AN EVALUATION OF THE EFFECTIVENESS OF RELAXATION

TRAINING AS A TREATMENT MODALITY FOR THE

HYPERKINETIC CHILD

by

RAY HOLT BROWN, B.A., M.A.

A DISSERTATION

IN

PSYCHOLOGY

Submitted to the Graduate Faculty of Texas Tech University in

Partial Fulfillment of the Requirements for

the Degree of

DOCTOR OF PHILOSOPHY

May, 1977

'iCf'f/ ACKNOWLEDGMENTS

As is usual in an enterprise such as a dissertation,

many individuals are worthy of special mention for the

assistance which they provided.

Dr. Robert P. Anderson, Chairman of my committee, is to

be commended for his guidance, encouragement, and direction

which was consistently backed by uncompromising scholastic

and professional standards. Also, I am highly indebted to

Dr. Anderson for introducing me to an area which ranks high

among my professional interests.

Drs. Theodore Andreychuk, Richard Carlson, June Henton,

Charles Mahone, and Joseph Rickard are acknowledged for

their encouragement and helpful assistance as members of the

committee. Special appreciation is offered to Dr. Rickard

for his assistance in making the pediatric population at

Fort Hood available to me.

The staff at U.S. Darnall Army Hospital, especially Dr.

Karen Allen, are acknowledged for their highly cooperative

acceptance of my endeavors.

Mrs. Nancy Holle and Ms. Alana Jones are highly com­

mended for the many hours which they spent in handling the

scheduling and actual operations involved in the treatment

aspects of the study.

Also, I would like to express a special note of appre­

ciation to those individuals who, early in my academic

ii

endeavors, provided guidance and encouragement while in­

stilling in me a high value for academic achievement. First

of all were my parents, Mr. and Mrs. V. R. Brown, who gently

encouraged and supported, but never made demands. Secondly,

I wish to express my.deepest appreciation for the guidance

which came from the late Dr. Charles A. Glazner. It was his

guidance which led me into the field of psychology and his

life, both academic and personal, which provided me with a

model to emulate.

I am greatfully indebted to my wife, Jeanine, for her

persistent support and especially the long hours which she

spent in typing and editing the manuscript.

Finally, I express my appreciation to by daughters,

Melissa and Casey, for patience and understanding which,

throughout this undertaking, far surpassed their years.

To Melissa, who finally said, "Daddy, we will go with you

if you promise not to talk about money, school, or disserta­

tion,." I now make that promise.

Ill

TABLE OF CONTENTS

ACKNOWLEDGMENTS ii

LIST OF TABLES vi

LIST OF ILLUSTRATIONS viii

I. INTRODUCTION 1

Purpose and Scope 1

The Field of Learning Disabilities 3

The Hyperkinetic Child Syndrome 9

Etiology 24

Diagnosis 39

Treatment / 54

Prognosis for the Hyperkinetic Child 80

Summary 81

Statement of the Problem - 83

II. METHODOLOGY 87

Population Characteristics 87

Selection of Subjects 87

Experimental Design 90

Procedures 93

Instruments 99

Statistical Hypotheses 111

Statistical Procedures 115

IV

III. RESULTS 119

Summary of Results 137

IV. DISCUSSION 138

Behavioral Rating Scales 138

Self Concept Measures 142

Psychometric Measures 145

General Issues 146

Suggestions for Further Research 152

V. SUMMARY AND CONCLUSIONS 156

LIST OF REFERENCES 162

APPENDICES 17 5

A. Permission Form 176

B. Subject Information Sheet 177

C. Davids Rating Scales for Hyperkinesis 178

D. Task Motivational Instructions 180

E. Conners Behavioral Rating Scale 182

F. Pretest Mean Scores 184

G. Non-adjusted and Adjusted Posttest

Mean Scores 18 6

H. Analysis of Variance Source Tables for the Conners Factors 188

I. Analysis of Variance Source Table Peabody Picture Vocabulary Test 190

V

LIST OF TABLES

1. Davids Scales—Pretest Mean Scores 184

2. Piers-Harris Scale—Pretest Mean Scores 184

3. Coding-—Pretest Mean Scores 184

4. Mazes—Pretest Mean Scores 185

5. Digit Span--Pretest Mean Scores 185

6. Davids Rating Scales—Non-adjusted and Adjusted Posttest Mean Scores 186

7. Piers-Harris Scale—Non-adjusted and Adjusted Posttest Mean Scores 186

8. Coding—Non-adjusted and Adjusted Posttest Mean Scores 186

9. Mazes—Non-adjusted and Adjusted Posttest Mean Scores 187

10. Digit Span--Non-adjusted and Adjusted Posttest Mean Scores 187

11. Analysis of Covariance Source Table Davids Rating Scales 120

12. Simple Main Effects Source Table Davids Rating Scales 121

13. Analysis of Variance Source Table Conners Scale 121

14. Tukey's HSD Test For Treatment Groups Davids Rating Scales 122

15. Tukey's HSD Test for Comparisons of All Means Davids Rating Scales 123

16. Analysis of Variance Source Table Conners-Defiance-Aggression 188

17. Analysis of Variance Source Table Conners-Daydrearning-Inattentiveness 188

VI

18. Analysis of Variance Source Table Conners-Anxious-Fearfulness 189

19. Analysis of Variance Source Table Conners-Hyperactivity 189

20. Analysis of Variance Source Table Conners-Well Adjusted State 189

21. Analysis of Variance Source Table Inferred Self-Concept Scale 128

22. Analysis of Covariance Source Table Piers-Harris Self Concept Scale 129

23. Tukey's HSD Test for Treatment Groups Piers-Harris Self Concept Scale 130

24. Analysis of Covariance Source Table Digit Span 134

25. Analysis of Covariance Source Table Coding 134

26. Analysis of Covariance Source Table Mazes 135

27. Analysis of Variance Source Table Peabody Picture Vocabulary Test 190

Vll

LIST OF ILLUSTRATIONS

1. Research Design HQ

2. Davids Rating Scales-Posttest Results 126

3. Conners Scale-Results 127

4. Inferred Self-Concept Scale-Results 132

5. Piers-Harris Self Concept Scale-

Posttest Results 133

6. Digit Span-Posttest Results 136

7. Coding-Posttest Results 136

8. Maxes-Posttest Results 137

Vlll

CHAPTER I

INTRODUCTION ~' " • •

Purpose and Scope

Hyperki,rie?::i s or hyperactivity is a complex syndrome

of behaviors preseni lr> a significantly large group of

preadolescent children^^ The behavior of these children is

characterized by exaggerated levels of activity., short

attention span, impulsivity, and distractibility= The syn­

drome is associated with disruptive classroom behavior and

is a great cause for concern among educators and parents.

Gaylin (19777 has stated that hyperkinesis is a condi­

tion which affects between six and 10 million children in

the United States. In a recent study conducted in Texas, A ijJ^^^

— V

Anderson, Williama, and. Rushing (1977) reported that eight

percent of the children in two elementary schools were

rated by teachers as hyperactive.

Numerous etiological theories have been posed to

vccount for hyperkinesis, but as Glennon and Nason (1974,

p. 818) commented, "The etiology of this syndrome is still

not clear." Most theories associate hyperkinesis with

organic brain damage or other physiological bases. tiowever,

psychogenic factors in the etiology of hyperkinesis have

also been considered. Anderson and his students (Anderson

et al-, 1977) developed a neuropsychogenic model of

hyperkinesis which aids in the understanding of both

etiology and treatment.

The diagnosis of hyperkinesis is a difficult, iiivei ed-,

and currently unrefined procedure. Most cases are probably

diagnosed somewhat subjectively from behavioral data pro­

vided by parents and/e*= teachers./ However, behavioral

rating measures, structured monitoring of activities, mechan­

ical measuring devices, psychometric instruments, and physi­

ological measures have added objectivity to the procedure.

An overwhelmingly large percentage of hyperkinetic

children are given stimulant drugs in an attempt to control

behavioral symptoms. ! Gaylin (1977) has reported that

methylphenidate (Ritalin) alone is routinely administered

to as many as two and a half million children each year.

/The high frequency of drug treatment has alarmed many

individuals and has seemingly precipitated the ovaluation

of altern-ative* modes of treatment such as traditional psy­

chotherapy and behavior modification techniques. More

recently, biofeedback and relaxation training have been used ~JfX yy^ HU^}rj''^J-d /-UL^.

in the treatment of hyperkinesis.). Brajod, Lupin, and Brand

11975) reported-positive results in a six-year-old hyper-

active boy who they treated with biofeedback and relaxation

training./ This preceded a series of investigations which

were designed to further evaluate the effectiveness of re­

laxation and biofeedback techniques in the treatment of

hyperkinesis.

The purpose of the current investigation w-a*-to further

ejyalua.te_ the effectiveness of relaxation training/and to

empirically examine important considerations which have not

been dealt with in other research which has appeared in the

literature. Specifically, this investigation was designed

to examine such variables as age, expectation set, and

attention as they relate to the effectiveness of relaxation

• training.

The Field of Learning Disabilities

Vftthin the last few ye tris some rather major changes

have been enacted within our educational systemsy^ The post

World- War—II era was^marked by rapid scientific advances,

new areas of academic emphasis, and greater academic demands,

even for grade school children. Educators were no longer

satisfied to merely label children who experienced academic

difficulty as "slow learners." As a result, an attempt has

been made to refine the differential diagnoses of children

with educational difficulties. Among the changes was the

inaeption of a new special education subspecialty referred

to as learning disabilities. V7hile the use of this term

is extremely popular, even to the layman,_ the various con­

cepts of the term reflect many semantic, etiological, and

diagnostic discrepancies. At least some of these discrep­

ancies and differences of opinion can be better understood

through a brief presentation of the developmental history

of the field of learning disabilities.

Senf (1976) traced the origin of the concept of learning

disabilities to 1963, at which time a steering committee

under the authority of the National Society of Crippled

Children and Adults and the Neurological and Sensory Disease

Control Program of the United States Public Health Service

was assigned the task of organizing a symposium on "The

Child With Minimal Brain Dysfunction." At this early stage,

two schools of thought were involved in generating the theo­

retical underpinning on which the concept of learning dis­

abilities was to stand. The medical-neuropsychological

school emerged and contributed a medically oriented etiolog­

ical theory of learning disabilities. The other contributing

source was the psychoeducational school of thought, the

primary focus of which was educational remediation. A med­

ically oriented definition came from the former school.

This has sometimes been referred to as the Task Force I

definition. This definition by Clements (1966) stated:

The term "minimal brain dysfunction syndrome" refers . . . to children of near average, average, or above average general intelligence, with certain learning or behavioral disabilities, ranging from mild to severe, which are associated with deviations of function of the central nervous system. These de­viations may manifest themselves by various combi­nations of impairment in perception, conceptualization, language, memory, and control of attention, impulse, or motor function.

During the school years, a variety of learning dis­abilities is the most prominent,manifestation of the condition which can be designated by this term, (p. 9)

Associated with the Task Force I definition of learning

disabilities were the symptoms of hyperactivity, perceptual-

motor impairments, emotional lability, general coordination

deficits, disorders of attention span, disorders of memory

and thinking, specific learning difficulties, speech and

hearing disorders, and finally equivocal neurological signs

and/or irregular electroencephalographic findings (Senf,

1976) .

Due to efforts put forth at the 1967 Northwestern Con­

ference at Northwestern University, an educationally rooted

definition was formulated. Kass and Mykelbust (1969) pre­

sented this definition as follows:

Learning disability refers to one or more significant deficits in essential learning processes requiring special education techniques for remediation.

Children with learning disability generally demon­strate a discrepancy between expected and actual achievement in one or more areas, such as spoken, reading, or written language, mathematics and spatial orientation.

The learning disability referred to is not primarily the result of sensory, motor, intellectual, or emo­tional handicap, or lack of opportunity to learn.

Significant deficits are defined in terms of accepted diagnostic procedures in education and psychology.

Essential learning processes are those currently referred to in behavioral science as involving per­ception, integration, and expression, either verbal or nonverbal.

Special education techniques for remediation refers to educational planning based on diagnostic proce­dures and results. (pp. 378-379)

Also, a legislative definition presented through the

National Advisory Committee on Handicapped Children was

dictated in 1968. This definition drew from both of the

preceding definitions and stated:

Children with special learning disabilities exhibit a disorder in one or more of the basic psychological processes involved in understanding or in using spoken or written language. These may be manifested in disorders of listening, thinking, talking, read­ing, writing, spelling or in arithmetic. They in­clude conditions which have been referred to as perceptual handicaps, brain injury, minimal brain dysfunction, dyslexia, developmental asphasia, etc. They do not include learning problems which are due primarily to visual, hearing, or motor handicaps, to mental retardation, emotional disturbance, or to environmental disadvantage. (Senf, 1976, pp. 262-263)

The Texas Education Agency (Bulletin 711, 1973) has

differentiated the "Minimally Brain Injured" child and the

child with "Language and/or Learning Difficulties." Sep­

arate definitions have been provided for each category as

follow:

Children who are MINIMALLY BRAIN-INJURED are those who are normal or above in intelligence, but who have learning difficulties directly attributable to an organic defect caused by a neurological condition, and who are unable to adjust to or profit from a regular school program without the provision of special education services. (p. 3)

LANGUAGE AND/OR LEARNING DISABLED children are chil­dren who are so deficient in the acquisition of language and/or learning skills including, but not limited to, the ability to reason,think, speak.

read, write, spell, or to make mathematical calcula­tions, as identified by educational and/or psycho­logical and/or medical diagnosis that they must be provided special services for educational progress. The term 'language and/or learning disabled chil­dren' shall also apply to children diagnosed as having specific developmental dyslexia. (p. 4)

In addition to this presentation of definitions, an

awareness of a number of developmental milestones in the

brief life of this area, learning disabilities, is deemed

useful. Senf (1976) pointed out that Public Law 88-164

marked the initial financial funding for training in the

area of learning disabilities. Within one year, an educa­

tionally oriented parent-professional group. The Association

for Children with Learning Disabilities, was formed. This

group escalated their membership to 20,000 in three years

and in so doing the term "learning disabilities" became

widely known and used. Senf pointed out that in 1966 a

training program was enacted within the Bureau of Education

for the Handicapped, United States Office of Education.

This program made university level training available for

the first time in the area of learning disabilities. Fol­

lowing the inception of this program, much money and man­

power were invested in this new academic subspecialty. The

Learning Disability Act of 1969 provided $85,000,000.00 for

research and training in the area of learning disabilities

(Senf, 1976, pp. 11-17).

8

The preceding overview can serve to make the reader

aware of the apparent lack of homogeneity among children

who have been classified as learning disabled. The lack of

homogeneity is alluded to throughout the literature and is

vividly pointed out in at least three references (Anderson,

Halcomb, Gordon, & Ozolins, 1974; Satterfield, Cantwell, &

Satterfield, 1974; Weithorn, 1973). Likewise, this hetero­

geneity is at least implied in the vast number of terms

which are frequently used interchangeably in describing the

learning disability syndrome. For example, Millichap

(1975) presented the following 19 alternative names:

1. The hyperactive child syndrome. 2. The hyperkinetic syndrome. 3. Minimal cerebral dysfunction. 4. Minimal brain damage. 5. Minimal brain injury. 6. The brain-damaged child. 7. The brain-injured child. 8. The perceptually handicapped child. 9. The perceptually disturbed child.

10. The dysfunctioning child. 11. The dyslexic child. 12. The clumsy child. 13. Chronic brain syndrome. 14. The Strauss syndrome. 15. The prechtl choreiform syndrome. 16. Specific learning disabilities. 17. Learning disorders. 18. Maturational lag syndrome.

19. Central nervous system dysfunctions. (p. 2)

Millichap was quick to point out that, based on hetero­

geneity, and lack of uniformity in the manifestations and

causes of the syndrome, no single term really provides a

satisfactory, total explanation of the learning disabled

child. Consequently, it is at this point that the scope of

this paper shall take on a more narrow focus. Glennon and

Nason (1974) identified the "hyperkinetic impulse disorder"

as a subset of "Minimal Brain Dysfunction" or learning dis­

abilities and it is this subset that will now be dealt with.

The Hyperkinetic Child Syndrome

Unlike the educational subspecialty of learning dis­

abilities, the symptoms characteristic of hyperkinesis are

not new. It has been pointed out (Feighner & Feighner,

1974; Satterfield, Cantwell, Saul, & Yusin, 1974) that this

syndrome was recorded in the form of a detailed case study

in 1844. Since that time a multitude of investigators and

writers have consensually validated a syndrome which begins

at or shortly after birth, is more prevalent in boys than

girls, and involves a number of presenting symptoms of

which the cardinal one is excessive motor activity.

Kahn and Cohen (193 4) reported the account of a syn­

drome which they had observed as a sequel to encephalitis.

The syndrome was marked by motoric hyperactivity, inability

to maintain attention, poor coordination, and impulsivity.

Due to the manifest behaviors and an association with neuro­

logical indications of central nervous system dysfunction,

the syndrome was labeled "organic driveness." This concept

of "driveness" quite accurately reflected the apparent lack

of control that the children had over their activity levels./

10

Bradley (1937) was another pioneer in the diagnosis and

management of the hyperkinetic child. He identified the

disorder and its characteristics of poor concentration,

short attention span, impulsivity, inability to delay grati­

fication, irritability, and explosiveness. He referred to

these behaviors as the "organic behavior syndrome." In

addition to identifying and naming the syndrome, Bradley

was the first physician to utilize benzedrine or other such

stimulant drugs as a mode of treatment.

Grinspoon and Singer (1973) reviewed the work of

Strauss and Lehtinen (1947) who discussed hyperactive be­

havior patterns exhibited in children with known brain-

injury. The association with organic causation led to a

renaming of the syndrome, in 1957, by two of Bradley's fol­

lowers. These two men, Laufer and Denhoff, referred to the

syndrome as "hyperkinetic impulse syndrome" and associated

it etiologically with head trauma, encephalitis, or other

related communicable diseases. They identified several

symptoms which were generally consistent with the behavioral

characteristics as noted by other contributors to this body

of literature. First of all, they noted hyperactivity as

the cardinal symptom of the "hyperkinetic impulse disorder."

Hyperactivity was typically noted from birth and involved

constant involuntary overactivity beyond the expected level

of the average child. The syndrome further involved poor

11

concentration and inability to maintain attention for any

appreciable period of time. They further described a sort

of emotional lability or extreme behavioral variability as

well as impulsiveness, inability to delay gratification,

irritability, low frustration tolerance, explosiveness, and

finally, poor academic achievement (Grinspoon & Singer,

1973).

An extremely large number of definitions of hyper­

kinesis have appeared in the literature, but these will not

be enumerated. Instead, one contemporary definition will

be cited. The various behavioral symptoms comprising the

syndrome will be discussed briefly and the overall charac­

teristics of the syndrome will be described.

Millichap (1975, p. 1) defined hyperactive behavior

as follows:

Hyperactive behavior, or hyperkinesis, is an unusual degree of motor restlessness that is purposeless and not directed toward a specific, meaningful goal. This random, excessive activity interrupts the child's attention and concentration and disrupts his ability to perform structured tasks. The failure to sustain attention on purposeful tasks and goals is the behav­ioral manifestation that differentiates the hyper­active child from the norm.

Braud (1974) added clarification to the nature of the

condition by emphasizing that hyperkinesis is not one single

behavior, but rather a syndrome or cluster of behaviors.

Keogh (1971) stated that confusion tends to encompass

the definition and understanding of the term, hyperkinesis.

12

The confusion is due primarily to the tendency to confound

hyperkinesis with other conditions which are medical, behav­

ioral, psychological, and/or neurological in nature. In so

doing, the term has become somewhat emotionally laden.

The tendency of most investigators has been to focus

on symptomatology rather than on the definition of hyper-

kinesis. The present review has followed the former with

an emphasis on symptomatology. Reviewing the literature

for behavioral symptoms and descriptive characteristics

resulted in a rather lengthy list. The items comprising

the forthcoming list resulted from a combination of clinical

experiences and empirical findings. Very few, if any, of

the writers were in full agreement concerning what symptoms

comprised the syndrome. In spite of their apparent lack of

agreement, there still was a great deal of consensus.

Keogh (1971) concluded that while hyperactivity is impre­

cisely defined, there exists a concurrent agreement on the

part of professionals and parents that " . . . they know it

when they see it" (pp. 102-103).

