; intellectual ability above ninety-seven for problems classified under the conduct category; duration of problem less than thirty months for referral problems classified under conduct, personality, functional illness, and learning and developmental problems; and good parental attitude toward the child for referral problems classified under conduct, functi- onal illness, personality, and learning and developmental prob- lems. ' 2. Age of referred child was statistically signif- icant when used as a predicting factor by parent, counselor, or researcher, for conduct and functional illness problems. The younger child seemed to benefit more from therapy when classified as a functional illness problem while the older child benefited more when classified as a conduct problem. 3. Intellectual ability seemed to have no sig- nificant relationship to case closure when used in reference to habit, personality, or functional illness categories. 4. Parental attitude toward child seemed to have no statistical significance to case closure when used in reference to referral problems classified under the habit uamfiwnsn m .uoHomssoo n Homewvsn m .uonuuwomoa U m coauumuwa vouummxm cw mqnmcoaumamm ucmuwmauww m u IV m n A a u HoHe essawesn Leanne u aoHeoenHo ensueexm eH uoz nanneoHenHom HenuHustHm -wssoo Hmuou m o m o o m I mono m o -uasamm Hausa. Hnuoa Hausa Hsuoa Hausa H e a a u sesame Hausa oN H N N H N m H N o o o o H H a nHaeoa e . eHHeo nuns t s. roe saseHuea « s . s i s aqueouwm n s Emanoum t t c-t e a t we soHessaa mocmw a s a s s -«HHauuH s s s m 3 as o m m o m m o m m o a m o m m I! Hnu mAoa euHHmsomumm. uapmm uosvsoo Hmcoauusom a wowsumoq UN MAQ I O" n q t ' I “ fl ‘ t L.‘ .. - ~ - w . .. w o - l . W w—15’8fi.‘ 3:" '2 “.4 w": " C “ ' "’ " q 0' v n - - '~- '0“ 1' l ' ‘ J J ’l’ i} flaw“ 5:» “I117 AM :5; mgzé', w-r an- I Page # h 35- Parental acceptance of interpretation: Yes ___ No ___ Comments: _i _‘l M Case closure: Successful Unsuccessful . Statistical closure: Same as above “_g __ Different than above i Therapist: Referral taken by: Additional comments: Q “J C awn DIR! “In 'v-v W“V CHILD GUIDANCE CLINIC FOLlOW-UP STUDY DIRECTIONS: Place an (X) after selected response. 1. ...... ------ Name of child seen at Traverse City Child Guidance Clinic: ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Last First Middle Child was initially referred to clinic for .............................................................................................................................. on .................................................... Do you feel that this was the main problem at the time of referral? Yes ........................ No ........................ If answer to above question is “No” please give your impression of what the main problem was at the time of referral? .................................................................................................................................................................................................................. .................................................................................................................................................................................................................. Has past problem, or problems. disappeared? Yes .................... No .................... Partially .................... Have additional behavior difficulties occurred since child was last seen at the Child Guidance Clinic in Traverse City? Yes .................. No .................... If so, state problem .................................................................................................. Assistance given to child at Child Guidance Clinic, in Traverse City, was of Great Help ................ Some Help .................... No Help .................... Do you feel that you have a better understanding of the problem, for which the child was referred, as a result of assistance received from the Child Guidance Clinic located in Traverse City? Yes .................... No ................... Since child has stapped coming to the Child Guidance Clinic, at Traverse City, has additional help been received from another agency, or agencies? Yes ................. No ...... . ............ Name of Agency .............. A ........... _ .......................................................................... If additional help has been received has it been of benefit? Great help .................. Some Help ................... No Help .................... Would you refer additional children who are having a behavior problem to a Child Guidance Clinic? Yes ............ No ................... Please give reason, or reasons. for your answer to above question. .................................................................................................................................................................................................................. ............................................................................................................................................................................................................. Please list any suggestions, or comments, that you may have pertaining to your relationship with the Child Guidance Clinic, located in Traverse City, Michigan. ................................................................................................................................................................................................................ .................................................................................................................................................................................................................. ............................................................................................................................................................................................................. Relation to referred child ........................................................................................................................................................... NORTHWEST MICHIGAN CHILD GUIDANCE CLINIC JAMES DECKER MUNSDN HOSPITAL TIAVCIBI CITY. MIDI-"BAN HAZEL D. HARDACRE DIRIGTOR April :3, 1959 Dear Parent: As a part of my doctoral dissertation, through Michigan State University, I am doing a follow-up study on all children seen at the Northwest Michigan Child Gufidance Clinic through the years 19504957. This study is being undertaken to help improve the services offered to children who will visit child guidance clinics in the near future. Your assistance is greatly needed. It would be greatly appreciated if you would fill out the attached questionnaire, and return it in the self-addressed and stamped envelope by May 22, 1959. Thank you for your kind cooperation and assistance. Sincerely you rs, I‘M‘J‘ gains HAROLD FAHS Psychologist Approval of: K427 .... Hazel .Hardacre, Director Northwest Michigan Child Guidance Clinic Created and Iinanced by Children's Fund OI Michigan 1937-54 Coutlnuecl aupport by participating counties and Michigan Department 0‘ Mental Health III- I I — v—t . ___ _ NDRTI'IWEBT MICHIGAN CHILD GUIDANCE CLINIC JAMES DECKER MUNSDN HOSPITAL TIAVIRIE CITY. MICHIGAN HAZEL D. HAIDACRE Dmtcrnn June 1, 1959 Dear Parent , I " You recently received a letter requesting that an enclosed Follow-Up Study be completed and returned. This Follow- Up Study is to help improve the services offered to children who will visit the Northwest Michigan Child Guidance Clinic in the near future. A self-addressed return envelope was included for your convenience. In tabulating the completed forms I find that your form is missing. No doubt this is due to the fact that you have been too busy, the form being misplaced, or some other adequate reason. It would be greatly appreciated if you would fill in the enclosed form and return it before June 12 , 1959. Your cooperation, and completed form, is a necessity in making this study a success. Thank you for your assistance. Sincerely yours , Halifax Harold Fahs , Psychologist CnataeI ancI IlnaneeJ by Children’s PuncI 0‘ Michigan I937-5‘ Continued] support In participating eonntlea and Michigan Depart-eat 0‘ Mental Health ROOM USE 0:... r ME \gfjtf ‘gt‘r 1.8%.4 $29. I 51:501. ”(F ("my v