Functional Analytic Psychotherapy among Mothers with Children with Disruptive Behavior

Children’s mental disorders have significantly increased worldwide in the last decades (Bitsko et al., 2016; Ferro García, Vives Montero, & Ascanio Velasco, 2009). Disruptive behavior represents one of the most prevalent disorders in this population, which involves negative effects on family and school contexts (Pan American Health Organization - PAHO, 2009). Misbehavior causes dissatisfaction among persons with whom the child frequently interacts, a situation that increases consultation and referrals to psychological services (Ministerio de Salud y Protección Social, 2015). Parental management skills have been tightly related to the presence of these problematic responses in children (Gadeyne, Ghesquière, & Onghena, 2004; Trenas, Osuna, & Cabrera, 2012), which directly affect their cognitive and social development (Gutman & Feinstein, 2010). Also, it has been proposed that parental behaviors are not only related to the appearance of children’s disruptive behavior, but also with its maintenance (Park, Johnston, Colalillo, & Williamson, 2016). This sets the relevance of parent-based interventions in the clinical psychological setting in order to enable children’s positive responses.

A wide variety of psychological treatments aims at modifying misbehaviors by treating the child directly: some examples are social skills training (O´Handley, Radley, & Cavell, 2016), problem-solving strategies (Christophersen & Mortweet, 2001), and emotional self-regulation (Graziano et al., 2015). However, considering the said relationship between parental conducts and child outcomes, other behavioral therapies have focused on training parents in handling strategies with suitable results decreasing their children’s rates of challenging behavior (Chainé & Pineda, 2014; Gil-Iñiguez, 2014; Kazdin, 2005; López Hernández, 2014; Masi et al., 2014; Presnall, Webster-Stratton, & Constantino, 2014). Correspondingly, different meta-analytic reviews have reached similar results about the effectiveness of parent training programs in the treatment of children’s problematic behavior (Kaminski, Valle, Filene, & Boyle, 2008; Robles Pacho & Romero Triñanes, 2011).

In this regard, we want to assess if Functional Analytic Psychotherapy (FAP) might represent an alternative for addressing children’s behavioral problems by treating their mothers’ problematic conducts, specifically those related with negative interpersonal interactions. The FAP is an approach of contextual behavioral sciences which makes particular emphasis on patient-therapist relationship to take advantage of learning opportunities that occur during sessions (Kanter, Tsai, & Kohlenberg, 2010; Kohlenberg, Tsai, & Kohlenberg, 2006; Valero-Aguayo, Ferro-Grace, Kohlenberg, & Tsai, 2011). Moreover, FAP promotes behavioral changes by enhancing client’s ality and interpersonal abilities (Follete & Bonow, 2009), and aims to decrease human suffering by facilitating changes through the therapeutic relationship (Haworth et al., 2015; Maitland & Gaynor, 2016). Specifically, the therapist job consists of identifying and modifying client’s clinically relevant behaviors (CRBs), understood as the target behaviors that occur during therapeutic sessions. Subsequently, these behavioral changes are expected to be generalized to the natural contexts in which the client interacts (Grow & Kodak, 2010; Kohlenberg & Tsai, 2007; Parra & García, 2006).

Different studies have examined the effectiveness of FAP in the treatment of adults’ mental diseases, such as depression (Kanter et al., 2006), emotional dependency (Busch, Callaghan, Kanter, Baruch, & Weeks, 2010), obsessive-compulsive disorder (Kohlenberg & Vandenberghe, 2007), posttraumatic stress disorder (Pedersen, Callaghan, Prins, Nguyen, & Tsai, 2012), and histrionic and narcissistic personality disorder behaviors (Callaghan, Summers, & Weidman, 2003), among others. Besides, other studies have focused on identifying FAP efficacy among adolescents (Cattivelli, Tirelli, Berardo, & Perini, 2012; Gaynor & Lawrence, 2002) and children (Gosch & Vandenberghe, 2004). These studies empirically support significant changes in clients’ behavior, in which CRBs1 (problematic behavior) decreases and CRBs2 (improvements in session) increases within the therapeutic process (Villas-Bôas, Meyer, Kanter, & Callaghan, 2015). However, there is no evidence of the effectiveness of FAP specifically in mothers in order to facilitate children’s behavioral changes. In this regard, the present study aims to examine the effect of FAP on children that present problematic behaviors in the school setting, by treating their mothers’ negative interpersonal interaction repertories.