The list of syndrome characteristics, comprised of the

combined descriptors as posited by an array of writers

(Braud, 1974; Burks, 1960; Cermak, Stein, & Abelson, 1973;

Feighner & Feighner, 1974; Glennon & Nason, 1974; Keogh,

1971; Laybourne, 1976; Morrison & Stewart, 1971; Satterfield,

Cantwell, & Satterfield, 1974; Spring, Greenberg, Scott, &

13

Hopwood, 1974; Stewart, Pitts, Craig, & Dieruf, 1966; Tarver

& Hallahan, 1974; Walker, 1974; Weithorn, 1973; Werry, 1968;

Wiens, 1972; Wunderlich, 1973; Zukow, 1974) includes the

1. Accident proneness ^ \yf^ J^' •:)^ > -2. Aggressiveness - (\Y^ t XJri^^' 3. Antisocial behaviors ^ C/ ^' " 4. Attentional deficits ^ 5. Auditory perception problems 6. Destructiveness 7. Distractibility 8. Driven behavior 9. Emotional lability

10. Enuresis 11. Excitability 12. Excessive fidgetting and wiggling 13. Abnormal electroencephalograms 14. Hostility 15. Impulsivity 16. Extreme inquisitiveness 17. Irritability 18. Low frustration tolerance 19. Memory deficits 20. Need to touch everything 21. 'Equivocal or soft neurological signs 22. Excessive talking in school 23. Non-goal directed motor activity 24. Normal intelligence 25. Perseveration 26. Physical immaturity 27. Poor concentration 28. Poor intersensory integration 29. Poor muscle coordination 30. Provocation of negative reactions in others 31. Poor peer relationships 32. Poor self-concept 33. Restlessness 34. Short attention span 35. Slow motor development 36. Social immaturity 37. Specific learning disabilities 38. Unresponsiveness to punishment 39. Visual-perceptual difficulties

14

Any one or a combination of the above stated behaviors

may exist in a given hyperkinetic child, but all of the

characteristics are not necessary to constitute hyperkinesis

In fact, no single child is likely to exhibit all of the

enumerated characteristics and behaviors. The list serves

to reiterate the lack of homogeneity even within a popula­

tion of hyperkinetic children. ^One cannot help but note

the negativism that is communicated in this group of adjec­

tives and descriptive phrases. Keogh (1971) stated that^

such descriptors are quite reflective of irritation on the

part of adults which is directed toward hyperkinetic chil­

dren. The lack of specificity and preciseness in the

definitions and descriptions of the hyperkinetic child is

also exemplified in the list. In spite of the implication

of heterogeneity, a number of symptoms do tend to be iden-

tified by most writers. Douglas (1972), for example, stated

that the core of symptoms involves behavior associated with

inability to sustain attention and inability to control

impulsiveness.

In a careful review of the literature, Simpson and-

Nelson (1974) were able to conclude that the definition or

even the description of hyperactivity could be neither spe­

cific nor precise. However, they were able to isolate two

primary aspects of thg^symptoms as reported in the litera­

ture. The first of these was a persistent and high level

15

of activity. The second was the situational or social in-

appropriateness of the motor activity.

Elevated motor activity is the cardinal symptom of the

hyperkinetic syndrome. However, some clarification and

qualification is in order with respect to the issue of

activity level. It is uncertain, for example, at what

point a child's motor activity becomes excessive^ Few

writers are as specific as Werry (1968) who stated that the

hyperkinetic child's daily motor activity is ". . . clearly

greater (ideally by more than two standard deviations from

the mean) . . . " (p. 583) than that of other children of

similar background. This is much more specific than most

writers and as a result the issue of measurement is clearly

brought into focus. Stabilometric cushions, counting

observed movements, and other such quantitative measures

have been employed in studies of hyperactivity. Perhaps

the most sophisticated of these devices was a modified,

automatically winding wristwatch referred to as an actometer

which was first used by Schulman, Kaspar, and Thorne (1965).

While technical difficulties are obvious in these measures,

an even more pertinent issue arises. To use only measures

such as those noted above is to ignore qualitative differ­

ences involving such things as the situational appropriate­

ness of particular motor activities. Tarver and Hallahan

(1974) spoke of hyperactivity as a situationally specific.

- r 16

socially de-fined phenomenon. They explained thts by stat­

ing that lack of motor control is probably evidenced only

in specific, often highly structured, situations. Highly

structured situations were defined as situations in which

a high level of motoric control was expected or demanded^:

Werry (1968) also addressed this issue and pointed out that

neither parents nor teachers often complain about the

child's activity level per se, but rather complain about

specific behaviors, including hyperactivity, as they con-

textually relate to a particular situation. He further

pointed out that the total daily activities of the child

must be closely surveyed if the hyperactive child is to be

diagnosed and differentiated from the disruptive, anti­

social, or aggressive child who is not hyperactive. Grin-

spoon and Singer (1973) addressed this issue in their sur-

vey article. They felt that the symptomatic improvement

reported in many studies reflected more organized, goal-

directed behavior which more nearly approximated the social

norms and did not simply indicate lowered activity levels./'

Reiterating the importance of social appropriateness,

-Sprague, Barnes, and Werry'(1970) pointed out how high

levels of motor activity in, for example, a free play situ­

ation, would not be seen in a negative light, but rather

would likely be interpreted as a positive act of ". . .

engaging his social environment . . . " (p. 626) through

17

socially acceptable behaviors. Cromwell, Baumeister, and

Hawkins (1963) stated that overactivity may actually be a

reflection of a short attention span and rapidly changing

goals of the child. >This, they felt, leads to fragmented,

disorganized, continually changing behaviors which result

in an impression of high activity level./ Carrying this

even further, Strauss and Kephart (1955) stated that short

attention span, distractibility, and hyperactivity all

refer to the same thing.

Douglas (1972) pointed out how hyperkinetic subjects,

almost without exception, experienced difficulty in sustain­

ing attention and in controlling their tendencies to re­

spond impulsively. Likewise, Tarver and Hallahan (1974)

reviewed 21 experimental studies in the broad area of atten­

tion deficits and were able to make several general conclu­

sions. However, before discussing these it should be

pointed out that the nomenclature varied across studies

and subject homogeneity cannot be assumed. First of all,

they noted a significantly higher level of distraction when

control groups were used for comparison purposes. Distract­

ibility was ofen based on embedded figure tasks where

figure-ground perception was critical. Secondly, they

noted that hyperactivity is a function of a particular situ­

ation, with higher activity levels found in highly structured

situations. Thirdly, they suggested that the hyperkinetic

18

children, as compared to normal controls, were much more

impulsive and less reflective. Finally, Tarver and Hallahan

(1974) stated that hyperkinetic children tend to lack the

ability to maintain attention over prolonged periods of

time.

Dykman and Ackerman (1976) confirmed the consistency

with which hyperactive children react impulsively and per­

form poorly on tests such as the Matching Familiar Figures

Test (MFFT) by Kagan, Rosman, Day, Albert, and Phillips

(1964). A high rate of errors associated with significantly

short latency periods on these embedded figure tasks has

been demonstrated in the literature, providing the empiri­

cally founded basis on which Tarver and Hallahan (1974)

concluded that a strong positive relationship exists between

hyperactivity and impulsivity. These authors went on to

state that subjects were, in the 21 studies reviewed, very

highly distractible, meaning that they manifested an ". . .

inability to filter out extraneous stimuli and focus selec­

tively on the task" (p. 567). The implication is that

hyperkinetic children are likely to experience great diffi­

culty in distinguishing relevant from irrelevant stimuli.

This sort of distractibility can easily lead to poor aca­

demic achievement and high levels of frustration. Atkinson

and Seunath (1973) compared 18 learning disabled children

with 18 normally achieving children on a structured.

19

attention demanding task, under the conditions of constant

stimulation and stimulus change. The results indicated that

the learning disabled subjects were influenced negatively by

stimuli changes, suggesting an attentional deficit. Differ­

ences were not noted under the constant stimulus condition.

As pointed au-t by- Douglas (1972) , little has been done

empirically to show what specific kinds of attention prob-4:1-\U -

lems hyperkinetic children actually have, although the lit--

erature reflects an obviously widespread acknowledgment that

such problems do exist. It was Douglas' contention, however,

that the attention task which causes the most difficulty for

the hyperkinetic child is a continuous performance task,

such as the vigilance task developed by Mirsky and Rosvold ,, _.

(1963). Through the Mirsky and Rosvold vigilance task, it

was shown that hyperkinetic children were able to identify

fewer'correct stimuli and also erroneously reported a

higher number of incorrect ones than did normal controls.

This was true on both visual and auditory forms of the

vigilance task. Likewise, a greater decrement in perfor­

mance over time was noted in the hyperkinetic population

than among normal controls.

In 1972, a series of studies concerned with attentional

deficits, as measured by a vigilance task, was begun at

Texas Tech University. The initial study (Anderson, Halcomb,

& Doyle, 1973) demonstrated the effectiveness of the

20

vigilance task as a method of examining the paramotorg raf

attention deficits. Likew±s.e, it yielded an effective,

objective method of classifying children with respect to

activity level. That is, children, through the vigilance

task, were classified as either hyperactive, normoactive,

or hypoactive. The task itself invalved the subjects'

pressing a button each time a particular combination of

colored lights appeared over a 3 0-minute period. Hyper­

active children made fewer correct detections and more

false alarms than subjects in either of the other groups.

A second study (Anderson-, Halcomb, Gordon, & Ozolins,

^1974) was designed to examine the effects of stimulant

medication on vigilance performance. Overall, no differ­

ences were seen between medicated and non-medicated hyper­

active children. However, when examined for age differences

(Seven, eight, and nine-year-old children constituted the

younger group while older children were 10, 11, and 12

years old.), the findings were significant for younger chil­

dren. Two possible interpretations of the findings were

discussed. The first was the possibility that the vigilance

task itself did not adequately differentiate for older chil­

dren. Secondly, they entertained the possibility that

older children tend not to be as responsive to the effects

of medication as are younger children. It should be pointed

21

out that clinical evidence does lend support to this sec­

ond interpretation.

Visual distractibility was the primary area under in­

vestigation in another vigilance task study by the Texas

Tech University group (Doyle, Anderson, & Halcomb, 1973).

When compared to normoactive and hypoactive children,

Doyle (197 6) concluded that hyperactive children were more

distractible and showed poor ability to properly select

stimuli. Likewise, they exhibited a poor focusing ability

and displayed erratic, sustained attention during the

vigilance task.

A fourth study by—Anderson, H aitroTfrb, Oizolins, and

Hopson (ia74) introduced auditory distractions to the vigi-

lance task. Two types of noise were employed. One involved

the presentation of a random white noise, the other involved

typical classroom noise. A measure of response l-crtency was

introduced- as an additional variable. The results showed

no significant difference involved with the random noise,

but extreme difference under the conditions of classroom

noise. Anderson-et-^1. _(1974) concluded that learning

disabled children have more difficulty in handling auditory

disturbance than do normal children and that this distract­

ibility is reflected in poor accuracy on tasks requiring

attention to details. The results then are consistent with

the visual distraction study (Doyle et al., 1973).

22

One of the most valuable contributions resulting from

these vigilance task studies was the empirical confirmation

crf~-t-he~- la^k-ul huiiiuyen-eity among -hmuLnuiy^ digdijled children

and the concurrent provision of an effective, erHpriiiualiy

benffSd method of differentiating children on the basis of

activity level. Also, support was provided for the long

held assumption that hyperkinetic children, when compared

to other subgroups of the learning disabled pouplation,

tend to be more deficient in their ability to sustain

attentions

Douglas (1972) reviewed studies involving impulsivity

in children and concluded that hyperkinetic children tend

to be impulsive and ^^or prone. She, from her literature

search, noted apparent differences between normal and

hyperkinetic children in terms of the tempo and speed of

cognitive functioning and decision making.

Campbell (1973) took measures of reflection-impulsivity

and field dependence-independence on 10 reflective, 10 im-

\ pulsive, and 10 hyperadtive boys. She hypothesized that

\ hyperactive boys would be more impulsive and also more field-

V

dependent than either the reflective boys or normal boys

who were selected as being cognitively impulsive. The re-

flective boys differed from the impulsive and'hyperactive /

boys with respect to field dependence-independence., This

was interpreted to indicate that school failure in

23

hyperactive children could not accurately be associated with

cognitive style differences between normal and hyperactive

children. In fact, the impulsive boys in the study, unlike

the hyperactive ones, were reportedly doing adequate aca­

demic work. Poor academic functioning was described as a

combination of cognitive impulsivity, extreme distracti­

bility, low frustration tolerance, and lack of persistence.

Marshall, Anderson, and Tate (1976) addressed the issue

of memory problems in the learning disabled child. They

noted that memory processes in learning disabled children

had not been well scrutinized under vigorous experimental

conditions. In a serial recall task, normal subjects

recalled more items than did learning disabled subjects,

even though their manner of processing was seen as identical.

Thus, cognitive processing was not shown to be different

when normal children were compared to a rather heterogeneous

group of learning disabled children.

Douglas (1972) identified some other broad areas in

which hyperkinetic children were able to function with lit­

tle or no impairment. She noted that on individually admin­

istered intelligence tests, hyperkinetic children performed

at the average or above average range. Second, no signifi­

cant differences were noted in areas of language ability,

comprehension, or conceptual thinking when normal and hyper­

active children were compared. Third, based on several

24

measures, no significant differences were noted on short-

term memory. She further contended that hyperkinetic

children were perhaps somewhat less disturbed by outside

distractors than some of the literature has suggested, but

quickly admitted that high distractibility is a distinguish­

ing feature. Douglas also acknowledged the tendency for

hyperkinetic children to move about more than normal chil­

dren, but added that their behaviors are directed toward

goals, albeit their own. Finally, she reiterated a point

previously stated in this paper. That is the quantity of

activity alone may not be the most critical aspect of the

hyperactivity syndromey| The problem th^, from Douglas'

framework, is one of impulse-control, atten.tion, and orga- :;

nized planning.^ She described the syndrome in lay terms,

as an inability to "stop, look, and listen'!* (p. 275) .

Etiology

The most conservative estimates regarding the preva­

lence of hyperkinesis range from three percent to six per­

cent of all grade school children (Barcia & Rabkin, 1974;

Feighner & Feighner, 1974; Glennon & Nason, 1974; Mendelson,

1971) while others (Grinspoon & Singer, 1973; Morrison &

Stewart, 1971) see the range extending upward toward eight

or 10%. In fact, Grinspoon and Singer (1972) stated that

some educators have estimated that as high as 15 or 20%

25

of grade school children may be hyperkinetic. What can one

say regarding the etiology of a syndrome that affects such

a large number of children? Regretfully, the answer to this

question is highly complex, controversial, and inconclu­

sively answered at the present time. As Glennon and Nason

(1974) noted, "The etiology of this syndrome is still not

clear: there is no single cause nor simple answer." They

further stated, "We're not yet certain of the etiology of

hyperkinesis . . . , but we do have evidence that there is

a hyperkinetic impulse disorder" (p. 818). Grinspoon and

Singer (1973, p. 539) stated that:

Although the medical community is increasingly aware of the complexities of defining the syndrome and tracing its etiology, hyperkinesis is no better understood than it was when Laufer and his associates defined it and postulated an organic basis of its existence.

To stop at this point of uncertainty would, however, be un­

fortunate, for the etiological knowledge regarding hyper­

kinesis is neither as tenuous nor as primitive as the

preceding statement might suggest. In fact, many etiologi­

cal explanations of the syndrome have been offered and are

helpful in the understanding of the syndrome.

Organic Etiology

Probably the earliest and most prevalent etiological

assumption involves the notion that specific learning dis­

abilities and hyperkinesis can be associated with organic

26

brain damage. Organic implications have been reflected in

a number of descriptive labels referring to hyperkinetic

children. For example, Kahn and Cohen (1934) referred to

the disorder as "organic driveness" and Bradley (1937)

coined the term "organic behavior syndrome." Likewise,

many state educational agencies have categorized children

under labels such as "minimal brain injury" or "minimal

brain dysfunction." In fact, a great deal of elaborately

detailed theorizing has involved the area of organic

etiology.

Weithorn (1973), in reviewing the literature, isolated

two factors believed to have been responsible for the long­

standing association of hyperkinesis with organic brain

dysfunctioning or some other central nervous system (CNS) •

malady. She related the first of these back to the writings

of Ebaugh (1923) and Kahn and Cohen (1939), both of whom

associated hyperactivity with symptoms which were typically

observed to occur as a sequel to encephalitis. The second

historical factor which Weithorn noted as linking hyper­

kinesis to CNS dysfunctioning came from the writings of

Strausfe and Lehtinen (194 7) who attempted to present a new

taxonomic explanation of retarded children. In so doing,

two categories resulted. These two categories were known

as familial (endogenous) retardates and brain injured (exo­

genous) retardates. Hyperactivity was noted as a primary

symptom in the exogenous or brain injured group.

27

The literature is filled with references associating

hyperkinesis with insult to the brain. While causality is

often inferred from a history of prenatal, paranatal, or

postnatal brain damage, it has also been related to rubella,

viruses, smallpox, cowpox, measles, polio, cerebral hemor­

rhage, and a number of other conditions (Anderson, 1970;

Millichap, 1975). Obviously, when trauma can be rather

conclusively identified, etiological association and diag­

nosis are likely to follow. However, in most cases,

etiology is not obvious and further speculation must follow.

Braud (1974) did an extensive review of the literature

and found that damage to any one of several areas of the

brain could produce hyperkinetic behavior and problems of

attention. Specifically, these symptoms had been associated

with injury or dysfunction to the temporal lobe, frontal

lobe, corpus callosum, limbic system, diencephalon, or the

ascending reticular activatin system (RAS).

Toffler (1972) observed that 50% of hyperkinetic chil­

dren who, psychometrically speaking, appeared to suffer

from brain dysfunction do not have abnormal electroenceph­

alogram (EEG) tracings. From this he concluded that the

damage was subcortical in nature and simply not manifested

in EEG records.

Burks (1960) arrived at a conclusion pointing to sub­

cortical damage after observing the effectiveness of

28

amphetamine therapy for hyperkinesis. His logic was based

on an assumption that the behaviors most affected by amphet­

amines included anxiety, overactivity and irritability, and

that these were regulated by deep, subcortical brain centers.

Laufer, Denhoff, and Solomons (1957) and Laufer and

Denhoff (1957) postulated an elaborate theory of hyperkine­

sis involving diencephalonic dysfunction. Their theory

stated that the interaction between cortex and diencephalon

was impaired in the hyperkinetic child, resulting in undue

insensitivity of the CNS to bodily stimuli. Dykman and

Ackerman (1976) reviewed the theory of Laufer and Denhoff

and explained it as an inhibitory control failure, improper

sensory filtration, poor coordination between cortical and

subcortical areas, or in simple terms, an attentional

deficit resulted.

Others, such as Silver (1971) and Satterfield, Cantrell,

Saul, and Yusin (1974) have presented organic theories of

etiology which involved the RAS and its effect on organis-

mic arousal.

Silver (1971) proposed that the hyperkinetic syndrome

relates to "neurohumeral deficiency which results in a

physiological dysfunction of the ascending RAS and secon­

darily of the limbic system" (p. 126). Both of these

systems were described as arousal systems and the function­

ing of the two was described as integrated and in balance

29

with each other when properly functioning. When the two

systems are appropriately adapted and balanced, equilibrium

is achieved and normal levels of behavior, learning, motiva­

tion, perception, etc. can be exhibited in the organism.

Concurrent dysfunction of the two arousal systems was

viewed as an explanation of both the symptoms of the hyper­

kinetic syndrome, such as distractibility, short attention

span, and symptoms of learning difficulties and emotional

lability.

Satterfield and Dawson (1971) investigated the electro-

dermal correlates in the hyperkinetic child syndrome. Con­

trary to their original expectations, they found that the

hyperkinetic subjects, when compared to the normal controls,

had lower basal skin conductance levels (SCL), smaller

amounts of non-specific galvanic skin responses (GSR), and

a smaller magnitude of specific GSRs. The authors concluded

that hyperkinetic symptoms in low SCL children came as the

result of lowered excitability of the midbrain RAS. They

suggested that high levels of clinically observable motor

activity were actually secondary to lowered levels of RAS

excitation. The motor activity was described as an attempt

by the child to increase his proprioceptive and exterocep­

tive sensory input.

Satterfield and Dawson, in the same 1971 publication, I

utilized the theory of low level RAS excitability to explain

30

the apparently paradoxical effects of stimulant drugs which

tend to produce a calming effect on the behavior of hyper­

kinetic children. Their theory stated that stimulant drugs

tend to increase the RAS activity which then leads to in­

creased electrodermal arousal, reduction of motor activity,

and a decrease in the high-amplitude, slow waves evidenced

on the EEG.

Satterfield, Cantwell, and Satterfield (1974) reviewed

four of their own studies which supported the low CNS

arousal concept. They concluded that lowered CNS arousal

leads to a lack of inner control over motor output and

sensory input, and finally results in behavioral and learn­

ing problems. Similar findings were reported by Spring,

Greenberg, Scott, and Hopwood (1974).

Weithorn (1973) discussed the possibility of two dif­

ferent types of hyperactivity. The first was described as

motoric hyperactivity and was associated with defective in­

hibitory mechanisms in the cortical motor system. The

second form of hyperactivity was referred to as a general­

ized hyperactivity', associated with defective inhibitory

mechanisms in the sensory sphere. The implication here, is

that a distinction is to be made between a motorically rest­

less child and one who is responding motorically to a multi­

plicity of stimuli. Weithorn, at this point, associated

this theory with the observation by Pope (1970) that

31

brain-injured children tended not to engage in more loco­

motion than non-brain-injured children, but rather displayed

a more aimless and undirected sort of locomotion.

Dykman and Ackerman (1976) postulated that hyperkinetic

children possess a strong stimulus hunger and tend to be

distractible even within a quiet environment due to extreme

restlessness and a continual searching for stimuli.

The preceding summaries of etiological theories serve

as a sampling of theories which are related to CNS function­

ing. Nothing in the foregoing discussion can lead the

reader to an unequivocal acceptance of a specific etiologi­

cal theory based on dysfunction in the brain or elsewhere

in the CNS. In fact, Douglas (1972), after reviewing the

literature, pointed out that, in many hyperkinetic children,

no evidence of brain damage can be found. Likewise, Grin­

spoon and Singer (1973) stated emphatically that much recon­

sideration be given to the hyperkinetic syndrome. They

were especially concerned about the vast amount of contra­

dictory evidence concerning the incidence of brain abnormal­

ity among clinically diagnosed "MBD hyperactives," as

opposed to "normal" children. Sprague (1976) pointed out

that when children with brain damage were examined, hyper­

activity was shown to be neither a necessary symptom, nor

even a common one. Likewise, Keogh (1971) extensively

32

reviewed the literature and concluded that the relationship

between hyperkinesis and cerebral dysfunction was in no way

one-to-one.

Satterfield, Cantwell, Saul, and Yusin (1974), after

gathering large amounts of data on 120 hyperkinetic chil­

dren, drew three conclusions. The first was that some

children with no hyperkinetic symptoms or behavioral prob­

lems seem to have abnormalities in their EEGs as well as

other minor neurologic abnormalities. Second, it was noted

that most brain-damaged children did not fit the clinical

picture of the hyperkinetic child syndrome. Finally, it

was pointed out that many hyperkinetic children have normal

EEG tracings and normal neurological examination findings

in general.

Werry (1968) factor analyzed 67 variables that were

frequently associated with hyperkinesis. His sample was

comprised of 103 physically healthy hyperkinetic children

of average intelligence. Ten independent factors were

extracted. The first factor involved general motor incoordi­

nation. The second factor involved an impaired drawing

ability as noted on instruments such as the Bender-Gestalt.

The sixth factor was EEG instability and the seventh factor

related to subcortical impairments.

Based on the results of this factor analytic study,

the author refuted the existence of a homogeneous brain

33

damage dimension. He further stated that, based on a low

degree of interrelatedness between neurological, cognitive,

behavioral, medical-historical, and EEG dysfunctioning,

each of these must be a reflection of different etiological

factors. The suggestion is that different etiological fac­

tors are indicated, the neurological data being too varied

to specify a single neurological basis of hyperkinesis.

Biochemical or Metabolic Etiology

Some researchers (Dykman & Ackerman, 1976; Feingold

1973; Powers, 1973-74; Satterfield & Dawson, 1971; Silver,

1971) have entertained the possibility that the etiology

of hyperkinesis is linked with a biochemical imbalance.

However, this has not been adequately researched. In fact,

Millichap (1975) stated that no proof exists to support the

contention that disorders of body chemistry are etiologi­

cally related to hyperkinesis.

Genetic Etiology

The possibility of a genetically based etiology has

been discussed by a number of researchers (Morrison &

Stewart, 1971, 1973a, 1973b; Silver, 1971). This line of

theorizing was based on the high prevalence of hyperkinetic

traits among natural, as opposed to adoptive, family members

of hyperkinetic children.

34

Another line of genetic theorizing has been related to

the high male:female ratio of hyperkinetic children.

Reports vary with respect to the ratio, but the range is

from 4:1 to 9:1 (Laufer & Denhoff, 1957; Morrison & Stewart,

1973a, 1973b; Silver, 1971; Werry, 1968). Dykman and

Ackerman (1976) suggested that this disproportionate ratio

may constitute grounds on which to entertain a polygenetic

theory of inheritance.

Developmental Lag Theory

Abrams (1968) spoke of a delayed or perhaps irregular

pattern of maturation in an attempt to explain the etiology

of the hyperkinetic syndrome. This irregular development,

he felt, could be related to chemical, genetic, metabolic,

emotional, or even unknown factors, any of which could

relate to the behavioral and academic problems of the hyper­

kinetic child.

Other Etiological Theories

The previously cited studies by Morrison and Stewart

(1971, 1973a, 1973b) may be interpreted to involve environ­

mental factors where behaviors are learned. Addressing

this issue of learned behavior, Anderson (1970) stated:

The hyperkinetic child may also learn to utilize his restlessness for achieving his own goals. He learns that being restless is a great source of attention and that it provides him an excellent technique of disengagement from his responsibil­ities, (p. 145)

35

Another etiological theory was presented by Arehart-

Treichel (1974) which addressed the possibility of harmful

effects of fluorescent lighting, and X-ray leakage from

color television sets which might lead to hyperkinetic symp­

toms. Dykman and Ackerman (1976) noted a line of thought

which linked hyperkinesis to inadequate parenting. These

and other similar theories have, however, met with little

support and have not been researched.

The Consideration of Psychogenic Factors

A number of writers (Cermak et al., 1973; Weithorn,

1973) have addressed the possibility of a psychogenic basis

for hyperkinesis. These authors were quick to point out

that differentiating psychogenic factors, neurologic factors,

or other factors can often be extremely difficult. Conse­

quently, all too few theorists have attempted to integrate

psychogenic factors into a total explanation of hyperkinesis.

Glennon and Nason (1974) , drawing from the work of Bradley

(1968) were able to distinguish between what they referred

to as primary and secondary causes of learning disability.

Primary factors included genetic factors, prenatal and post­

natal circumstances, injuries, and infections. Secondary

etiolotical factors included psychological, emotional, and

social elements and poor parental handling of children.

36

Marivit and Stenner (1972) differentiated the hyper­

kinetic syndrome into two distinct patterns. The first of

these was labeled as a hyperactive phenomenon while the

second was referred to as a hyperreactive condition. The

former was said to involve true organic etiology while the

latter was said to be predominantly a learned, psychologi­

cal response to environmental factors. This reportedly

involves emotional disturbance and anxiety which becomes

motorically manifested.

Anderson (1970) pointed to the behaviors of impulsivity,

hyperactivity, and emotional lability, noting that these

characteristics have obvious social effects. Eventual

results include discouragement, feelings of inferiority,•and

academic frustration. Drawing from the Adlerian viewpoint,

Anderson noted that these children become discouraged due

to their perceived inability to achieve and attain success.

In an attempt to compensate for this discouragement, func­

tional misbehavior often results.

A Neuropsychogenic Model

A mixed, neuropsychogenic model is an alternative view­

point from which to examine the hyperkinetic syndrome.

Based on the previously stated etiological theories, it

seems logical to this writer, to examine the syndrome from

this point of view.

37

The neuropsychogenic model as presented by Anderson

(1970) represents an interactionist model which " . . .

assumes that minimal brain dysfunction serves as a basis or

background for the development of the child's estimate of

himself and life" (p. 36). Both neurologic and psychological

factors must be recognized and both must be considered in

treatment plans.

More recently, Anderson et al., 1977, elaborated and

expanded the interactionist theory, the result being a

simple, but unique and theoretically meaningful explanation

of the hyperkinetic syndrome. The model involves an aware­

ness of the effects of the child's total environment or

total "system." Anderson and his students have labeled

their system as the WARD model.

The WARD model involves a child whose total gestalt

is comprised of both a family and an academic environment

as well as what is described as an internal environment.

The internal environment is comprised of genetic, intellec­

tive, and medical-physical factors which affect the orga­

nism. The family environment is also a function of various

components including parent-child relationships, sibling

relationships, social and educational class of the family,

and the overall life style and stability of the family unit.

The child's academic environment is a function of both the

specific educational setting (administrative policy.

38

teaching methods,and physical facilities) and psychosocial,

relational aspects (the teacher-child relationships, peer

relationships, and need achievement) within the particular

setting. The hyperkinetic child's total environment and

his/her evaluation of personal experiences are responsible

for the unique, specifically individual, phenomenal self

which develops.

Anderson et al. 1977 referred to the overall activities

of the child as the behavioral output. It is from these

observable behaviors that the diagnosis of hyperkinesis is

typically made and also, the basis on which the need for

intervention is ascertained. This refers to the many symp­

toms which have been previously discussed in this paper.

Following the WARD model, a decision regarding inter­

vention is to be made after observation of the child's

behavioral output. The decision is twofold. First of all,

outside sources such as family members, school officials,

a physician, a psychologist, or some combination of these,

are often placed in the position to make a decision regard­

ing intervention. Their choice can be either to intervene

or not to intervene, but implementation cannot be attained

without a second affirmative, this one from the child. The

ultimate decision regarding the implementation of the chosen

plan of intervention affects the total system, child, family,

and academically involved individuals.

39

The WARD model provides a highly unified, multidisci-

plinary approach to the understanding and the treatment of

hyperkinesis. The model attends to etiology, but goes

beyond that and recognizes the hyperkinetic child as part

of a total environmental system. While not stated in the

model, there seems to be an implied agreement with Werry

who in 1968 stated, "For the practioner, etiology is impor­

tant only as it points the way to treatment or prognosis"

(p. 586). Likewise, this environmental system concept

would appear to be harmonious with the advice of Weithorn

(1973). He stated that:

Until the etiologies are clearly identified, symptoms, not causes should be the focus of treatment. While attempting to understand the complexities of etiology in both physiological and psychological aspects, it is necessary for all professionals who come in con­tact with these children to also provide information on the best educational milieu for them, to counsel parents on their special needs and problems, and to provide appropriate therapeutic and supportive aids, (p. 44)

Diagnosis

Two points have been made in the preceding discussion.

The first is that the population of hyperkinetic children

is a rather heterogeneous group, with symptomatic varia­

tions from child to child. The second, and related point,

is that the issue of etiology is neither a simple nor clear-

cut matter. With these two conclusions in mind, it is evi­

dent that the diagnosis of hyperkinesis is also a difficult.

40

involved, and presently somewhat unrefined task. Also, it

is a task on which there is no global consensus among pro­

fessionals. Still, the issue of diagnosis is important and

should, as Werry (1968) communicated, serve some function

other than merely providing a child with a label. The

diagnosis should somehow serve to enhance our understanding

of the individual child and his/her symptoms, while provid­

ing useful data on which to generate a plan for behavioral

management. It is with this awareness that an overview of

diagnostic procedures will be presented.

Behavioral Ratings

One of the most widely used means of diagnosing the

presence of hyperkinesis has involved subjective ratings

by parents, teachers, or involved professionals who are in

a position to observe the overt behaviors of children.

From this practice, several well known, clinically useful

rating scales have emerged.

Even though one primary goal of most individuals who

are trained to think in scientific fashion is to objectify

data collection procedures, the utility and effectiveness

of subjective rating scales cannot be overlooked. This is

especially true at our present stage in the scientific in­

vestigation of learning disabilities and hyperkinesis in

particular. It should be pointed out, in defense of

41

subjective measures, that since etiology of hyperkinesis is

not the main issue, all one can really accomplish through,

for example, medical diagnosis, is to confirm what someone

had already observed behaviorally.

Conners (1969, 1970) developed rating scales which

have met with widespread use in studies with hyperkinetic

children. The first (1969) of these scales was the Teacher

Rating Scale, originally developed for use in drug studies.

Conners' rationale was based on the assumption that teach­

ers were in an excellent position from which to observe

children in a variety of situations. Also, teachers were

believed to be capable of comparing children under observa­

tion to the standards of normative samples previously

established.

The resulting instrument was designed by Conners to

tap a wide range of behaviors observable to the classroom

teacher. It consisted of 39 items involving a variety of

behavioral problems. Factor analysis then resulted in

five clusters or factors. These were: (1) defiance or

aggressive conduct; (2) daydreaming-inattentiveness; (3)

anxious-fearfulness; (4) hyperactivity; and (5) well

adjusted state. The instrument was subjected to sound

empirical investigation involving the comparison of a drug

treatment group and a placebo group. Test-retest of the

placebo group over a one month period indicated stability

42

(.71 to .91) satisfactory enough to warrant usage of the

instrument.

Jones, Loney, Weissenburger, and Fleishmann (1975)

attested to the widespread and effective use of the Conners

scale in the monitoring of drug treatment procedures. They

were* able to cite several studies which attested to both

the reliability and the validity of the instrument.

In 1970, Conners factor analyzed parent symptom ratings

of 316 psychiatric clinic patients and 365 normal children.

His goal was to distinguish between hyperkinetic, neurotic,

and normal children. All subjects attended public school,

had an IQ of 80 or more, and were without signs of organic

brain dysfunctioning. The scale was comprised of 79 symp­

tom behaviors which were rated from one to four. This

rating involved 24 general categories. Ten of these cate­

gories were statistically significant with respect to

their ability to discriminate between neurotic and hyper­

kinetic children. Hyperkinetic children were rated sig­

nificantly higher in the areas of speech problems,

bed-wetting, over assertiveness, problems in relating

both to siblings and peers, restlessness, temper tantrums,

and lying. The five principal factors resulting from fac­

tor analysis were: (1) aggressive conduct disorder; (2)

anxious-inhibited; (3) antisocial reaction; (4) enuresis;

and (5) psychosomatic problems. The hyperkinetic

43

children were especially high on the aggressive conduct

disorder.

Another popular rating scale for the assessment of

hyperkinesis was developed by Davids (1971). Davids stated

that he drew from the early works of individuals such as

Bradley, Denhoff, and Laufer to assess those traits which

comprise the syndrome of hyperkinesis. The resulting

instrument was comprised of six items, the first five of

which constitute an index of hyperactivity: (1) hyper­

activity; (2) short attention span; (3) impulsivity; (4)

irritability; and (5) explosiveness. Each involved a

rather precise explanation of the behavior being rated.

Rater response on each of the six items involved checking

one of the following: (1) Much Less Than Most Children;

(2) Less; (3) Slightly Less; (4) Slightly More; (5) More;

or (6) Much More Than Most Children.

Cowgill, Friedland, and Shapiro (1973) introduced an

instrument consisting of seven general categories, each of

which was defined by a number of associated behaviors.

Each category was to be rated on the basis of a four point

scale. The seven overall categories included: (1) matu­

rity; (2) immaturity; (3) poor attention span; (4) impul­

siveness; (5) poor social and emotional adjustment; (6)

poor motor control; and (7) poor speech and language.

Norms were provided for both the number of behaviors

44

checked on each category and also for the overall rating.

Data from this scale were deemed effective by the authors

in accurately discriminating learning disabled children from

control children.

Werry (1968) discussed the Werry-Weiss-Peters Activity

Scale, a rating scale which taps a child's level of observed

activity in the following seven situations: (1) during

sleep; (2) while watching television; (3) while doing home­

work; (4) at play; (5) while sleeping; (6) while away from

home (except school); and (7) at school. A number of items

appeared under each of the seven situations and rating for

each item involved a choice of "no," "some," or "much."

Page, Janicki, Bernstein, Curran, and Michelli (1974)

developed a 10 item hyperkinetic index which they used in

a drug study involving Pemoline (Cylert). Actually, two

forms were developed, one for teachers and one for parents.

Each item was to be rated on the following basis: (1)

just a little; (2) pretty much; or (3) very much. The 10

items included excitability-impulsiveness, degree of learn­

ing, two types of restlessness, extent to which the child

finishes tasks, maturity or immaturity level, distractibil­

ity or attention span, frustration tolerance, extent to

which demands must be met, and extent to which the child

disturbs others. The parents' form was identical except

for alterations on the last two items.

45

Fowlie (1973) introduced the following seven questions

by which parents could make a subjective, preliminary, and

nonprofessional diagnosis of hyperkinesis in their own

children:

1. Does he finish what he starts - be it.chores, games, projects, etc.?

2. Does he play with children cooperatively? 3. Is he flexible about sudden changes in plans

and in new situations? 4. Is he impulsive and does he take risks without

thinking? 5. Does he dawdle and procrastinate a lot? 6. Does he 'fool around' and do most everyting at

mealtime except eat? 7. Does he get overstimulated, 'high as a kite,'

or lose control when angered or excited? (p. 353)

Rappaport and Benoit (1975) introduced a new and some­

what novel method of gathering subjective data. In addi­

tion to parent and teacher rating instruments, they

incorporated information kept in diary form by mothers and

also data collected by way of naturalistic observations in

the home environments of hyperkinetic children. The home

visits were for one hour and involved the recording of

three observations: (1) the number of spontaneous shifts

in activity; (2) the total number of interactions with

parents, peers, siblings, and property; and (3) a global,

subjective rating of hyperkinesis. Correlations between

diary information, home observations, and clinic observa­

tion were reportedly quite high. Especially high correla­

tions were noted between the psychologist's ratings of

46

negativistic behaviors and diary reports of active, nega-

tivistic behaviors.

Three instruments have been quite effective for re­

search work, especially when teachers or other profession­

ally trained raters were involved. In fact, Jones et al.

(1975) have cited research which suggests that these

measures may often tap hyperkinesis which tends to be other­

wise unobservable during the typically brief, often super­

ficial, clinic visit. These authors pointed out that

" . . . while hyperactive children continue to be referred

to clinics and medical practioners, the final diagnosis of

hyperkinetic syndrome appears to rely heavily upon behav­

ioral reports provided by parents and teachers" (p. 389).

Such reports can be particularily meaningful when the

rating instruments provide specific examples and good

definitions of the behaviors being monitored.

Objective Measures

Attempts have been made to objectify the prr :'' dure of

monitoring childrens' behaviors in order to measu.-i activ­

ity, attention span, impulsiveness, or a number of other

behaviors associated with hyperkinesis. These a. tempts

have typically involved some sort of mechanical device

which taps a unitary dimension of the hyperkinetic syndrome.

Quite frequently this one dimension has been movement. For

47

example, Hutt, Hutt, and Ounstead (1963) utilized a grid-

marked floor within a room to measure the frequency of

actual changes in location on the part of children. Also,

they were able to measure the time a child spent on a

particular activity.

Pope (1970) made use of a number of tasks in an attempt

to objectively assess motor activity in a brain-injured

group of children. He utilized a room which was divided

into four quadrants, each being furnished with a table

which held five identical toys. Children were allowed to

play in the room under a number of different instructional

sets. Measurement involved observations from an adjacent

room as well as readings from two accelerometer activity

instruments worn by each child.

Sophisticated actometers were the contribution of

Schulman et al. (1965). These instruments were styled in

a fashion related to the self-winding watch.

Sprague et al. (1970) utilized a stabilimetric cushion

to measure the extent of seat movement on the child's part

during an experimental task.

Montagu and Swarbrick (1974) described two measures

of the unrestricted movements of a child within an experi­

mental room. The first of these made use of an ultrasonic

system which quantified all motor activity. The second

method measured locational changes only and employed a

48

matrix of electrical pressure mats, such as used in burgular

alarm systems. These were located Under the carpet.

Finally, mention will again be made of the vigilance

tasks (Anderson et al., 1973; Mirsky & Rosvold, 1963) which

were previously described in some detail. This procedure

has already proven to effectively discriminate hyper­

actives, hypoactives, and normoactives. Further sophistica­

tion has been developed (Anderson, Sherman & Williamson,

1976; Williamson, Anderson, & Sherman, In press) and in­

volves another means of measurement, provided from a

stabilimetric cushion in combination with the vigilance

task.

Many of the instruments used to measure hyperkinesis

tap singular dimensions e.g., motor activity. Many of

them, however, ignore qualitative differences in behavior.

Other devices measure the strength of response without

accounting for the overall amount of movement. Some fail

to take into account the child who is active yet attentive.

However, the modification of the vigilance task should pro­

vide information relative to these questions. Still, an­

other issue must be raised where expensive computerized

equipment is employed. That issue involves economics and

availability of these expensive and elaborate devices.