Participants

The sample consisted of five mothers who informed about children’s behavioral problems within the school setting: disruptive behavior, confrontations with peers, and low involvement in classroom activities. Children were male, with an average age of 7.2 (SD = 1.3). Mothers’ average age was 32 (SD = 3), three of them were professionals, one was a technician, and the other one had high school studies. Regarding marital status, three participants were married and two were divorced. All the participants belonged to middle-income families. In order to protect participants’ identity, case one will be called Mary, case 2 Sophie, case 3 Martha, case 4 Elsa, and case 5 (control) Leticia, throughout this paper. It is pertinent to inform in advance that Mary and Elsa decided to discontinue the process, but the results achieved were relevant and therefore d and d in the present study.

Participants attended the therapy sessions voluntarily or due to referral of their children’s school. Their participation was voluntary and had no cost in order to promote participation. Exclusion criteria concerned children who had previous psychotherapeutic processes and those with specific conditions that better explain the presence of disruptive behavior, such as biological conditions, relevant changes in child environment (e.g., recent parental separation), child abuse, and depression or anxiety symptoms.

Instruments

Personal Data Questionnaire (PDQ). This questionnaire was used to gather relevant information from each case, such as sociodemographic information, family structure, parent-child interactions, mothers’ beliefs about child behavior, effects related to the problematic behavior, children’s development, psychological and medical background, and information to make up the al analysis of mothers’ target behaviors.

Functional Idiographic Assessment Template (FIAT-Q). This is a self-report questionnaire that consists of 117 statements related to interpersonal interactions that allow identifying problematic behaviors in a given situation. A Likert scale (-3 = strongly disagree, -2 = moderately disagree, -1 = mildly disagree, 1 = mildly agree, 2 = moderately agree, 3 = strongly agree) identifies the level at which interpersonal problems are presented. These problems are classified in 5 classes: assertion of needs (class A), which refers to the way clients express their needs, desires, and values to others, and s scape and avoidance responses; bidirectional communication (class B), which is related to clients’ skills to effectively give feedback to others’ behaviors, or to accept it; conflict (class C), which denotes clients’ difficulties to respond adequately to interpersonal conflictive situations; interpersonal closeness (class D), that represents clients’ behaviors that obstruct the building of close relationships and reduce the opportunities to get in touch with social reinforcements; and emotional experience and expression (class E), which is associated with clients’ difficulties to effectively express feelings and to identify and respond accordingly to others’ emotional responses (Callaghan, 2006). The FIAT-Q has shown adequate internal consistency in previous studies (.94) (Darrow, Callaghan, Bonow, & Follette, 2014).

Observational record sheet for CRBs1 and CRBs2. This data sheet was used by the therapist and two trained observers to register the frequency of the CRBs by analyzing the videotaped recorded sessions. The CRBs consisted of the different classes of behaviors assessed by the FIAT-Q (classes A to E), including mothers’ observed behaviors during assessment sessions.

Observational record sheet for teachers. This instrument was used by teachers in order to register children’s target behaviors in the school setting: disruptive behavior (screaming, interrupting class by standing up, and talking with peers when the teacher is speaking) and confrontations with peers (physical fights, hiding other belongings, using rude vocabulary, and making fun of others) as problematic behaviors; and class participation as a positive response (frequency of times when the child answered a question provided by the teacher or raised his/her hand to participate).

Video coding system guide. This guide was used by observers for the registration of mothers’ CRBs when analyzing videos. The guide d information regarding the problematic behavior of each mother (FIAT-Q classes), as well as the instructions for the identification of CRBs by episodes: one tally for a CRBs (1 or 2) was given when the mother emitted a target behavior after the therapist’s evocation.

Procedure

First, adult participants signed the informed consent to initiate the therapeutic process. This document d information regarding study aims, the use of data for research purposes without revealing personal information, and the procedure, as well as the voluntary participation and the possibility to leave the research at any instance of the process.

Individual sessions with each participant were proposed in order to develop the study. On the first assessment session, mothers completed the PDQ and FIAT-Q questionnaires. Subsequently, an evaluation phase was initiated consisting of an in-depth interview to contrast the information provided in the questionnaires, based on the construction of the al analysis of target behaviors for each case. As a result, mothers’ CRBs1 were identified in terms of the subscales of the FIAT-Q.