49

Psychometric Diagnosis

Attempts have also been made to utilize psychometric

tests for the diagnosis of hyperkinesis. Douglas (1976)

made a plea that psychologists " . . . put together a diag­

nostic battery to tap this 'attention-impulsivity' syndrome"

(pp. 141-142). While some standardized instruments do tap

areas of relative low performance in the hyperkinetic

child, no clear-cut diagnostic test or even battery of

tests is yet available by which a firm diagnosis can be made.

Douglas (1972) observed certain psychometric areas in

which hyperkinetic children tend to do more poorly than

do normal children. She found, for example, that hyper­

kinetic children performed more poorly on the Stanford

Arithmetic Test and on the reading speed of the Gates

Reading Test than did normal children. Likewise, she

stated that the hyperkinetic group received lower IQ scores

than normals on some, unnamed, group administered intelli­

gence tests. Also, hyperkinetic children were said to

have consistently scored lower than normals on the Good-

enough Harris Draw-a-Person Test, the Bender Visual-Motor

Gestalt Test, and the Lincoln-Oseretsky Schedule of Motor

Development. From reviewing the research literature,

Douglas (1972) further stated that hyperkinetic children

also have great difficulty on tasks such as the MFFT due to

an inclination to choose too quickly while making a

TEXAS TECH LIBRARY!

50

significantly high number of errors. Also, the Porteus

Mazes were found to discriminate between the two groups,

the interpretation being that the task involves planning

ability, impulse control, and also perceptual-motor coordi­

nation. Keogh (1971) was able to support these findings

involving the MFFT and Porteus Mazes through a brief review

of the empirical research.

Anderson (1963) noted a high frequency of rotations

on the Bender Visual-Motor Gestalt Test and also suggested

that the Wechsler Intelligence Scale for Children (WISC),

when given to hyperkinetic children, would often yield a

significantly higher Verbal IQ score as compared to the

Performance IQ. Huelsman (1970) identified a disabled

reading pattern characterized by a lowering of specific

Verbal subtests on the WISC. However, contrary to these

clinical findings, Douglas (1972), in her research program,

found no consistent WISC subtest pattern for hyperkinetic

children. She reported no significant differences between

hyperkinetic and normal children on 41 of the measures

employed, including various tests of reading, language,

auditory discrimination, lateral discrimination, or short-

term memory. Douglas did find consistent differences on

the Goodenough Harris Draw-a-Person Test, the Bender Visual-

Motor Gestalt Test, and the Lincoln-Oseretsky Schedule of

Motor-Development. She stated that these instruments in­

volved both visual-motor ability and concentration.

51

In an attempt to isolate measures best suited for the

ideal test battery mentioned above, Douglas (1972), dis­

cussed a study by Campbell and Douglas (1972), in which 41

normal boys were tested. Instruments used were selected

from those which, based on Douglas' prior research, had

seemed to best discriminate between normal and hyperactive

children. Also added to the battery were IQ and anxiety

measures. Statistical analysis of these data resulted in

a correlational matrix which reflected significant correla­

tions among tests which were thought to measure Douglas'

"stop, look, and listen" dimension. There were few signif­

icant correlations involving either intelligence or anxiety

measures. Factor analysis of the test data resulted in

four factors. The first was comprised of significant load­

ings involving the following tests (in order of their

loading): Porteus Mazes, the Children's Embedded Figures

Test of Field Dependence-Independence, teachers' ratings on

a hyperactivity scale, the eye-motor coordination subtest

of the Frostig Motor Development Schedule, aggressive

responses on a story completion test, the Bender Visual-

Motor Gestalt Test, a listening task, the MFFT, and another

story completion test'involving frustration. The second

factor appeared to be an intelligence factor while the

third appeared to reflect anxiety. The fourth factor was

52

not discussed and accounted for a small amount of the total

variance.

Obviously some psychometric tests are capable of tap­

ping defective performance in hyperkinetic children. How­

ever, a question may be asked regarding the relationship

between these test results and actual life situations.

Caution should be maintained in the use of standardized

test instruments, trying to be certain that the data from

such are, in some way, related to tasks which the child

has to perform on a daily basis. For in the words of

Layborne (197 6):

It should be noted that parents do not bring their children in for treatment to increase their abil­ity on the Draw-A-Man and Frostig Figure Ground Tests, or even to demonstrate improvement on neuro­psychological tests. They bring them in because of gross symptomatology which causes the parents considerable distress. (p. 130)

Physiological Measures

Due to the heavy emphasis on organic theories of the

etiology of hyperkinesis, there is a somewhat implicit

assumption that diagnosis should involve medical-

physiological measures. Again, however, diagnostic skills

have not yet reached the level of sophistication to where

confirmation of the syndrome is possible from a routine,

medical procedure. Perhaps the fault in this implicit

assumption is that it also assumes that organic brain damage

53

has to be involved with etiology. However, it was pointed

out earlier in this paper that medical diagnosis of hyper­

kinesis tends only to serve as validation for previously

observed behavior.

The most commonly used instrument in assessing organic

damage is the EEG and Burks (1960) pointed out that only

about 50% of all hyperkinetic children have abnormal EEG

tracings. Also, some five to 15% of normally behaved chil­

dren tend to register abnormal EEGs. Therefore, neither

false positives nor false negatives would be uncommon if

diagnoses were based only on EEG records. Also, EEG records

are typically very unreliable over time.

Buckland, Burgeous, Vickland, Flagg, and Tollison

(1975) attempted to differentiate hyperkinetic and normal

children on the basis of GSRs under various conditions.

Results showed that normal and hyperkinetic groups did

differ significantly in the level of skin conductance and

in mean change amplitude of non-specific response during a

period of rest. However, in discussing their findings,

the authors stated that GSR measurements tend to indicate

a wide range of arousal patterns and, for the most part,

are not particularly meaningful as a diagnostic device.

The previously discussed study by Satterfield and

Dawson (1971) did show lower basal SCL and smaller amounts

of non-specific GSRs as well as a smaller magnitude of

54

specific GSRs in the hyperkinetic subjects than in the nor­

mal ones. Still, no significant diagnostic application has

been indicated.

Some authors (Laufer & Denhoff, 1957) have suggested

that the response to drug therapy should serve a diagnostic

function. That is, when symptomatic behaviors were noted,

drug therapy could be initiated and symptomatic changes

would warrant a diagnosis of organically based hyperkinesis.

Treatment

Many studies have been reported in the literature

related to the treatment of hyperkinesis. The vast majority

of these involved medical management of the hyperkinetic

child through drug therapy. Other studies involved non

chemical treatment methods, but here the literature proved

to be far less extensive than the medical literature.

Medical Treatment

While drug therapy includes the usage of a number of

different drugs, most medicated, hyperkinetic children are

treated with CNS stimulant drugs. Grinspoon and Singer

(1973), in an historical overview, indicated that the usage

of such drugs is not a new technique. In fact, they traced

the origins of amphetamine treatment back to 1937, at which

time Bradley effectively used Benzedrine on a number of

children who were identified as having school related

55

behavior problems. After treating 30 children, Bradley

(1937) noted that 14 showed marked improvement in their

level of academic performance. Fifteen children became dis­

tinctly subdued in terms of emotional responses, while one

child became more hyperactive.

Solomons (1971) noted that methylphenidate (Ritalin)

was first used in 1958 as a means of managing children with

behavioral disorders. It has since become the most popular

agent in use with hyperkinetic children. Solomons went on

to point out how the use of these stimulant drugs, as well

as tranquilizers and other psychoactive drugs, has rapidly

expanded since the 1950's. While both the methodological

quality and the results of studies on drug treatment vary

widely. Spring, Greenberg, Scott, and Hopwood (1974) noted

that improvement rates vary between 44% and 70%. With this

level of reported success, it is not surprising that drug

therapy is highly prescribed for the hyperkinetic child.

The effectiveness of the stimulant drugs has been

described as a paradoxical action based on the noted calm­

ing effects on hyperkinetic children. However, it was the

contention of Laufer, Denhoff, and Solomons (1957) that

hyperkinesis results from diencephalic dysfunctioning.

They hypothesized that either structural impairment or a

maturational imbalance between the diencephalon and the

cortex rendered the diencephalon incapable of inhibiting

56

or screening irrelevant stimuli. The function of the stimu­

lant drug was to stimulate the inhibitory function of the

diencephalon and prevent the irrelevant stimuli from over­

whelming the cortex.

Glennon and Nason (1974) also contended that the

effects of the stimulant drugs are not actually a paradoxi­

cal reaction. These authors expressed a theory of slow

cortical maturation, related to an understimulated cortex.

They pointed out that, following stimulant drug therapy,

the quantity of activity actually increases, but restless­

ness diminishes while thinking and behavioral responsiveness

become more normal. <_ -

Satterfield, Cantwell, and Satterfield (1974), in

their empirical work involving SCL and EEG measures, hypoth­

esized that stimulant medication increased CNS arousal and

also raised inhibitory levels in hyperkinetic children.

The increased inhibitory control served to reduce inappro­

priate, non-goal directed behaviors. The key point of their

neurophysiological theory involved low arousal and poor

inhibitory controls over motoric behaviors. The lack of

"inner control," in turn, resulted in a "flooding of the

brain by sensory signals arising from within and without"

(p. 842). The result was behavior which was affected by

much irrelevant stimuli over which the child had no control.

These authors stated that stimulant medication does not

57

reduce the distracting impulses, but rather stimulates and

restores the CNS to a more normal state and allows a greater

degree of behavioral control. They placed much emphasis on

the child's inability to control his behaviors without

medical treatment and contended that other, non-medical

modes of therapy, cannot be expected to be successful.

Stimulant Medication

Weiss, Werry, Minde, Douglas, and Sykes (1968) placed

13 hyperkinetic children on dextroamphetamine and compared

them with an equal number of children on a placebo. After

three to five weeks, notable differences were reported on

two of four behavioral dimensions on a rating scale.

Sykes, Douglas, Weiss, and Minde (1971) conducted a

study comparing 19 normal control children with 4 0 hyper­

kinetic children, half of whom received methylphenidate and

half of whom were given a placebo. Dependent measures

included the Continuous Performance Test (CPT) and a sta­

bilimetric cushion to measure motoric restlessness. The

hyperactive children were clearly inferior to the controls

in terms of ability to make correct responses on the vigi­

lance task while avoiding incorrect responses. Following

the introduction of drug and placebo treatment, significant

improvement was seen in those receiving methylphenidate.

Campbell, Douglas, and Morgenstern (1971) reported two

studies which included an evaluation of the effects of

58

methylphenidate on hyperactive children as compared to an

equal number of normal control subjects. Measurements were

made utilizing several psychometric indices. The hyper­

active children were evaluated to determine the effects of

drug therapy on these measures believed to be reflective of

cognitive >styles. Findings suggested that drug therapy

resulted in a lowering of impulsive behaviors and an im­

proved ability to inhibit incorrect responses.

Comly (1971) conducted a study of 40 learning disabled

children. The study involved a double-blind, placebo-

dextroamphetamine design utilizing both parent and teacher

behavioral rating scales. The results dramatically indi­

cated behavioral improvement in children treated with

dextroamphetamine, as rated by both parents and teachers.

Denhoff, Davids, and Hawkins (1971) explored the

effects which dextroamphetamine exerted on 42 hyperkinetic

children, as reflected on the Davids Rating Scales for

Hyperkinesis. Both placebo and drug effects were examined

and results were felt to indicate that teachers, through

proper evaluation, could accurately identify hyperkinetic

children in the classroom. Likewise, those children selected

as hyperkinetic showed significant behavioral improvement

while on dextroamphetamine.

Conrad, Dworkin, Shai, and Tobiessen (1971) attempted

to determine the effects of dextroamphetamine on behavioral.

59

academic, and perceptual-cognitive functioning of hyper­

kinetic children. At the same time, they compared the

effects of this drug with prescriptive perceptual-cognitive

tutoring. The results were interpreted to suggest that

dextroamphetamine contributed to a reduction of hyperkinetic

behavioral symptoms and improvement in performance on vari­

ous measures of perceptual-motor and cognitive development.

Tutoring was clearly less effective than the drug.

Steinberg, Troshinsky, and Steinberg (1971) examined

46 learning disabled children in a double-blind crossover

design utilizing two treatments—placebo and dextroamphet­

amine drug therapy. The drug treated group showed behavioral

improvement which was clearly distinguishable from placebo

effects. Also, it was noted that the best results from

dextroamphetamine were seen in children with at least one

neurological hard sign or two or more soft signs.

In 1972, Douglas studied the effects of methylphenidate

on hyperkinetic children. The results indicated that the

drug enabled the children to better sustain attention and

control their impulsivity.

Anderson et al. (1974) noted that performance on the

vigilance task was positively affected by methylphenidate

in younger children (seven-nine years), but did not posi­

tively affect the attention span of older (10-12 years)

hyperactive children.

60

Greenberg, Deem, and McMahon (1972) did a study com­

paring the effects of three drugs, dextroamphetamine,

chlorpromazine (Thorazine), and hydroxyzine, as well as a

placebo. They utilized a double-blind design and examined

61 hyperactive boys. Ratings by a teacher, a psychologist,

and a pediatrician discriminated behavioral differences due

to drug therapy. Other discriminating variables were the

WISC and the Porteus Mazes. Overall results showed

chlorpromazine and dextroamphetamine to be equally effective,

significantly more so than either hydroxyzine or placebo.

Aman and Sprague (1974) examined the learning and

retention effects of 18 hyperactive children who were ran­

domly assigned to receive either placebo, methylphenidate,

or dextroamphetamine treatment. The results of alternating

training and retention sessions were measured by a recog­

nition task, a paired associate task, and a maze task.

Based on the results of this study, it was concluded that

neither of these drugs significantly improved learning or

retention.

Werry and Aman (1975) compared the effects of methyl­

phenidate and haloperidol (Haldol) on attention, immediate

recognition memory, and seat activity in hyperactive chil­

dren. Results of this well designed study indicated that

drug effects were small.

61

Grinspoon and Singer (1973) reviewed the literature

regarding the effects of amphetamines on the components

of behavior. They speculated on the possibility that vari-

ous scales and various objective measures may tap very

different aspects of activity. They also restated the

previously mentioned idea that activity must be examined

qualitatively in terms of its situational appropriateness.

The perceived symptomatic improvement reported in many

studies, they felt, might simply be reflective or more

organized, goal-directed behavior and closer approximation

of social norms.

Other Drug Treatments

A number of other pharmacological agents have been

employed in the treatment of hyperkinesis and are worthy

of brief mention.

Caffeine has received some attention as a stimulant

agent capable of improving attention and concentration in

hyperkinetic children (Schnackenberg, 1973; Wunderlich,

1973). The actual chemical effectiveness of this agent,

in the typically small doses, is quite questionable.

Imipramine (Tofranil) has also been utilized with some

apparent degree of success. Winsberg, Bialer, Kupietz,

and Tobias (1972) assessed the relative effectiveness of

imipramine, placebo, and dextroamphetamine. They found no

62

significant differences as reflected on the Purdue Pegboard,

the CEFT, the Bender Gestalt, or the Porteus Mazes. A be­

havioral rating scale by Conners did, however, yield sig­

nificant results indicating that imipramine is an effective

agent for the control of hyperactivity and aggression in

children with severe behavior problems.

Waizer, Hoffman, Polizos, and Engelhardt (1974) treated

19 children with imipramine for eight weeks, then switched

to four weeks of placebo. Based on behavioral ratings,

deteriorated behavior was noted upon initiation of placebo

and discontinuation of imipramine.

Rappaport, Quinn, Bradbard, Riddle, and Brooks (1974)

did a double-blind study comparing the effects of imipramine,

methylphenidate, and placebo treatment on 76 hyperactive

boys. All of the dependent measures resulted in findings

favoring methylphenidate. Imipramine, however, was more

effective with children who were especially inhibited and

anxious.

Whitehead and Clark (1970) conducted a pilot study

designed to compare lithium carbonate, placebo, and

thioridazine (Mellaril) in terms of their effectiveness in

the treatment of childhood hyperkinesis. Neither objective

nor subjective measures reflected any difference between

lithium and placebo groups. Thioridazine produced some

mild reduction of activity.

63

Page, Janicki, Bernstein, Curran, and Michelli (1974)

examined the effects of pemoline (Cylert) on hyperkinesis.

A double-blind drug-placebo design resulted in positive

findings with regard to pemoline as measured by a large

number of subjective and objective measures. Numerous side

effects were, however, associated with usage of the drug.

Dykman, McGrew, Harris, Peters, and Ackerman (1976)

conducted two studies in an attempt to evaluate the effi­

ciency of the stimulant medication, pemoline. They found

both pemoline and methylphenidate to be superior to placebo

effects, but also found methylphenidate to be the more

effective of the two stimulant drugs. Perhaps more impor­

tantly, however, they noted the need for drug efficacy

studies to also examine individual effects. Their obser­

vation was that some children responded well only to

methylphenidate while others improved more while on pemoline.

The Case Against Drug Therapy

A review of the drug related literature may leave the

reader with many questions and little certainty concerning

the effectiveness of drug therapy. Questions arise due to

many factors including inconsistency of methodologies, un­

certainty of just what is being measured, and apparent

contradictions from study to study. Wiens, Anderson, and

Matarazzo (1972), addressed these issues by pointing out

64

that the contradictions and differences of opinion consti­

tuted sufficient evidence from which to conclude that there

is yet no definitive research data on which to base solid

conclusions regarding the effectiveness or the hazards

associated with drug therapy.

Sulzbacher (1971) reviewed 1100 drug related studies

and found that only 210 were judged as having adequate con­

trols. The controlled studies were further broken down in

terms of the type of dependent measures, that is, objective

or subjective. Only 20 studies were found to objectively

indicate that behavior change was a function of drug therapy

while 57 studies showed no significance as reflected by

objective measures. When research utilizing subjective

measures was examined, positive drug effects were indicated

in 86 of 133 studies.

Why, then, based on such ingonclusive research data,

do we persist in the medication of hundreds of thousands of

school children, often without prior efforts to fully eval­

uate their overall situation or attempt to treat them non-

.medically? Offir (1974) answered this rhetorical question

by stating very bluntly that:

We are a nation of pill poppers and potion pushers. Most of us believe in better living through chem­istry, and we prove it by investing billions of dollars worth of prescriptions and over-the-counter remedies to pep us up, calm us down, or keep us at an even keel. It is hardly surprising, then, that many Americans reach for drugs to dose their over­active children, (p. 49)

65

In agreement with this rather negative note, Grinspoon and

Singer (1973) stated that the apparent enthusiasm regard­

ing the administration of stimulant drugs was such that

serious evaluation of the drugs' efficiency and attempts to

adequately define and diagnose the disorder were being

ignored. Likewise, Douglas (1972) admitted a general lack

of understanding regarding how these drugs work to produce

behavior changes. She suggested that this alone places '

the clinician in a position of ethical concern unless the

medications are used only when symptoms are extremely debil­

itating. To support this argument further, Grinspoon and

Singer (1973) reviewed the toxic effects which often result

from drug therapy, even when behavioral benefits occur.

The most common of these are: anorexia, insomnia, gastro­

intestinal distress, dizziness, fine tremors, coldness of

the extremities, and pallor of the skin. Douglas (1976),

even suggested the possibility of more serious problems

such as heart damage. Others have noted that hyperkinetic

symptoms are sometimes exacerbated following medication.

A growing concern is reflected in the writing of many

individuals (Dykman & Ackerman, 1976; Furman & Feighner,

1973; Fowlie, 1973; Grinspoon & Singer, 1973; Walker, 1974)

which relates to the possibility of masking certain of the

child's symptoms without actually facing the underlying

problem or being knowledgeable of the etiology. This

66

involves an opinion that medication alone cannot solve all

of the multiple behavioral problems involved in the syndrome

and that it should serve only as a method of enhancing the

child's chances of being receptive to remedial education

programs, psychotherapy, or some other approach aimed at

the base of the problem.

Grinspoon and Singer (1973) addressed another issue,

concerning the chemical treatment of hyperkinesis. This

issue related to the possibility of infringement on the

civil rights of children. They expounded on a 1968 comment

by Ladd and stated that:

Using drugs to 'modify' classroom behavior constitutes a covert subversion of what should be our educational ideas. If an important aim of our educational institu­tions were really to help young people deal with and learn to regulate their 'self-destructive' or even 'anti-social' tendencies it would make little sense to give them drugs as soon as they exhibited restless or unruly behavior. Students, and perhaps especially those at the elementary level, need and deserve educa­tional environments designed to help them come to grips with their natural dispositions and learn to use in a certain way what Philip Jackson at the Uni­versity of Chicago has nicely called their own 'ex­ecutive powers.' Any form of intervention that relieves a restless or unruly child of the need, or deprives him of the opportunity, to use his executive powers deprives him to that extent of the chance to develop insight and skill in self-control.' (p. 544)

We must then, based on this philosophy, heed the words

of Douglas (1976) and "shift our efforts . . . toward an

attempt to help these children through a training approach"

(p. 146) or some form of treatment which does allow the

67

child to exercise his own "executive powers" and frees him

from the possibility of toxic side effects from chemical

treatment.

Non-Medical Treatment

Least the foregoing discussion concerning the negative

aspects of drug therapy be misleading, some clarification

is in order. This issue, which several authors have

addressed (Barcai & Rabkin, 1974; Conners, 1973; Dykman &

Ackerman, 1976; Minde, K., Lewin, D., Weiss, G., Lavigueur,

H. , Douglas, V., & Sykes, E., 1971), is simply that drug

treatment alone, or drugs without first considering alterna­

tive treatment methods, may be a costly error. This is

based on the assumption that drugs alone teach the child

nothing, except perhaps that he is "sick" and in need of

medication. When drugs are used at the exclusion of other

forms of treatment, long-term improvement may well be sacri­

ficed with the only result being a temporary masking of

symptoms.

From an idealistic standpoint, the multimodality

approach to treatment such as that discussed by Satterfield,

Cantwell, and Satterfield (1974) would seem desirable.

This involves individualized treatment based on comprehen­

sive assessment of each child and his family. The argument

for such an approach was based on their view of the

68

hyperkinetic child as a multi-handicapped individual who

probably suffers from low self-esteem, academic failure,

depression, poor peer relationships, and other secondary

emotional symptoms. Also, such a child often becomes the

family and/or classroom scapegoat, thus further exacerbat­

ing his/her disability. When these dynamics are operative,

alternative treatment methods should be explored and these

should take into account the child's total "system" as

earlier discussed in this paper. A number of these alter­

natives will now be briefly reviewed.

One possibility is to manipulate the child's environ­

ment in such a way as to minimize the distraction of extra­

neous stimuli. Glennon and Nason (1974) dealt briefly with

this issue, suggesting the utilization of special seating

arrangements, perhaps study cubicles, making changes in

room decor, and so on. VJerry (1968) concluded that hyper­

kinetic children were in need of a structured environment

in which daily routines are regular, limits are firm, and

overstimulation and excessive fatigue are avoided. Barsh

(1965) stated a belief that changes will occur in the

child's control of his behavior when his environment is

restructured. This environmental manipulation was described

as a means of helping the child to compensate for lack of

inner control and was described as the first step in help­

ing him to gain self-control.

69

The possible use of psychotherapy in the treatment of

hyperkinesis has been mentioned several times already in

this paper, but actual studies involving such have seldom

appeared in the literature. When this mode of treatment

has been mentioned, the tone has been rather pessimistic

except where behavioral therapies were utilized. One excep­

tion to this was noted by Cermak et al. (1973). They gave

a positive report concerning the effects of activity group

therapy. Based on subjective findings, they contended that

the group setting could afford opportunities for social

learning resulting in the acquisition of new social skills,

better concentration, more self-confidence, and less dis­

ruptive behavior.

Werry (1968) contended that, in the treatment of hyper­

kinesis, the trend is away from more traditional, insight

oriented psychotherapies. Instead, the emphasis is on

those observable behaviors which actually bring the child

into conflict with his world. Treatment then, typically

involves a system of rewards and/or punishments utilizing

conditioning procedures.

Grinspoon and Singer (1973) were careful to point out

that the use of behavioral techniques has great potential

with respect to the hyperkinetic child., They contended that

when used properly these techniques can serve as a vehicle

by which hyperkinetic children can utilize their own power

70

and self-control to accomplish the goal of extinguishing

maladaptive symptoms. They further contended that behaviors

learned in this manner will generalize to situations beyond

that in which the new learning occurred. However, these

authors were quick to point out that behavioral techniques

could not be viewed as a panacea and, like drugs, could be

abused if the involved parties were not sensitive to the

individual needs, talents, and preferences of involved

children. Dykman and Ackerman (1976) also cautioned that

the reinforcement must be related to that aspect of the

task which is to be learned and that the task must be real­

istically attainable. They further cautioned that care must

be taken to avoid the possibility of utilizing a reinforcer

which overly excites the child.

Taking a behavioral approach to the problems involved

in hyperkinesis, Wunderlich (1973) stated a belief that

hyperactive behavior is frequently, yet unconsciously

rewarded by well-meaning, but ineffective parents and teach­

ers. This typically involves adult over reactions and the

paying of excessive attention to extraneous movements and

other hyperactive symptoms. This situation then, speaks

to the issue of parental or teacher involvement in treat­

ment plans and should involve teaching these adults the

basic concepts of behavioral theory.

Furman and Feighner (1973) saw the need to educate the

parents of hyperkinetic children regarding their parent-child

71

interactions. They chose to add videotape feedback to a

treatment program which had previously relied on chemo­

therapy and traditional parent group counseling. They

videotaped parent-child interactions and then immediately

played them back for the parents, without the children. In

this case, behavioral modification principles were applied

to the parents, rather than the children. That is, parents

were reinforced for appropriate interaction and for not

reinforcing the child's maladaptive symptoms. Results were

reportedly very favorable with noted generalization to the

home environment.

A rather large number of examples of the clinical

application of behavioral therapy can be found in the lit­

erature. Quay, Sprague, Werry, and McQueen (1966) success­

fully utilized flashing lights as a reinforcer for attentive-

ness. Dykman and Ackerman (1976) referred to the effective

use of both contingency management plans and token economy

conditioning procedures. Lovitt (1973) successfully used

self-charting of behaviors as a management procedure.

Meichenbaum (1971) trained children to talk themselves into

responding less impulsively.

Alabiso (1975) utilized both social and token rein-

forcers with eight, institutionalized, hyperactive retar­

dates. He was able to operantly control their attention

span, their focus of attention, and also their selective

72

attention in a laboratory situation. It was further re­

ported that this training effectively generalized to the

classroom situation.

Christensen and Sprague (1973) compared the effects of

methylphenidate, placebo, and a token reinforcement system.

Subjects were 16 hyperactive retardates. The resuls indi­

cated that the effects of methylphenidate were minimal as

compared to those of the behavioral modification program.

The authors concluded that medication to control hyper­

active, mentally retarded children is probably unnecessary

when a sound behavioral management program can be utilized.

Anderson, Sherman, and Williamson (1976) did pilot work

involving a somewhat novel approach to the modification of

hyperactive behaviors within the classroom situation. It

was their goal to train children to be more attentive.

Their method involved visual feedback in response to non-

attending behaviors. Specifically, they placed a small box

with light emitting diodes on the desk of children pre­

viously identified as hyperkinetic. An observer activated

the child's unit when nonattending behaviors were noted.

This procedure resulted in dramatic decreases in non-

attending behaviors and equally striking increases in out­

put of academic "busy work."

Simpson and Nelson (1974) stated a desire to simplify

training procedures by minimizing the number of behaviors

73

to be modified. Their desire was to select a higher-order

behavior related to the overall level of activity. They

chose respiration, believing this to involve a sensitive

system of behaviors. It was felt that when this system was

controlled, self-control of disruptive motor behaviors would

also result. They utilized both operant conditioning prin­

ciples and biofeedback. Actually the study was plagued by

a number of methodological flaws, but still, support for

the effectiveness and feasibility of the procedure was

obtained. Perhaps the most negative finding was that the

ability to control breathing behaviors did not seem to gen­

eralize to the classroom situation.

Nail (1973) having done some earlier pilot work with

alpha feedback training, set out to explore how this might

affect the hyperkinetic or learning disabled child. Three

groups were studied: an alpha feedback group, a false feed­

back placebo group, and a no treatment control group. It

was hypothesized that alpha feedback training would result

in an increased amplitude of alpha waves and parallel behav­

ioral improvement. Improvement was noted, but statistical

significance was not achieved. It was further hypothesized

that increased alpha would result in .increased attention

span and comprehension on a learning task. There were no

significant differences among the three groups in terms of

overall achievement, but reading improvement was noted

74

within the treatment group. The overall lack of significant

findings led to the speculation of several theories, one of

which was that alpha may be the wrong focal point in terms

of biofeedback modes. However, alpha did appear to help a

number of individual children, but the reason for such

remains uncertain. Nail mentioned the possibility of im­

provement being related to the special attention, or some

other unknown factor.

Braud (1974) conducted an ambitious study involving a

comparison of the effects of electromyographic (EMG) bio­

feedback with the effects of audio taped progressive

relaxation as applied to hyperkinetic children. Dependent

measures included: Digit Span, Coding, Visual Sequential

Memory from the Illinois Test of Psycholinguistic Abilities

(ITPA), the Bender-Gestalt Test, six behavioral rating

scales, and EMG readings of muscle tension. The study indi­

cated that, prior to treatment, hyperkinetic children were

significantly more muscularly tense than were non-

hyperkinetic children. Both treatments, biofeedback and

progressive relaxation training, resulted in significant

decreases in muscle tension. Also, both procedures resulted

in a significant decrease with respect to hyperkinetic symp­

toms as reflected on parent rating forms. The two treatment

groups did not differ significantly in terms of behavioral

improvement. Both resulted in decreased crying, decreased

75

frustration, decreased hostility, and overall indications

of emotional improvement. Likewise, significant improve­

ment was noted on both the Bender-Gestalt Test and the

Visual Sequential Memory subtest of the ITPA.

It might be noted that the lack of difference between

the results of biofeedback and progressive relaxation is

not surprising. Fray (1975), in a study involving the

treatment of essential hypertension, found progressive relax­

ation to be about as successful as EMG biofeedback. Melzack

(1975), also cautioned his readers not to view biofeedback

as a new panacea and suggested that symptomatic relief

probably resulted from distraction, suggestion, relaxation,

and a sense of control, all of which are involved in, but

not dependent on biofeedback devices.

Braud et al. (1975) treated a six-year-old hyperactive

boy with severe academic problems by use of EMG biofeedback.

He was treated over a seven-week period and then seen on a

seven-month follow-up. He reportedly achieved a substantial

decrease in muscular tension and a continued ability to con­

trol his hyperactivity. Psychometric posttesting at some

unspecified period reflected improvement on four ITPA sub­

tests ranging from 2 5 to 56 months. Attention span and

positive changes in self concept were subjectively noted as

was the alleviation of a number of previously noted psycho­

somatic symptoms. Generalizability to other situations was

76

inferred due to the fact that the EMG posttest, reflected

low muscle tension seven months beyond the last training

session, even though it was administered by a stranger in

an area different from that in which training was

conducted.

Haight, Irvine, and Jampolsky (1976) reported a pilot

feasibility and demonstration study which was designed to

explore the usefulness of EMG training with hyperkinetic

boys. Four of the subjects received nine feedback sessions

and were compared with an equal number of control subjects.

Dependent measures were administered in pre-post fashion

and included EMG readings as well as seven psychometric

instruments. No statistically significant findings were

noted, but three subjects in the EMG training group showed a

lowering of muscle tension as compared to two control sub­

jects who,showed similar improvement. Likewise, all four

experimental subjects showed reduction in the level of

hyperactivity, while such improvement was also noted in two

control subjects. Psychometric testing reportedly showed

trends suggesting improvement. The authors attributed

their lack of statistical significance to lack of control

for the Hawthorne effect.

Connoly, Besserman, and Kirschvink (1974) used EMG and

Jacobsonian relaxation techniques in a pilot study involving

eight hyperkinetic children. Subjects were pretested on a

77

large number of psychometric instruments, parent and teacher

ratings, and EMG recordings. Following eight sessions of

only 20 minutes each, all children showed significant lower

levels of hyperactivity as reflected on the rating scales.

Also, improvement on the Coding and Mazes subtests of the

WISC was statistically significant.

Shouse and Lubar (1976) contended that a significant

correlation existed between somatomotor inhibition and con­

ditioned increases in sensorimotor rhythm (SMR). They felt

that this suggested a potential for SMR biofeedback training

for hyperkinetic children. Two children were provided SMR

training and the final conclusion was that SMR conditioning

could facilitate treatment effects already established with

medication.

Guralnick and Mott (1976) utilized respiration feedback

in an attempt to treat an 11-year-old learning disabled

child who appeared to have no voluntary control over his

respiratory movements. Vital reflex mechanisms were normal,

but breathing was shallow and speech patterns were disturbed.

Following free, non-structured exploration of the relation­

ship between respiratory movements and biofeedback, in­

creased external and self-directed control over the direction

and volume of breathing was achieved. The results of this

case history spoke to the potential usefulness of such

biofeedback techniques.

78

The preceding review of biofeedback literature sug-

gested that such procedures are promising in the treatment

of hyperkinetic children. However, based on the Braud

(1974) study, it seems that progressive relaxation may

hold the same potential, but without the expense or confin­

ing aspects imposed by the biofeedback equipment. A limited

number of studies have explored the effectiveness of progres­

sive relaxation in the treatment of hyperkinesis. This form

of intervention is included in what Braud (1974) referred to

as self-control training. Self-control training, she felt,

is indicated as an adjunct therapy or perhaps a primary

therapy based on findings which suggest that, even when drug

therapy is effective, certain behaviors, including aggres­

sion, irritability, and low frustration tolerance, still

persist.

Carter and Synolds (1974) presented an audio relaxation

tape to 32 minimally brain-injured children- three times a

week for four weeks. These experimental subjects were com­

pared with classmates who served as controls. Independent

judges, with very high interjudge reliability, rated hand­

writing samples of each child noting the following specific

variables: space, size, consistency, line quality, letter

formation, neatness, and overall legibility. The program

appeared quite effective in enhancing handwriting quality,

with transfer noted to nonexperimental situations. Also,

79

these changes were stable over an unspecified time period

without continued intervention.

Lupin, Braud, Braud, and Duer (in press) utilized a

series of commercially prepared tapes for children and

adults. These tapes were designed to teach progressive

relaxation and utilized imaginative stories. They were

specifically produced by Lupin for use with hyperactive

children with other behavior problems. Thirteen children

constituted the sample for the study by Lupin et al. All

13 were treated over a two and one-half month period. Some

were medicated while others were not. Parents were required

to participate by listening to prepared tapes as follows:

(1) an explanation of behavior modification principles;

(2) instructions on how to utilize the overall prepared pro­

gram; (3) adult relaxation exercises; and (4) story tapes

incorporating visual imagery as a means of reinforcing re­

laxation. Children also used six different tapes. The

first of these taught basic relaxation techniques. The

second involved a discussion of attitudes. The remaining

four tapes were described as trips in the imagination and

involved visual imagery plus actual visual and auditory

stimuli designed to facilitate imagery.

A number of measures were made to evaluate this program

of relaxation training. These included: (1) daily parental

records including frequency of tape usage and noteworthy

80

behaviors; (2) pre and post parent rating scales; (3) pre

and post psychometric data including Coding, Digit Span,

and Object Assembly of the WISC and Visual Sequential Memory

of the ITPA; and (4) pre and post classroom behavioral

ratings. Statistically significant results were found on

three different ratings of classroom behavior: (1) working

on assigned tasks; (2) fidgeting and nervous behaviors.

Relaxation training resulted in improvement in all three

classroom behaviors. Parent rating was reportedly reflec­

tive of positive change, but statistical analyses were not

mentioned. Positive changes in the Digit Span and Coding

subtests were both statistically significant. Also, the

authors reported that the degree of home participation was

seemingly a critical variable, but no statistical analysis

was employed to test this observation.

/ Prognosis for the Hyperkinetic Child

In response to any questions concerning the long-term

prognosis of the hyperkinetic child, the answer must again,

communicate uncertainty. However, there is some evidence

to suggest that the problems secondary to, or somehow

related to hyperkinesis do persist into adulthood.^ Several

authors (Cermak et al., 1973; Huessy, Metoyer, & Townsend,

1974; and Werry, 1968) spoke of overall, long-term social

and academic adjustment problems and extremely low self

81

concepts which tend to follow the actual hyperkinetic symp­

toms. Dykman and Ackerman (1975) followed 23 hyperactive

boys from grade school until age 14. Of these, only three

presented no problem to the home, school, or community at

age 14. Barcai and Rabkin (1974) related childhood hyper­

kinesis to delinquent or other antisocial behaviors in

later life. Explaining this, they stated:

The life history of the hyperkinetic child begins, then, with a set of deficient constitutional, tempermental patterns which mark him for potential rejection. He is not provided with, or cannot benefit from, parental limit-setting because of his unpredictability and thus becomes involved early on in an aggression-retaliation cycle. These factors make the choice of a delinquent life style a most functional one. (p. 395)

Two other studies (Mendelson, Johnson, & Stewart, 1971;

Weiss, Minde, Werry, Douglas, & Nemeth, 1971) suggested

that attentional handicaps persist into the teens and be-

yond as does academic underachievement. Also, emotional

immaturity, low self esteem, feelings of hopelessness, and

absence of future goals were noted. These studies collec­

tively speak to the need to find ways in which to help this

group of troubled children.

Summary

Hyperkinesis has been defined as a highly complex

cluster of behaviors characterized primarily by motoric

restlessness, poor attention, and exaggerated levels of

82

I activity. Other associated behaviors, such as academic

underachievement, have been noted, but questions remain as

to whether these are primary or secondary factors. Other

characteristic behaviors are more obviously secondary and

include severe frustration, poor interpersonal skills,

markedly lowered self esteem, and antisocial behaviors.

(Knowledge of the hyperkinetic child syndrome is still

greatly lacking with respect to etiology, diagnosis, and

treatment. Some factors such as organic brain dysfunction

tend to correlate highly with hyperkinesis, but cause and

effect relationships have not been clearly validated. Like­

wise, various treatment modalities have provided sympto­

matic relief, but again, a thorough understanding of these

effects is still lacking.

The use of stimulant drugs has become the most popular

mode of treatment and, in fact, hyperactivity has frequently

been reduced by medication.' However, numerous authors

(Denhoff et al., 1971; Weiss et al., 1968) have noted that

other related behaviors, especially aggression and dis­

tractibility, seem to persist, even under medication^ Also,

negative side effects with chemical treatment have been

commonly reported in the literature. These reports have

been severe enough to generate questions regarding the use

of these chemical agents. These concerns have related to

both potential physical hazards and also ethical

considerations.

83

Numerous attempts have been made to utilize alterna­

tive treatment approaches in an attempt to modify those

behaviors of the hyperkinetic child which often are un­

affected by medical treatment. A major goal of these new

treatment efforts has been to improve the long-range, nega­

tive prognosis which has so often been associated with the

hyperkinetic child syndrome.

Statement of the Problem

The issue of treatment for the hyperkinetic child is

of paramount importance and deserves maximum effort from

physicians, educators, psychologists, and researchers who

are involved with these children, Sprague (1976) very r

adequately articulated this concern when he stated that:

The emphasis on diagnosis and prediction in this area has turned people's interests, energy, time, and money away from training or treatment per se, which is most unfortunate. To use a trite phrase, what is needed is a reordering of the priorities, so that the lion's share of the time, energy and money is not devoted to diagnosis and prediction, but ample resources are made available for the main job at hand, namely the training of children, (p. 110)

\ Recent efforts have been made to explore new treatment

modalities which may be impactful on a number of the mal­

adaptive symptoms often seen in hyperkinetic children^

This can be evidenced in the studies by Braud (1974) and

Lupin et al. (in press), which have strongly suggested that

relaxation training may serve a vital role in the treatment

84

of hyperkinetic children. While the results of these

studies are generally encouraging, several questions remain

unanswered. Brand's study, for example, included some

rather subjective conclusions concerning the positive

changes in self esteem as related to the relaxation proce­

dures. Also, neither the Lupin nor the Braud study

accounted for possible age differences. In fact. Brand's

subjects ranged from six to 15 years of age. Her design

yielded only the collective results for all subjects, with­

out examining possible age differences. Neither these two

studies, nor other relaxation studies with hyperkinetic

children, have examined the possibility of experimental

differences due to mere attention factors, unrelated to

relaxation training itself. The expectancy set under which

subjects were given an explanation of relaxation is another

variable which has not been previously considered with a

hyperkinetic population.

Following the advice of Halcomb (1976), the current

study progressed in an orderly and systematic fashion from

the two previous, related studies. The intent of the

research project was to further evaluate the effectiveness

of relaxation training for the hyperkinetic child. Many

questions remained unanswered by the studies of Braud (1974)

and Lupin et al. (in press). Only through this step-by-

step progressive approach to research can the effectiveness.

85

utility, and practicality of the treatment be assessed.