Sessions were video recorded for analysis and registration of mothers’ CRBs. Later, in order to increase the reliability of information, all sessions with the five participants were d by the therapist and two trained observers (professionals in psychology) who registered the frequency of CRBs1 and CRBs2, which were operationally described in the observational record sheet for each participant. Professionals registered a tally in the sheet each time they observed a target behavior. An interobserver agreement index was calculated to identify the percentage of times observers’ registrations matched in both assessment and intervention phases.

Then, when the data collected during the assessment phase was stable, treatment was initiated: following the rules posted by Tsai et al. (2009), four participants received FAP intervention, CRBs1 were evocated in order to be ally modified, and CRBs2 were evocated to be reinforced, increasing the probability of occurrence. The control-case (Leticia) received treatment based on psychoeducation in children’s behavioral management strategies. Specifically, Leticia was trained in the use of reinforcement and negative consequences in the interaction with her child. The FAP-based intervention consisted of 12 sessions approximately, one hour each, and 8 sessions of psychoeducation were performed with Leticia. Treatment sessions were also recorded to continue the registration of the CRBs by therapist and observers.

Simultaneously, an in-depth interview with the children’s school group director was conducted to identify target behaviors topography. In the same meeting, group directors were trained for disruptive behavior frequency registration in the observational record sheet. They were provided with an operational definition of each behavior to facilitate identification and registration. The training process consisted of an applied example inside the classroom using the sheet and by discussing what was observed. All participants were asked to complete observations during at least 10 weeks (matching with mothers’ assessment and intervention sessions) in a period of 50 minutes, two times per week, in two different situations, hours, and days each week (e.g., Martha’s child was observed by the group director on Monday mornings in science class and on Thursday afternoons in music class each week).

According to the information provided by participants during the assessment phase, and according to the results of the FIAT-Q and al analysis, mothers’ CRBs1 were identified. Table 1 presents the operational definition of each participant’s problematic behavior observed in the therapeutic context.

Table 1

Operational Definition of Mothers’ CRBs1 according to the FIAT-Q Classes

Table 1 shows that emotional experience and expression was the most prevalent problematic behavior (CRB1) in the sample, followed by problematic behaviors related to bidirectional communication. According to the description, mothers’ negative was observed to entail an impact on the interactions with their children, which in turn causes mothers’ negative emotions due to a perceived inability to control child responses.

Data about mothers’ CRBs1 and CRBs2 frequencies are presented in Figure 1. These data consist of the average of frequencies registered by the three observers for each weekly session with each participant.

Results suggest changes for the four mothers who were treated with FAP (Mary, Sophie, Martha, and Elsa), while no changes for the case-control (Leticia) were observed. For the four experimental participants, the figure denotes a reduction in frequency average of the problematic behavior (CRBs1), while an increase in positive behaviors (CRBs2) is observed. Specifically, Mary showed a reduction in negative emotional expressions and an increase in opposite responses. These changes were identified by session number 7, and the interobserver agreement index for CRB1 was 89% and 63% for CRBs2, which implies that observers coincided, especially in the identification of a reduction of negative behaviors. Results for Sophie also suggest a decrease of bidirectional communication problems and an augmentation of CRBs2 during the FAP-based intervention phase. These changes were observed by session 5, and the interobserver agreement index was 87% for the problematic behavior and 78% for the positive ones, indicating suitable accordance between professionals. Martha exhibited changes by session 7 in emotional expression (80% of agreement) and bidirectional communication problematic repertories (71% of agreement). Also, an increase of positive outcomes related with each class was observed (with an index of agreement of 76% and 87% respectively). Finally, changes within the assessment and treatment phases for Elsa were identified. A reduction of negative emotional experiences and expressions is clearly observed by session 5, with an interobserver agreement index of 88%, and 88% for positive behaviors during the therapeutic sessions.

Results for Leticia (control-case) indicated a slight decrease in mothers’ negative emotional expression by session 5. Interobserver agreement was 88% for CRB1 and 92% for CRBs2. Due to the ineffectiveness of the psychoeducation in this participant and the increasing behavioral problems of her child at the school, the therapist initiates the FAP by session 9. Five sessions were developed and initial changes were observed in mothers’ behavior. However, Leticia abandoned the treatment due to her job schedule.

Regarding the number of sessions for each participant, it is pertinent to mention that Sophie and Martha completed the process by accomplishing therapeutic objectives, while Mary and Elsa discontinued the process due to early observed changes in children’s behavior in both school and home settings. Finally, as mentioned before, the case-control (Leticia) abandoned the process four sessions after ning the implementation of the FAP-based intervention.