The following research questions have remained empirically

unvalidated and constitute the. focus of the current

investigation:

I. Will an attempt to treat hyperkinetic children

through systematic relaxation procedures result in signifi­

cant behavioral improvements as noted on behavioral rating

scales?

a. Will differences in behavioral ratings prove to be

related to the age of the children?

b. Will differences in behavioral ratings prove to

be related to the instructional set under which the chil­

dren received relaxation training?

c. Will differences in behavioral ratings, prove to be

related to mere attention, in the absence of relaxation

training or motivational instructions?

II. Will an attempt to treat hyperkinetic children

through systematic relaxation procedures result in signif­

icantly more positive measures of self concept?

a. Will differences in self concept prove to be related

to the age of the children who receive relaxation training?

b. Will differences in self concept prove to be re­

lated to the instructional set under which the relaxation

was conducted?

86

c. Will differences in self concept prove to be

related to mere attention, in the absence of relaxation

training or motivational instructions?

III. Will an attempt to treat hyperkinetic children

through systematic relaxation procedures result in signif­

icantly improved performance on Wechsler Intelligence

Scale for Children - Revised (WISC-R) subtests?

a. Will differences on the WISC-R subtests prove to

be related to the age of the children?

b. Will differences on the WISC-R subtests prove to

be related to the instructional set under which the relax­

ation training was conducted?

c. Will differences on the WISC-R subtests prove to

be related to mere attention, in the absence of. relaxation

training or motivational instructions?

CHAPTER II

METHODOLOGY

The purpose of this chapter is to describe the proce­

dures and instruments utilized in answering the research

questions. Those areas which are discussed include:

(1) population characteristics: (2) selection of subjects;

(3) experimental design; (4) procedures; (5) instrumenta­

tion; (6) research hypotheses; and (7) statistical analyses.

Population Characteristics

Subjects considered for participation in this study

were referred by the Pediatrics section, Darnall Army

Hospital, Fort Hood, Texas. The pediatric clinic serves

the dependents (up to age 12) of military and retired mili­

tary personnel in the Central Texas area. More than 50,000

servicemen were stationed at Fort Hood during the period of

the study. Some of the dependent children of these service­

men attended school on the base, but the vast majority

attend public schools in communities throughout the Central

Texas area.

Selection of Subjects

As pointed out in Chapter I, the diagnosis of hyper­

kinesis is neither a simple procedure nor an exact science.

Consequently, subject selection can be difficult. Probably

87

88

the most reliable and objective approach to making the

necessary diagnosis would involve the vigilance task as

described by Anderson et al. (1973). However, since the

vigilance task was not available, a more subjective approach

to subject selection was employed for this study.

The initial phase of subject selection involved review­

ing a list of children who had been diagnosed as hyper­

kinetic by a pediatrician and/or a psychologist at Darnall

Hospital. In most instances, referral to the clinic and

subsequent diagnosis of hyperkinesis were preceded by a

school initiated referral.

In addition to the professional diagnosis, the children

had to meet the following' qualifications in order to be

included in the study:

1. Acceptable age was six through eleven years.

2. A score of 19 or more had to be obtained on the

Davids Rating Scales (Davids, 1971). This cut­

off point was selected due to prior empirical work

with the instrument (Davids, 1971; Denhoff et al.,

1971) which resulted in four ranges relating to

the degree of hyperactivity. Those children who

manifested very few or no behavioral indications

of hyperkinesis consistently received Davids

ratings of less than 19. Consequently, this lower

range was labeled as "Clearly Not Hyperkinetic."

89

No child who had been identified as hyperkinetic

and referred for participation in this study

received a Davids score of less than 19.

3. A measurable IQ of 80 or more was required.

4. Written parental permission for participation in

the study was required and included a statement

of intent to complete the research program.

Potential subjects who met the above criteria were not

considered for participation in the study if:

1. They were on medication for hyperkinesis or had

been medicated one week prior to the onset of the

study. It was further agreed that medication was

to include the therapeutic use of coffee.

2. They had been diagnosed as psychotic, autistic, or

severely emotionally disturbed.

3. They had physical problems, such as poor hearing,

which would impede treatment effects. One child

who carried a diagnosis of hyperkinesis was ex­

cluded due to the fact that he had been temporar­

ily placed in a body cast for treatment of a

spinal disorder.

Based on these criteria, five subjects were assigned

to each of eight different groups. The relatively small >

sample size was deemed adequate based on the previously

reported significant results of Braud (1974). She utilized

90

the same relaxation program which was employed in this

study and with a cell size of five subjects attained sta­

tistical significance on numerous measures. Also, the

availability of qualified subjects turned out to be a

critical factor.

Experimental Design

The design which this study utilized was a more complex

version of the Pretest-Posttest Control Design (Campbell and

Stanley, 1963). The design, in its basic form, was concep­

tualized as follows:

R 0 X 0 R 0 0

The authors utilized a notation system in which "R" repre­

sented random assignment to treatment groups while "0"

represented an observation (dependent variable), and "X"

represented some treatment (independent variable).

For the purpose of this study, the basic Pretest-

Posttest Control Group Design was expanded as follows:

R 0 X , 0 R 0 X^^ 0 R 0 X^^ 0 R 0 - 0 R 0 X, , 0 R 0 Xj 2 0 R 0 X, -, 0

R 0 ^^ 0

The notations presented in the expanded design are identical

to those discussed above, but with additions. The lower

91

case letters, "a" and "b," represent two separate age

groups of children which were compared across three differ­

ent treatments, "1," "2," and "3." The "a" groups were

comprised of children, age six through eight who were ran­

domly assigned to one of three treatment groups or a no-

treatment control group. The "b" groups were comprised of

children, age nine through 11 and they were also randomly

assigned to one of the four possible groups. The desire

to examine differential effects of age related to a belief

that increased levels of cognitive development will enhance

the effectiveness of relaxation training. That is, older

children should be able to understand and follow both the

instructions and concepts of relaxation better than

younger children.

The two treatment groups, X . and X, , represent those

subjects who were exposed to relaxation training in con­

junction with an elaborate statement of treatment expecta­

tions. At specified times during the study, these subjects

were told with energetic enthusiasm how helpful the relax­

ation training would be to them. This procedure was

modeled after the concept of Task Motivational Instructions

(TMI) as presented by Barber (1969). Barber defined the

Task Motivational Instructions as ". . . exhortative state­

ments that a high level of.performance is possible and

expected" (p. 44). Barber researched this concept rather

92

extensively and found it to produce very favorable results

when used as an adjunct to hypnotherapy. Barber defined TMI

not as a treatment modality in itself, but rather as an

added variable which facilitates task attainment. He

stated (1969, pp. 70-71) that TMI includes at least two in­

dependent variables. The first of these was labeled

"cooperate-try instructions" or instructions which, for

example, state that task performance depends on willingness

to try or cooperate. The second variable was labeled as

"statements that it is easy to respond to suggestions and

to experience the suggested effects." Andreychuk (Personal

Communication, 1977) viewed TMI as a demand characteristic

or expectation which can enhance the effectiveness of a

treatment by making suggestions and stating expectations.

He used biofeedback as an example and stated that recent

research has shown that effectiveness of this treatment can

be enhanced by the addition of hypnosis or TMI. Andreychuk

contends that while the effects of TMI are not necessarily

viewed as long-lasting, they are viewed as something more

than a generally encouraging attitude. This is believed

to relate to the presence of specific instructions and

suggestions.

Groups X 2 ^^d ^h2 ^^c^iv^^ relaxation training iden­

tical to the preceding groups, but in the absence of any

verbally expressed expectations or encouragement.

93

Groups X^2 and X ^ were attention placebo groups,

while two additional groups, one from each age range,

served as controls who received no treatment at all. Using

the Campbell and Stanley (1963) notation, the no-treatment

control groups are represented by the'absence of an "X"

between the first and second observations ("0").

Procedures

Medical records of prospective subjects were reviewed

to gain a preliminary indication of each child's eligibility

for the study. When it appear that subjects were eligible,

telephone contact with the parent was made. At that point,

a brief explanation of the study was given. It was ex­

plained that their pediatrician had requested their partici­

pation in research designed to evaluate safe, non-medical

treatments which might eventually serve to help hyperactive

children or children who are overly active. As an ethical

consideration, it was explained that more than one treat­

ment was under evaluation.

If the parent agreed, an appointment for both parent

and child was arranged. At that time, written permission

was obtained on a prepared form (Appendix A) and the Subject

Information Sheet (Appendix B) was completed. The parent

was asked to complete the rating scale by Davids (Appendix

C), while the child took the Peabody Picture Vocabulary Test

94

(PPVT). The child was randomly assigned to one of the four

possible groups within his appropriate age level if he met

the criteria for inclusion.

Pretest

Following assignment to the appropriate treatment

group, the pretest battery of psychological tests was

completed.

In addition to the two previously mentioned instruments,

all subjects completed the following: (1) The Piers-Harris

Children's Self Concept Scale; (2) The Mazes subtest of the

WISC-R; (3) The Digit Span subtest of the WISC-R; (4) The

Coding subtest of the WISC-R. These are discussed in more

detail in the section on instrumentation.

Relaxation Training

The primary focus of the study involved the evaluation

of relaxation training as a treatment method for use with

hyperactive children. While this specific application of

relaxation is rather new, the concept of progressive relax­

ation is not. Jacobson (1928) noted the beneficial effects

available through learning a systematic approach to muscle

relaxation. He contended that by learning to relax muscles

and groups of muscles, a habit response would be formed.

Jacobson proposed that progressive or differential relax-^

ation could lead to the absence of undue contradiction and

95

often served to make people aware, frequently for the first

time, that tension had been unknowingly present; He con­

tended that a positive effect could often be attained in as

few as two or three sessions.

Others (Lazarus, 1971; Wolpe & Lazarus, 1966) have more

recently made effective use of this basic technique. Lupin

(1974) commercialized an audio-taped program of relaxation

training which was designed especially for children. This

has been employed with hyperkinetic children on at least

two occasions (Braud, 1974; Lupin et al., in press). The

program drew from the basic concepts as proposed by Jacobson,

but extended the program to include visual imagery and sound

effects designed to further enhance relaxation. Also, it

incorporated an approach believed to enhance the children's

self concept.

The relaxation program developed by Lupin consists of

six tapes. The first of these provides a brief explanation

of relaxation training as well as general instructions on

the process of progressive relaxation. The second tape,

entitled "Old Me, New Me," is a story which discusses atti­

tudes, their effects on relationships with other people,

and the effects of relaxation on attitudes. The remaining

four tapes were described as "trips in the imagination."

Specific titles are: "Trip to the Beach"; "Trip to a Star";

"Trip to the Woods"; and "Trip to the Colorado Mountains."

t

96

These story trips involve the use of both visual imagery and

sound effects which are appropriately associated with a par­

ticular story. Lupin et al. (in press), contended that

these effects serve to reinforce the child's feelings of

relaxation while also communicating specific instructions

on how to handle particular forms of stress, how to accept

criticism, and how to effectively express negative feelings.

These tapes were incorporated into the treatment of

four experimental groups. Those included groups were:

^al' ^a2' bl' ^^^ ^b2*

Experimental Treatment Group Procedures (X •, , X, . -al^ bl

Relaxation + TMI)

The Lupin tapes comprised the treatment which groups

X . and X, -. received. The relaxation training consisted of

12 sessions, each of which was approximately 40 minutes in

length. Sessions were scheduled on a three per week basis,

but some individual modifications were required. During

the first three sessions of treatment only the first tape,

entitled "Relaxation Exercises" was utilized. The subjects

were asked to sit or recline in a comfortable position in a

recliner which was located in an office of the clinic. They

practiced the exercise twice during each of the three

sessions.

All subsequent sessions began with relaxation training,

utilizing the general relaxation exercise tape. The second

97

half of sessions four through 12, however, involved taking

one of the imaginary "story trips." These "story trip"

tapes were utilized sequentially on a one time basis through

session eight. Then, during the last four sessions, sub­

jects were allowed to select the story tape which they

preferred.

In addition to simply learning the relaxation technique,

all subjects in groups X -. and X, ,, were presented the TMI.

These instructions were systematically presented in the form

of an audio-taped introduction at the beginning of sessions

one, four, seven, and 10. Also, at the beginning of sessions

two, three, five, six, eight, nine, 11, and 12, the monitor

stated, "Remember and do exactly what the tapes say and you

will find that some very nice things will begin to happen to

you." The complete presentation may be seen in Appendix D.

The essence of the instructions was encouragement of im­

proved ability to listen, to pay attention, to enhance self

concept, to gain a sense of relaxation, and make general

self-improvements.

Experimental Treatment Group Procedures (X ^ ^KO ~

Relaxation Only)

The subjects in these two groups received relaxation

training identical to that described for the X - and X-^-^

subjects. However, the TMI was omitted and no verbal

98

encouragement was offered the children comprising these

experimental groups.

Attention Placebo Group Procedures (X^3, X^^ - Attention)

The two attention placebo groups, like groups X ^ and a^

^b2 ^^scribed above, were conducted in the absence of any

verbalized statement of expectation and the purpose of the

sessions was not mentioned.

Subjects in the placebo groups (X^^ and Xj^^^ were seen

three times a week over a four-week period. Subjects in

these two groups merely listened to professionally recorded

audio tapes which contained selections of outstanding works

of children's literature. These stories were selected with

the aid of an elementary reading teacher.

Positive Reinforcement

An attempt was made to provide positive reinforcement

for attendance of all 40 subjects. Beginning with the pre­

test session, a small token reward was presented at the end

of each session.

Research Assistant

A single assistant was employed to serve as monitor for

the relaxation and placebo groups. This individual was

given instructions in the mechanics of running subjects of

both treatment and placebo groups, but was given no details

99

concerning the actual intent of the study. The monitor

knew only that a study was being conducted and that subjects

were overly active children.

No Treatment Control Group Procedures

The no treatment control subjects and their parents were

seen only twice following the selection procedures. The

first of these occasions was for pretesting on all instru­

ments. At that time, parents were informed that their chil­

dren would be seen again in four weeks for further testing.

The stated purpose of testing was simply to gain "research

information." At the second appointment, all instruments

were, on a posttest basis, completed for the untreated

subjects.

Instruments

The selection of instruments for use in this study was

based on two factors. First of all, it was deemed critical

that a particular measure be sensitive to changes in hyper­

kinetic children as a result of the treatment. Secondly,

since two separate age groups were compared, it was neces­

sary that scores not reflect inherent developmental

differences.

One instrument served as a screening device in subject

selection. In addition to this, seven dependent measures

were taken.

100

Peabody Picture Vocabulary Test

The PPVT (Dunn, 1965) is an untimed, individual test

which typically takes 15 minutes or less to administer. The

booklet consists of three practice plates and 150 test

plates, each of which contains four numbered pictures. The

same booklet is used for two forms, the only difference

being that the stimulus words are changed.. Administration

involves the examiner's reading of stimulus words to which

the subject responds by pointing to, verbalizing, or somehow

indicating the picture which best illustrates the word.

Buros (1965) noted that standardization of the instru­

ment was based on 4,012 children and young people. Alter­

nate form reliabilities for the various age levels ranged

from .67 to .84. Buros further noted that studies with

wider age ranges have reported much higher correlations,

ranging from .89 to .97. While no test-retest reliability

appeared in the test manual, Buros (1965) noted a test-retest

coefficient of .88 after one year. The sample from which

this was derived consisted of 29 physically disabled

children.

While validity studies are still somewhat lacking,

Buros (1965) noted that correlations with the Stanford Binet

Mental Aqes have been in the high .70's and low .80's. WISC

IQ correlations have been of the same order.

101

In general, the test has been described as attractive,

interesting, and " . . . probably now the best of its kind"

(Buros, 1965, p. 823). For this study, its purpose was

only to serve as a screening device in the selection of

subjects.

Davids Rating Scales for Hyperkinesis "~

It was deemed necessary to examine behavioral changes

in hyperkinetic children as perceived by their parents. The

Davids Scales served both as a screening instrument and also

as a dependent measure. As previously pointed out in this

paper, parent rating scales have proven to be effective in

the measurement of behavioral change in children. Both

Braud (1974) and Lupin et al. (in press) used such rating

scales and were able to successfully measure the effects of

relaxation training on the hyperkinetic child syndrome.

Braud utilized four separate scales. Three of these (Lupin

Scale, Conners Scale, Cowgill Scale) were correlated with

the Davids Scales (Davids, 1971), which was chosen for this

study, and the resulting correlation coefficients ranged

from .80 to .87.

The Davids Scales were selected for use in this study

due, first of all, to its brevity, but also due to its

thorough, detailed definition of behaviors to be rated.

When compared to other rating scales, the characteristics

/

102

to be rated are much more clearly defined by Davids. Also,

in examining various behavioral scales and their usage, no

mention of reliability was found on scales other than Davids'

instrument. Davids contended that:

In several unpublished studies conducted in the late 1950s and 1960s we found these rating scales to have adequate reliability and to also possess consider­able clinical utility, (p. 499)

Burns and Lehman (1974) used graduate students as tutors

for 20 children. The Davids Scales were utilized and each

child was rated by a different tutor. An analysis of the

internal validity of the summated ratings resulted in co­

efficients of .87 and .94 for the first and second adminis­

trations of the scale. The test-retest reliability of the

total ratings between the two administrations was .92. From

these findings, the authors suggested that the categories

comprising the Davids Scales were homogeneous for each

administration and that rates were stable in the extent to

which they rated the children as being hyperkinetic.

Denhoff et al. (1971) utilized the Davids Rating Scales

as a screening device by which hyperkinetic children were

accurately identified. Also, through their work, sensitiv­

ity to changes related to drug treatment was noted. That is,

its diagnostic utility was demonstrated. Again, this was a

factor which led to the selection of this particular

instrument.

103

In summary, the Davids Scales became the instrument of

choice due to: 1) its brevity; 2) its clarity in defining

behaviors; 3) the reported levels of adequate reliability

and validity; 4) its sensitivity in measuring effects of

both drug and relaxation treatment; and 5) its demonstrated

diagnostic ability.

The Davids Scales, as described in Chapter I, consists

of seven items, the first six of which serve as a measure

of hyperkinesis. These six items are: (1) hyperactivity;

(2) short attention span and poor powers of concentration;

(3) variability; (4) impulsiveness and inability to delay

gratification; (5) irritability; and (6) explosiveness.

Each item is rated on a scale of one to six and the total

score is obtained by adding the six ratings.

Piers-Harris Children's Self Concept Scale (The Way I Feel About Myself)

Piers and Harris (1969) developed a self report instru­

ment which is believed to tap self concept in a wide age

range of children. The instrument was written at a third

grade reading level and the authors encouraged individual­

ized usage of the instrument below that age. For the purpose

of this study, all items were read to the children and

responses were marked by the examiner.

The instrument consists of 80 first-person declarative

statements to which the child responds with either a "yes"

104

or a "no." Approximately half of the items are worded so

as to indicate a positive self concept while the others are

stated in a manner indicating a negative self concept.

Negative terms such as "don't" are avoided so as to minimize

confusion of wording.

The scale was standardized on 1,183 children in grades

four through 12. The authors found, and Buros (1972) re­

affirmed, that there were no consistent sex or grade differ­

ences in means. Consequently, norms were reported for the

entire sample, without respect to age, grade, or sex.

Internal reliability coefficients for the instrument

ranged from .78 to .93 while retest reliability coefficients

were from .71 to .77. Correlation coefficients between the

Piers-Harris Scale and other similar instruments have been

reported to be in the mid .60's. Buros (1972) noted that

care had been taken to see that the scale did ,not correlate

unduly with social desirability. He stated that the scale

had sufficient reliability and validity to be used in

research and recommended that the instrument be used in

studies where changes in self concept were expected. The

importance of a control group was also pointed out due to

the observation that retesting typically reflects slight

increases in most subjects.

Piers and Harris (1969) reported a factor analytic pro­

cedure which was performed on the 80 item scale results of

105

457 students. The resulting factors accounted for 42% of

the variance and six were large enough that the authors

felt them to be interpretable. These six factors were

described as: (1) "Behavior," (2) "Intellectual and Social

Status"; (3) "Physical Appearance and Attributes"; (4)

"Anxiety"; (5) "Popularity"; and (6) "Happiness and Satis­

faction." Buros (1972), however, stated that the instru­

ment is probably more unidimensional than multidimensional.

Consequently, preferred usage of only the total self con­

cept score was.implied. It was this total scale which was

utilized in this study as a dependent measure of change in

self concept.

Wechsler Intelligence Scale for Children-Revised (WISC-R)

The 1949 version of the Wechsler Intelligence Scale for

Children (WISC) has been a widely used instrument for the

clinical assessment of intelligence in children. Buros

(1972) spoke of the WISC as the "individual intelligence

test of choice for children" and noted that it has survived

a generation in which there was ". . . an atmosphere of

test burnings. Congressional investigations, restrictive

legislation, and claims that the IQ test is an instrument of

subtle torture . . . " (p. 802). Buros (1972) stated that

the instrument was well standardized, stable, and correlated

well with other tests of intelligence.

106

Wechsler (1974) revised and improved the older version

of his instrument. The new test was standardized on 2,200

children, equally divided as to sex and age. Both whites

and nonwhites were included.

Reliability coefficients for the Full Scale IQ scores

were .95 and .96. Validity studies comparing the Full

Scale WISC-R IQ scores to IQ scores from other instruments

ranged from .73 (Stanford Binet) to .95 (WAIS at 16 years,

11 months).

For this study, three subtests were utilized. These

included Digit Span, Coding, and Mazes.

Digit Span

Digit Span is a supplementary subtest of the verbal

portion of the WISC-R. According to Lutey (1970) , the

Digit Span subtest is a test of retentiveness, attention,

and rote memory. Both Braud (1974) and Lupin et al. (in

press) found hyperkinetic children to improve in function­

ing on this task following relaxation training. The assump­

tion was that attention was enhanced through relaxation

training.

Reliability coefficients on the Digit Span subtest

range from .71 to .84 and average .78. Test-retest stabil­

ity ranges from .73 to .80.

107

Coding

Coding is another subtest of the WISC-R. Lutey (1970),

in reviewing the literature concerning this subtest, found

no real inconsistencies with respect to what the test is

believed to be measuring. In summary. Coding was described

as a measure of numerical facility, of ability to learn an

unfamiliar task, of perceptual speed, and of eye-hand coordi­

nation. The score is based on both speed and accuracy.

Again, the choice to select this particular measure

stems from the fact that Braud (1974) and Lupin et al. (in

press) found it to be sensitive to the effects of biofeed­

back and relaxation training. The inference was that when

tension is reduced the child's efforts are more productive

on this visual-motor task.

Reliability coefficients on the Coding subtest range

from .63 to .80 and average .72. Test-retest stability

ranges from .63 to .77.

Mazes

The Mazes subtest of the WISC-R is a paper and pencil

test in which the child is asked to trace an unbroken line

through a maze, similar to the puzzles often found in chil­

dren's game and puzzle books. It is much like the Porteus

Maze Test which has often been described as an instrument

which is sensitive to treatment changes in hyperkinetic

108

children (Conners & Eisenberg, 1963; Conners, Eisenberg, &

Sharpe, 1964; Eisenberg, Conners, & Sharpe, 1965; Epstein,

Lasagna, Conners, & Rodriguez, 1968). Poor performance on

the Porteus Maze Test has been interpreted as a function

of impulsivity on the part of the hyperkinetic child.

Lutey (1970) stated that successful achievement on the

Wechsler Mazes requires careful planning and the ability to

follow a visual pattern. When planning ability is lacking

or the child is easily distracted, poor performance on the

subtest is believed to follow.

Split-half reliability coefficients for the Mazes sub­

test ranged from .62 to .82 and averaged .72. Test-retest

after three to five weeks yielded stability coefficients

ranging from .63 to .77.

Conners Teacher Rating Scale (Conners Scale)

Conners (1969) developed a 39 item rating scale to be

utilized by teachers for rating the level of hyperactivity

in children (Appendix E). The initial intent was to measure

the effectiveness of drug therapy, but other researchers,

including Braud (1974), have found the scale to be sensitive

to changes resulting from biofeedback and relaxation train­

ing. The 3 9 items comprising the scale involve a number of

behavioral indices which, when factor analyzed (Conners)

109

1969), resulted in five groupings. These included: (1)

defiance or aggressive conduct; (2) daydreaming-

inattentiveness; (3) anxious-fearfulness; (4) hyperactivity;

and (5) well-adjusted state. As pointed out previously,

Conners (1969) compared a drug treatment group with a

placebo group and then statistically evaluated test-retest

of the placebo group over a one-month period. The statility

coefficients (.71 to .91) were deemed satisfactory enough to

warrant empirical usage of the instrument.

This rating scale was distributed directly to school

principals of children participating in the study. This was

done following posttesting of the last group of subjects.

These administrators distributed the materials to the

teachers of the subjects and following completion of the

scales, teachers utilized a pre-addressed and stamped

envelope to return the materials to the author of the study.

Inferred Self-Concept Scale (ISCS)

McDaniel (1969), stated that the development of the

Inferred Self-Concept Scale came as the result of her frus­

tration with other instruments which had been designed to

measure the somewhat ambiguous notion of self concept. Many

of these problems were felt to relate to the frequent use of

self report in attempts to measure self concept. Included

among the specific concerns related to the use of self

110

report measures were: defensiveness, age, language skills,

intelligence, and response sets. These factors were felt

to result in major validity problems and a need to control

as many confounding factors as possible. The result was

the ISCS which utilized observers (teachers or counselors)

to assess the students' self concept as they inferred it

from manifest behaviors. The 30 items of the ISCS are

rated on a scale of one to five. Item directionality (posi­

tive or negative) was altered in an attempt to avoid any

response set on the part of .the rater.

The normative sample was composed of 90 boys and 90

girls who were Title I students at 16 public elementary

schools in Austin, Texas.

Several attempts were made to examine rater reliability

To begin with, total counselor ratings and total teacher

ratings were found to yield a correlation coefficient of

.58. Secondly, an attempt was made to determine the rela­

tionship between counselor and teacher 30-item ratings for

each student. These correlation coefficients ranged from

.07 to .58 and it was stated that, " . . . their ratings on

29 of the 30 items were significantly related at or beyond

the .05 level in a positive direction" (p. 5). In general,

it was noted that teacher ratings on the ISCS were signifi­

cantly higher than were counselor ratings.

Ill

Split-half reliabilities reported by McDaniel (1973)

were: (1) .86 for counselors; (2) .86 for teachers; and

(3) .90 for counselors and teachers combined.

Test-retest reliability for a six-month period ranged

from .49 in sixth grade children to .84 in first grade

children.

Validity studies are somewhat lacking, but the pre­

viously discussed item selection procedure was viewed by the

author as a form of content validation. Correlation studies

with other self concept instruments was generally avoided on

the assumption that, " . . . there is little basis for com­

parison" (p. 6). The correlation between the ISCS and

semester grades was significant at the .01 level while the

ISCS and observed behaviors correlated at the .05 level.

Such was presented as evidence of validity.

The instrument was distributed by principals, completed

by teachers, and returned to the investigator.

Statistical Hypotheses

The following a. priori hypotheses were stated and sub­

jected to statistical analyses, all comparisons being made

with posttest data:

I. Following training, children will show differen­

tial ratings of behavior as noted on both the Davids Scales

112

and the Conners Scale. Specifically, it is anticipated

that:

A. Those children receiving relaxation training with

the TMI will obtain significantly lower (more positive)

ratings than will Control subjects.

B. Those children receiving relaxation training only

will obtain significantly lower (more positive) ratings

than will Control subjects.

C. Those children receiving relaxation training with

the TMI will obtain significantly lower (more positive)

ratings than those receiving relaxation only.

D. Children receiving only attention will obtain

ratings which are not significantly different from those

obtained by Control group subjects.

E. Older children receiving relaxation training with

the TMI will receive significantly better scores on the

rating scales than will younger children who receive re­

laxation training with the TMI.

F. Older children receiving relaxation training only

will receive significantly better scores on the rating

scales than will younger children who receive relaxation

only.

G. Younger children receiving only attention will

receive significantly better scores on the rating scales

than will older children receiving attention.

113

II. Following training, children will show differen­

tial measures of self concept as noted on both the Piers-

Harris Self Concept Scale and the Inferred Self-Concept

Scale. Specifically, it is anticipated that:

A. Those children receiving relaxation training with

the TMI will obtain significantly more positive scores than

will Control subjects.

B. Those children receiving relaxation training only

will obtain significantly more positive scores than will

Control subjects.

C. Those children receiving relaxation training with

the TMI will obtain significantly more positive scores than

those receiving relaxation only.

D. Children receiving only attention will obtain

scores which are not significantly different from those

obtained by Control group children.

E. Older children receiving relaxation training with

the TMI will receive significantly more positive scores on

the self concept scales than will younger children who

receive relaxation training with the TMI.

F. Older children receiving relaxation training only

will receive significantly better scores on the self con­

cept scales than will younger children receiving relaxation

only.

114

G. Younger children receiving only attention will

obtain significantly more positive scores on the self con­

cept scales than will older children receiving attention.

III. Following training, children will show differen­

tial WISC-R subtest scores. Specifically, it is antici­

pated that:

A. Those children receiving relaxation training with

the TMI will obtain significantly higher scores than will

Control subjects.

B. Those children receiving relaxation training only

will obtain significantly higher scores than will Control

subjects.

C. Those children receiving relaxation training with

the TMI will obtain significantly higher scores than those

receiving relaxation only.

D. Children receiving only attention will obtain

ratings which are not significantly different from those

obtained by Control group subjects.

E. Older children receiving relaxation training with

the TMI will obtain significantly better scores than will

younger children who receive relaxation training with the

TMI.

F. Older children receiving relaxation training only

will obtain significantly higher scores than will younger

children who receive relaxation training only.

115

G. Younger children receiving only attention will

obtain significantly higher scores than will older children

receiving attention only.

Statistical Procedures

A pretest-posttest control group paradigm constituted

the basic design for this study. Data were initially

gathered with five dependent measures. In addition, two

other dependent measures were completed by the school

teachers of subjects on a posttest only basis.

Data gained from the seven measures were analyzed on

an IBM 37 0 computer which is housed at the Computer Center

at Texas Tech University. The Data Text program was util­

ized. The analyses included the computation of descriptive

statistics, 2 X 4 Completely Randomized Factorial Analyses

of Covariance, and 2 X 4 Completely Randomized Factorial

Analyses of Variance.

Further comparisons among means were made using Tukey's

Honestly Significant Difference (HSD) Test as described by

Kirk (1968).

Descriptive Statistics.

The Data Text program yielded a number of descriptive

statistics including: (1) the number of subjects for whom

scores were requested, (2) various means, (3) standard

deviations, (4) within cell bivariate statistics

116

(correlation coefficients), (5) effects, (6) adjusted means,

and (7) adjusted effects.

Analysis of Covariance

Analysis of covariance is an extension of the regres­

sion model for analysis of variance and provides a straight

forward method of adjusting for extraneous sources of vari­

ation. That is, analysis of covariance is a method of

statistical control rather than a method of experimental

control. The procedure combines the advantages of regres­

sion analysis with the advantages of analysis of variance

and involves the measurement of concomitant variables (co-

variates) as well as the dependent variable.

Huck (1972) noted that most researchers utilize analy­

sis of covariance because of its ability to control for

mean differences due to the covariate when random assignment

is not possible. He repudiated this belief, however, and

pointed out that random assignment is an important assump­

tion of covariance analysis. The primary purpose of co-

variance, according to Huck, is to increase the statistical

power by reducing within-group variability.

In the present study, both the control of various co-

variates and an increase in statistical power were deemed

highly important. Pretest data on five dependent variables

served as the basis from which correction for the covariates

117

was made. Corrected means resulted and these were utilized

in analyses which yielded the data appearing in the analysis

of covariance source tables.

Analysis of Variance

For those measures on which pretest data were not avail­

able, the 2 X 4 Completely Randomized Factorial Analysis of

Variance as described by Kirk (1968) was employed.

Tukey's Honestly Significant Difference (HSD) Test

The HSD Test is a multiple comparison test by which one

can make all pairwise comparisons among means. Experiment-

wise error rate is set at alpha (.05).

This procedure was utilized to locate the point of

variance when a significant F resulted on either an analysis

of covariance or an analysis of variance.

Tests of Simple Main Effects

Kirk (1968) pointed out that when any two or more inde­

pendent variables are found to interact, interpretative

caution must be exercised. Specifically, main effects must

be qualified and Tests of Simple Main Effects become neces­

sary. This procedure was employed in the current study in

instances where significant interactions were noted.

Through this procedure the source of indicated variance was

more closely isolated.

118

Graphic Conceptualization of the Design

The Completely Randomized Factorial Design by which

data were analyzed can be graphically illustrated as

follows:

Relaxation + TMI

Younger Children (6-8 years)

Older Children (9-11 years)

Relaxation Attention No Treatment Only Placebo Control Group

Figure 1. Research Design

CHAPTER III

RESULTS

Data obtained from this investigation were initially

subjected to either an analysis of covariance or an analy­

sis of variance, whichever was appropriate. In this

manner, statistical hypotheses listed in the previous

chapter were tested. Where F ratios were found to be sig­

nificant, Tukey's HSD Test was utilized to determine the

source of variance and to evaluate specific hypotheses.

These results have been discussed separately for each

hypothesis.

For those measures which were subjected to analysis

of covariance, resulting mean scores appear in the Appen­

dices. Pretest mean scores for those five measures appear

in Appendix F (Tables 1-5) while both uncorrected and

corrected posttest scores appear in Appendix G (Tables 6-

10) .

Hypothesis I.

The first general hypothesis was advanced on the

assumption that differences would be noted on the posttest

behavioral ratings of children in the four groups. The

Davids Scales and the Conners Scale were the dependent

measures.

119

120

All four F ratios resulting from the analysis of

Davids scores (Table 11) were significant beyond the .05

level of confidence. The significant F for the Covariates

indicated that a significant relationship existed between

the covariates and the dependent measure, thus justifying

the use of covariance to gain statistical control. Both

main effects. Group and Age, resulted in significant F

values, suggesting the presence of differences related both

to the treatment group and to the age group. A significant

Group X Age interaction was also noted, thus a Test of

Simple Main Effects was conducted (Table 12). The first

general hypothesis, as related to the Davids Scales, was

accepted as stated, and further examination of specific

comparisons was in order.

TABLE 11

ANALYSIS OF COVARIANCE SOURCE TABLE DAVIDS RATING SCALES

Source

Group

Age

Interaction

Covariates

Unit (Error Term)

SS

8.24

66.41

44.41

249.58

151.23

df

3

1

3

1

31

MS

27.09

66.40

14.80

249.58

4.88

F

5.55**

13.61***

3.03*

51.16***

P

.004

.001

.044

<.001

121

TABLE 12

SIMPLE MAIN EFFECTS SOURCE TABLE DAVIDS RATING SCALES

Source

A (age)

A at b.

A at b2

A at b^

A at b^

(Relax + TMI)

(Relax Only)

(Attention)

(Control)

B (Group)

B at a

B at a2

(young)

(old)

AB (Interaction)

Unit (Error Term)

SS

66.40

3.92

.47

.09

.14

81.28

1.63

694.76

44.40

151.23

df

1

1

1

1

1

3

3

3

3

31

MS

66.40

3.92

.47

.09

.14

27.09

.54

231.59

14.80

4.88

F

13.61**

.80

.10

.02

.03

5.55**

.11

47.48*

3.03*

P

.004

NS

NS

NS

NS

.001

NS

.013

.044

However, statistical significance was found for

neither Group nor Age effects on the Conners Scale (Table

13). Consequently, this measure did not yield data which

was supportative of the hypothesis and all specific hypoth­

eses predicting differences among means on this measure

were rejected.

TABLE 13

ANALYSIS OF VARIANCE SOURCE TABLE CONNERS SCALE

W fS^

Source . SS df MS

Group

Age

Interaction

Unit (Error Term)

731.50

12.19

1478.64

4203.67

3

1

3

21

243.83

12.19

492.88

200.00

1.22

.06

2.46

.33

>.50

.09

122

Hypothesis I. A.

The comparison of group means for Davids scores was

conducted by use of Tukey's HSD Test (Table 14) and did

not take age into consideration. Examination of the table

led to the acceptance of this hypothesis. The Relaxation

+ TMI group did receive more positive ratings on the

Davids Scales than did control subjects (p<.05).

TABLE 14

TUKEY'S HSD TEST FOR TREATMENT GROUPS DAVIDS RATING SCALES

Relax + TMI Attention Control Relax Only

Relax + TMI = 26.51 .281 2.13* 3.65**

Attention = 26.79 1.85 3.37**

Control = 28.64 1.53

Relax Only = 30.16

*Critical Values = 1.90 (p=.05).

**2.34 (p=.01).

Conclusions were qualified based on the fact that

there was an interaction between the effects of age and

the effects of treatment. Closer examination of the

Simple Main Effects (Table 12) indicated that positive

treatment effects related to Relaxation + TMI were present

only for older subjects on the Davids Scales. This is

further noted in Table 15.

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Hypothesis I. B.

Posttest Davids ratings for Relaxation and Control sub­

jects were compared using Tukey's HSD Test (Table 14) with­

out respect to age. This comparison of means revealed no

statistically significant differences, thus the hypothesis

was rejected.

Hypothesis I.e.

It was predicted that the TMI condition would be a

major contributor to the positive effects which were hypoth­

esized to result from relaxation training. This was exam­

ined with the use of Tukey's HSD Test, again without respect

to age. The resulting comparison of means (Relaxation +

TMI Group and Relaxation Only Group) was significant (p<.01)

and results were in the predicted direction. Thus, the

hypothesis was supported, but the previously noted inter­

action made the acceptance of the finding subject to quali­

fication. That is, differences among groups were present

only among older subjects (Table 14).

Hypothesis I. D.

Attention subjects, upon posttest, did not differ from

Control subjects on either the Davids Scales or the Conners

Scale (Tables 13 and 14). This was as predicted, therefore

the hypothesis was accepted. However, due to the overall

125

lack of statistical significance on the Conners Scale, in­

terpretative potential was minimized.

Hypothesis I. E.

Analysis of Davids scores (Table 15) across age groups

did reveal significant differences (p<.01) in the predicted

direction for Relaxation + TMI subjects. Thus, this hypoth­

esis, as examined by the Davids Scales, was accepted.

Hypothesis I. F.

A comparison of younger children with older children,

all of whom received relaxation training without the TMI

condition was made with posttest Davids Scales results.

Tukey's HSD Test (Table 15) reflected no significant dif­

ferences, so the hypothesis was rejected.

Hypothesis I. G.

A comparison of age differences for subjects receiving

attention was made (Table 15) for Davids results. Tukey's

HSD Test (Table 15) reflected no statistically significant

differences and the hypothesis was rejected.

The Davids Rating Scales

The overall results of this investigation, as related

to the posttest data of the Davids Scales can be viewed

graphically in Figure 2. The older children who experienced

Relaxation + TMI showed significantly lower scores on the

126

Davids Scales than did the younger children receiving the

same treatment. While older children in general, had more

positive scores under the conditions of the other three

treatments, the differences were not significant.

32

31

30

Davids 29

Rating ^^ Scales

27

26

25

24

23

Q younger

^ older

Relax + TMI Relax Attention Control

Figure 2. Davids Rating Scales-Posttest Results

The Conners Scale

Overall results of the Conners Scale may be viewed

graphically in Figure 3. No statistically significant dif­

ferences were noted, but the trends are interesting.

Younger children achieved more positive scores than did

older children from the corresponding groups. The only

exception to this came in the Control groups where older

children achieved much more positive ratings than did

127

younger children. It should be pointed out that the in­

strument was completed for only 29 of the 4 0 subjects

involved in the investigation. Treatment group size ranged

from two to four subjects for each of the eight cells

within the design.

Conners Scale

90

85

80

75

70

65

60

55

50

O

..( ;

Q younger

A older

Relax + TMI Relax Attention Control

Figure 3. Conners Scale-Results.

It was previously noted that Conners (1969) factor

analyzed the 39 item scale and isolated five factors which

he-labeled as follows: (1) defiance or aggressive conduct;

(2) daydreaming-inattentiveness; (3) anxious-fearfulness;

(4) hyperactivity; and (5) v/ell-adjusted state. A decision

was made to independently examine these five factors on a

post hoc basis through analyses of variance. No significant

differences among treatment groups or age were found through

128

these analyses. The source tables may be examined in

Appendix H (Tables 16-20);

Hypothesis II.

This second general hypothesis predicted differences

on measures of self concept. Measures utilized for testing

the hypothesis included the Piers-Harris Self Concept Scale

and the Inferred Self-Concept Scale.

The Inferred Self-Concept Scale failed to measure sta­

tistically significant differences. The Analysis of Vari­

ance source table for this measure appears in Table 21.

TABLE 21

ANALYSIS OF VARIANCE SOURCE TABLE INFERRED SELF-CONCEPT SCALE

Source

Group

Age

Interaction

Unit (Error Term)

SS

557.46

540.10

342.32

3360.50

df

3

1

3

21

MS

185.82

540.10

114.10

160.02

F

1.16

3.3

0.71

P

.35

.08

>.50

Total 4800.3 28 171.44

The absence of statistical significance for both Group

and Age effects led to rejection of the general hypothesis

and all specific hypotheses predicting differences among

means as measured by the Inferred Self-Concept Scale.