Changes in children’s behavior within the mothers’ intervention process are presented in Figure 2. Data represents the average frequency for each behavior according to the group teacher registration.

The figure shows a decrease of disruptive behaviors and confrontations with peers for the four children whose mothers were treated with FAP. On the contrary, no changes in negative conducts were observed for Leticia’s child, a case that received contingency management training. Also, it is observed that class participation - considered a positive behavior - increases in a differentiated way for each participant. For example, the increase in the positive behavior of Mary’s child is easily observed compared with the other children, whose changes in class participation were less significant and more fluctuant. Correspondingly with Leticia’s results during the first intervention phase, her child showed unremarkable changes in both positive and negative behaviors. During FAP-based sessions Leticia’s child behaviors were not registered because he was suspended from the school.

This study aimed to identify the effect of FAP in a group of mothers who had difficulties in managing the behavioral problems of their children. Furthermore, the study aimed at identifying if changes in mothers’ behavior led to changes in their children’s behavior. In this regard, a decrease in mothers’ behavioral problems (CRBs1) was identified in participants who received FAP-based therapy. Also, changes in children’s behavior in the scholar setting were observed, in which negative performances decreased while positive outcomes increased.

According to the findings, mothers’ CRBs1 were primarily related to difficulties in emotional experience and expression, and with issues in communication strategies. Information provided by the al analysis during the assessment phase suggests that these difficulties permeate mother-child interactions. In this respect, Brumariu and Kerns (2015) proposed a close a relation between mothers’ emotional responses and communication strategies and children’s emotional development. Further, the authors proposed that problems in bidirectional communication in mother-child interactions might lead to anxiety symptoms in children. On the contrary, Pearson and Pillow (2016) showed that mother-child communication based on positive emotional expressions enhances children’s social understanding. These studies provide information about the way mothers’ CRBs1 have a negative effect on children’s behavior, such as those existing in the sample.

Participants treated with FAP showed a reduction in CRBs1. On the contrary, the treatment based on contingencies management training did not represent remarkable changes in mothers’ problematic behaviors. This result can be related to the emphasis that FAP promotes in the therapist-client relationship, which is characterized by closeness and emotional validation, leading to mothers’ emotional and behavioral changes that were generalized to other contexts according to their verbal report. On the contrary, the psychoeducational training in contingencies management mainly focuses on providing the mother with handling strategies, which may not significant changes outside the therapy, despite clients’ comprehension of them.

The decrease in CRBs1 implied an increase in CRBs2 according to the therapist and observer’s records of videotaped sessions. In this research, the inverse proportional relationship between a decrease in behavioral problems and an increase in alternative and incompatible behaviors was recognized. This result suggests that therapist skills to evocate and reinforce positive outcomes were effective (Kanter et al., 2010) and that it was possible for the observers to identify these situations by analyzing video-recorded sessions with a high percentage of agreement between them.

Besides, changes in children’s behavior were observed in participants that were treated with FAP, while no observable changes were identified in the case-control. These results suggest that mothers’ learning process of alternative positive behaviors, as a result of the intervention strategies that were used based on discrimination, reinforcement, and evocation may have had a positive effect on their children’s behavior without being directly treated. This possible relation is explained by the generalization principle, which states that changes obtained during the psychotherapeutic process are extended and maintained in other scenarios (Brumariu & Kerns, 2015; Callaghan et al., 2003; Ferro, Valero, & Vives, 2000); in this case they were extended to mother-child interaction in the family setting. It was observed that changes exhibited by the children kept stable in time, even in cases mothers discontinue the process due to observed positive outcomes.

Likewise, measurements obtained in the present study about children’s behavior provide information about the generalization of human behavior (Dinsmoor, 1995). Compared with previous studies aimed to identify the effectiveness of FAP, the present study proposed the use of control measures obtained in the school setting to identify children’s behavioral changes. In this regard, this research represents an initial approach to support the generalized effects of FAP in modifying both mothers’ and children’s behavior, only by treating one of them. This line of research holds promising to allow for a more impactful approach for treating children’s behavioral problems by addressing those who provide the strongest influence on a daily basis: their parents.

Limitations of the present study that results regarding the effectiveness of FAP cannot be generalized to other cases given the idiographic approach that concerns single case study methodology. Also, this was a transversal study, which implies that the relationship between variables has to be interpreted carefully. For further studies, it would be appropriate to observe children’s behavior in other contexts, such as home, to have more support information to argue mother’s behavioral generalization.