Posttest Piers-Harris scores were subjected to Analysis

of Covariance (Table 22).

129

TABLE 22

ANALYSIS OF COVARIANCE SOURCE TABLE PIERS-HARRIS SELF CONCEPT SCALE

Source

Group

Age

Interaction

Covariates

Unit (Error Term)

SS

454.59

101.90

60.25

4406.30

df

3

1

3

1

31

MS

151.53

101.90

20.08

4406.30

30.83

F

4.92**

3.31

0.65

142.93***

P

.007

.079

>.500

<.001

Two resulting F_ ratios were significant beyond the .05

level of confidence. The significant F for the covariates

(p<.01) indicated that a significant relationship did exist

between the covariates and the dependent measure, thus

affirming the need to utilize statistical control. The

only other statistically significant F ratio related to the

treatment (Group) effects, without respect to age. Thus,

the general hypothesis was accepted as stated.

Hypothesis II. A.

The comparison of group means for Piers-Harris scores

was conducted by use of Tukey's HSD Test (Table 23). This

test indicated a significant difference (p<.01), in the

predicted direction, between Relaxation + TMI subjects and

Control subjects. The hypothesis was accepted.

130

TABLE 23

TUKEY'S HSD TEST FOR TREATMENT GROUPS PIERS-HARRIS SELF CONCEPT SCALE

Control Attention Relax Only Relax + TMI

Control = 54.80 2.37 6.13** 8.80**

Attention = 57.17 3.77 6.43**

Relax Only = 60.93 2.66

Relax + TMI = 63.60

*Critical Values = 4.77 (p=.05).

**5.95 (p=.01).

Hypothesis II. B.

Adjusted means of the Relaxation group and the Control

group were tested for differences with Tukey's HSD Test

(Table 23). The Relaxation subjects were found to have

significantly (p<.01) more positive Piers-Harris scores

than Control subjects, thus the hypothesis was accepted.

Hypothesis II. C.

Difference between the Relaxation + TMI subjects and

Relaxation Only subjects as measured by the Piers-Harris

Scale were not found to be statistically significant (Table

23), thus the hypothesis was rejected.

Hypothesis II. D.

As predicted, no difference was noted between Attention

subjects and Control subjects on Piers-Harris scores (Table

23). Neither were differences found on the Inferred

131

Self-Concept Scale, but this finding lacks interpretative

value as no statistically significant differences were

noted on the measure (Table 21). The hypothesis was

accepted.

Hypothesis II. E.

The Analysis of Covariance for Piers-Harris scores

(Table 22) indicated no statistically significant age dif­

ferences. Thus, without further analyses, it was concluded

that older and younger subjects receiving Relaxation + TMI

did not differ and the hypothesis was rejected. Hypotheses

II. F. and II. G. also predicted age differences on the

Piers-Harris Scale and based on the same analysis (Table 22)

both were rejected.

The Inferred Self-Concept Scale

Overall, no significant differences due either to age

or treatment group were noted from results of the Inferred

Self-Concept Scale (Figure 4). However, the instrument was

completed for only 29 of the 40 subjects involved in the

investigation. This included from two to four subjects for

each of the eight groups within the design.

The Piers-Harris Self Concept Scale

The overall results of this investigation, as related

to the adjusted posttest data of the Piers-Harris Self Con­

cept Scale can be viewed graphically (Figure 5). This

132

125

120

115

Inferred ,,„ Self- ^^^ concept ^Q5 Scale

100

95

90

a.

Q younger

A older

Relax + TMI Relax Attention Control

Figure 4. Inferred Self-Concept Scale-Results.

visual presentation of test data clearly depicts the pre­

viously reported differences among treatment groups. Also

noted are consistent, although not statistically signifi­

cant differences among age groups. In all cases, older

children had higher (more positive) scores than did younger

children in the corresponding treatment group.

One additional pairwise comparison of mean scores, also

resulted in significant differences. That is, without

respect to age, the Relaxation + TMI group received higher

(more positive) posttest scores than did children in the

Attention groups.

133

67

66

65

64

63 Piers-Harris 52 Self Concept ^i Scale

60

59

58

57

56

55

54

\

c

\

\

A

youngerQ

olderA

Relax + TMI Relax Attention Control

Figure 5. Piers-Harris Self Concept Scale Posttest Results.

Hypothesis III.

The third general hypothesis predicted differential

levels of performance on three subtests of the WISC-R:

Digit Span, Mazes, and Coding. Data.for each subtest were

subjected to Analysis of Covariance (Tables 24, 25, and 26)

On these three analyses, only the F ratios for covariates

were significant (p<.001) indicating that a significant

134

relationship did exist between the covariates and the de­

pendent measure. No statistically significant differences

for Group or Age effects were indicated, thus all specific

hypotheses predicting differences on these three measures

were rejected.

TABLE 24

ANALYSIS OF COVARIANCE SOURCE TABLE-DIGIT SPAN

Source

Group

Age

Interaction

Covariates

Unit (Error Term)

ANALYSIS

Source

Source

Age

Interaction

Covariates

Unit (Error Term)

SS

16.66

1.09

5.68

170.87

94.34

df

3

1

3

1

31

TABLE

OF COVARIANCE

SS

16.66

1.09

5.68

170.87

94.34

df

3

1

3

1

31

MS

5.55

1.09

1.89

170.87

3.04

25

SOURCE

MS

5.55

1.09

1.89

170.87

3.04

F

1.83

0.36

0.62

56.15***

P

.164

>.500

>.500

<.500 .

"] 4 , 1

TABLE-CODING 'V

F

1.83

.36

.62

56.15***

P

.164

>.500

>.500

<.001

Hypothesis III. D.

This hypothesis predicted a lack of statistically sig­

nificant differences between Attention and Control group

performance on WISC-R subtest scores at posttest. Based

135

on Analysis of Covariance results (Tables 24, 25, and 26),

this hypothesis was accepted, but interpretive value is

minimized by the overall lack of statistical significance.

TABLE 26

ANALYSIS OF COVARIANCE SOURCE TABLE-MAZES

Source

Group

Age

Interaction

Covariates

Unit (Error Term)

SS

4.99

3.51

16.66

143.57

69.63

df

3

1

3

1

31

MS

1.66

3.51

5.55

143.57

2.25

F

.74

1.56

2.47

63.97***

P

>.500

.221

.081

<.001

The Digit Span Subtest

No significant differences related to either age or

treatment effects were measured by the Digit Span subtest

of the WISC-R (Figure 6). Even visually, it is rather ob­

vious that differences are not great. Still it is inter­

esting to note that except for Control group subjects,

younger children had slightly higher scores than the older

subjects. Also, all groups performed slightly higher than

did the Control groups on this measure.

The Coding Subtest

The use of Coding as a dependent measure in this inves­

tigation resulted in no statistically significant findings.

The overall results, as measured by Coding scores, can be

pictorially viewed in Figure 7.

136

11

10

Digit Span

8 younger Q older A

Relax + TMI Relax Attention Control

Figure 6. Digit Span-Posttest Results.

Coding

10

9

8

7

6 youngerQ older*

Relax + TMI Relax Attention Control

Figure 7. Coding-Posttest Results.

The Mazes Subtest

Again, this measure was essentially insensitive to

changes related to the treatments under investigation.

Still, a graphic display of the posttest results is pre­

sented to further reflect findings as measured by the

Mazes subtest (Figure 8).

137

Mazes

12

11

10

9

8

Q younger

dfe older

Relax + TMI Relax Attention Control

Figure 8. Mazes-Posttest Results.

Summary of Results

Overall, statistical significance was found on only

two of the seven dependent measures. These were the Davids

Rating Scales and the Piers-Harris Self Concept Scale, both

of which were administered immediately after termination of

treatment. Treatment effects were noted on both measures

with the Relaxation + TMI groups being most positively

affected. Age effects were noted on the Davids Scales, with

older children receiving significantly higher ratings.

Older subjects also received higher, but not statistically

significant, scores on the Piers-Harris Self Concept Scale.

Measurable differences were not noted on follow-up ratings

within the school setting,

CHAPTER IV

DISCUSSION

The purpose of the present chapter is to discuss the

, , results of the study, provide interpretive comments, examine

the findings for potential areas of practical application,

and make suggestions for further research. Hypotheses will

be discussed categorically, then some general issues will

be addressed. Also, applications of the treatment under

investigation will be discussed and recommendations for

future research will be offered.

Testing of hypotheses was carried out on data resulting

from seven dependent measures. The hypotheses encompassed

two major areas of comparison: differences among age groups

and differences among treatment groups. For discussion

purposes, each of the dependent measures was classified into

one of the three following categories: (1) behavioral

rating scales; (2) measures of self concept; and (3) psycho­

metric measures affected by attention, impulsiveness, and

concentration.

Behavioral Rating Scales

Two different behavioral rating scales were utilized

for data acquisition. These were the Davids Scales (Davids,

1971), which parents completed, and the Conners Scale

(Conners, 1969), which teachers rated on a posttest basis.

138

139

The effectiveness of these instruments to discriminate hyper­

kinetic children from non-hyperkinetic children and the sen­

sitivity of these measures to behavioral changes resulting

from relaxation training and biofeedback has been documented.

While the Davids Scales reflected significant differ­

ences when data were subjected to analyses, the Conners

Scale showed no statistically significant differences.

Without considering age effects, both Relaxation + TMI

and Attention groups received significantly more positive

ratings on the Davids Scales than did Relaxation Only

subjects. Only the Relaxation + TMI group was signficantly

different from the Control group. The preliminary evalu­

ation of these findings indicates that positive treatment

results were related primarily to the expectancy encompassed

in the TMI procedure. Also, on preliminary evaluation of

the results, it appears that mere attention has positive

effects. The overall mean score for Attention subjects was

significantly more positive than the mean for Relaxation

Only subjects. While no direct attempt was made to directly

impact the overall family environment, mere parental aware­

ness of the children's involvement in a treatment plan may

have resulted in parental reinforcement of positive

expectations.

Age was found to be an important factor on Davids

Scales results. Overall, older subjects achieved slightly

140

more positive ratings than did corresponding groups of

younger children. However, the only comparison of corre­

sponding age groups which reflected statistical significance

was seen for the Relaxation + TMI groups. Treatment effects,

as measured by the Davids Scales, were significant only for

older children. When the mean scores of the four younger

groups were compared for significant differences (Table 15),

none were found. Comparison of the four means for older

children did, however, reflect statistically significant

differences. The Relaxation + TMI group achieved signifi­

cantly more positive scores than either the Control or the

Relaxation Only subjects. No statistically significant

difference was noted between the Relaxation + TMI group and

the Attention group, although the Relaxation + TMI group

did achieve somewhat more positive ratings.

The failure to achieve positive effects through the

relaxation procedures, in the absence of the TMI element,

is noteworthy. As a result of this finding, no affirmative

conclusion can be made regarding the positive effects of

relaxation training alone, as measured by the Davids Scales.

It can be assumed that the positive effects of Relaxation +

TMI, measured by the Davids Scales, resulted from the added

effects of the TMI or subject suggestibility. A lesser

degree of positive results can seemingly be attributed to

the mere attention provided through hearing entertaining

141

stories. Relaxation training without a well defined objec­

tive and no statement of expectation' may be viewed as

meaningless or confusing to children, while story tapes at

least make some sense and are not viewed as a purposeless

exercise. The effectiveness of relaxation was no different

for older as opposed to younger children.

The posttest Conners Scale did not reflect mean differ­

ences related to treatment or age effects. Several possi­

bilities for this lack of significant results are entertained

It is probable that effects simply did not carry over from

the time of training until the time of teacher evaluation.

This lag time did not exist for parental ratings. It is

further believed that the training failed to generalize to

the school environment. Other limitations relate to the

teachers who served as raters. No rater reliability infor­

mation is available, but the possibility of varied rating

styles cannot be ignored. Teacher expectation may possibly

have biased the ratings also. That is, due to written com­

ments on permanent records or word of mouth reports of

reputations, children may have received more negative

ratings than were justified. Also, no attempt was made to

modify or impact the teachers or the academic environment

in general. Thus, in view of the WARD model of hyperactiv­

ity, a major portion of the child's total environment was

left unchanged. From a behavioral framework, teachers'

142

responses to children's behaviors were not altered. Thus,

reinforcement of hyperactive behaviors continued and behav­

iors were left unaltered. At the same time, some subjects

may have managed, during early weeks of the school year,

to control some of their hyperkinetic symptoms until a

degree of familiarity within the classroom was attained. In

any event, the Conners Scale did not validate the findings

of the Davids Scales.

Self Concept Measures

Two measures of self concept were utilized as dependent

measures in this investigation. The Piers-Harris Self Con­

cept Scale (Piers, 1969) was administered to each child on

both a pretest and a posttest basis. The Inferred Self-

Concept Scale (McDaniel, 1973) was completed by'teachers on

a posttest basis only. Only the Piers-Harris Scale reflected

significant differences when data were subjected to analyses.

The analysis of covariance for the Piers-Harris Scale

reflected only differences related to treatment (Group)

effects. Children who received Relaxation + TMI achieved

the highest self concept scores at posttest. Posttest

scores of the Relaxation + TMI groups were, in fact, found

to be significantly higher (more positive) than those of

both the Control group subjects and the Attention group sub­

jects. Statistically significant differences were not noted

143

betweeen the Relaxation + TMI group and the Relaxation Only

group. The implication then, is that the relaxation proce­

dure, with or without the TMI, led to improvement in self

concept which was statistically greater than that associated

with mere attention or no treatment. Unlike the positive

effects that TMI seemingly added to the behavioral changes

(Davids Scales), the addition of TMI made no statistically

significant difference to which the Piers-Harris Scale was

sensitive. However, examination of Figure 4 reflects a

visable, yet statistically non-significant difference be­

tween Relaxation + TMI and Relaxation Only groups. This

noted difference was in the predicted direction. This is

accounted for by the achievement of higher scores for older

Relaxation + TMI subjects. Also, unlike the Davids Scales

results. Attention proved to be no better, statistically,

than the absence of treatment. A slight difference (Atten­

tion greater than Control) can be examined visually in

Figure 4, but such does not approach significance.

The lack of significant difference between the Relax­

ation + TMI group and the Relaxation Only group leads one

to examine the content of the TMI (Appendix D). The TMI

placed heavy emphasis on behavioral change and made sugges­

tions that improvement was almost certain to follow partici­

pation in the exercises. Suggestions regarding changes in

self concept, however, were very minimal in the TMI.

c

144

Suggestions and suggestibility are believed to be important

in eliciting change. However, it is felt that suggestions

should be very specific in nature. Perhaps specific mention

of anticipated positive changes in self concept would have

resulted in an increased change beyond that related to only

relaxation training or the TMI which did not directly

address the issue of self concept.

The Inferred Self-Concept Scale, like the Conners Scale,

was a posttest only instrument and was completed by teachers

early in the Fall of 1976. Analysis of this data resulted

in no statistically significant differences related to Age

or Group effects. Several possible explanations for the

lack of significance are offered. As in the Conners Scale,

it is believed that treatment effects did not carry over

from the time of training until the time of teacher evalu­

ation. Likewise, treatment effects failed to generalize to

the classroom situation. Again, no attempt was made to

therapeutically impact the educational environment of these

children. Consequently, it may be assumed that teachers'

reactions to children's behaviors have not been altered and

some reinforcement of maladaptive behaviors continued.

Therefore, those behaviors from which self concept was

inferred have not changed. Also, as in the Conners Scale,

a question of rater reliability must be entertained as must

the possibility that teachers' ratings were biased by

145

negative expectations resulting from negative reputations,

written comments, or the mere labeling of children as hyper­

active. It is possible too, that a measure of inferred

self concept differs from a self report and that internal,

emotional changes of self esteem, were not yet manifested in

those behaviors from which inferences were to be made on

McDaniel's instrument. Nevertheless, the Inferred Self-

Concept Scale failed to lend validity to changes in self

esteem which were indicated by the Piers-Harris instrument.

Psychometric Measures

The three WISC-R subtests were selected as dependent

measures due to previous reports of sensitivity to change in

hyperkinetic children which resulted from relaxation train­

ing. This sensitivity was believed to relate to cognitive

impulsivity, distractibility, poor attention, etc. which

affected these measures. Thus, any increase in these sub­

test scores was felt to relate to a decrease in some of the

symptoms of the hyperkinetic syndrome.

Some tentative explanations for the lack of signifi­

cance are offered. One issue which has not been discussed

in relation to other measures, although it may be relevant

is the overall length of treatment. Twelve hours of train­

ing over a four-week period may well be too brief a period

to attain positive results which are measurable on these

146

instruments. Braud (197 4), for example, treated hyperactive

children on a twice per week basis for 12 weeks. The addi­

tional eight weeks may be necessary to achieve significant

improvement on measures of this sort.

The issue of suggestibility is also brought into focus.

It was previously stated that the TMI made direct suggestive

statements concerning behavioral changes which could be an­

ticipated. This was linked to significant behavioral changes

which were noted. Also, the relaxation tapes provided sug­

gestive statements about self concept. However, neither the

tapes nor the TMI presentation dealt with expectations

related to academic functioning, task performance, or test

taking skills. Had the TMI dealt directly with expected

improvement in these areas, significant changes may have

resulted.

General Issues

Some general issues related to the overall investiga­

tion are discussed.

Sample Characteristics

The sample on which this investigation was conducted

consisted of dependents of military or retired military per­

sonnel who resided near a military base. One may raise

questions concerning the extent to which research conclusions

may be generalized to other populations.

147

As a general rule, these military families are rather

mobile and it is not uncommon that children change school

environments every year or two. In some cases, moves are'

even more frequent. The potential for emotional effects

related to this mobility cannot be ignored. This potential

is then compounded by the fact that a large percentage of

the school populations from which these subjects came are

also military, and highly mobile. Seemingly, the effect is

that these military dependents grow up with an unusually

small number of lasting relationships. Classrooms are fre­

quently in a state of rapid transition and here again the

potential for emotionally related stress may be much higher

than one might expect in a less mobile community. It seems

logical to conclude that emotional factors may be contrib­

uting to what subjectively appears to be an extremely high

incidence of hyperkinesis in military dependents.

Descriptive data concerning the 40 subjects helps to

better define the population. The parents of these children

were found to have formal educations ranging from seven to

18 years, with a mean of 13.5 years. Sixty-nine percent of

the fathers were enlisted military while 31% were commis­

sioned officers.

Of the 40 children in the study, 34 were Caucasian,

three were Mexican-American, two were Black, and one was

Korean. Based on information provided by the parents, 58%

148

of the sample had, at some time prior to the study, been

treated pharmacologically for hyperkinesis. Sixty percent

listed a known birth or medical condition which is commonly

associated with hyperkinesis. The mean IQ of the subjects

was 102.55 with all groups being statistically equal

(Appendix I, Table 27).

Selection of Subjects

The criteria for subject selection was discussed in

detail in a preceding chapter and shall not be reiterated

at this point. The procedure was generally viewed as ade­

quate for the purpose of this study,, but a more objective

method, such as the vigilance task (Anderson et al., 1973),

is highly recommended as a more empirically sound method of

discriminating hyperactive from non-hyperactive children.

Certainly, the vigilance task would minimize parental bias

in the selection procedure, a factor which was not completely

controlled in this study. Even though all subjects compris­

ing the current sample carried a diagnosis indicating hyper­

kinesis, factors such as the influence of an insistent parent

on the pediatrician cannot be overlooked. That is, it is

conceivable, although not evident, that some children with

behavioral problems may have been erringly diagnosed as

hyperkinetic and included in the study. Access to the vigi­

lance task as a screening device could insure a higher degree

149

of subject homogeneity and serve to maximize objectivity

m subject selection for research purposes.

Statistical Procedures

Prior to preliminary examination of data resulting

from the dependent measures, it was planned to utilize a

Split Plot Factorial Analysis of Variance Design (Kirk,

1968) which would include both pretest and posttest measures

in the analyses. However, on the five measures where pre­

test data were available, preexisting differences were

strongly suspected. Consequently a decision was made to

analyze these data through a Completely Randomized Factorial

Analyses of Covariance (Kirk, 1968). Through this procedure,

pretest data served as a basis on which to statistically

correct for the effects of covariates. Thus, extraneous

sources of variance were minimized and seemingly, the most

meaningful analyses of data possible resulted.

Methodological Procedures

Some general procedural points believed to constitute

negative or limiting factors within the investigation were

evidenced. These relate to the physical location under

which the study was conducted. To begin with, initial con­

tact with each child was in a pediatrician's office within

the clinic. V hile this was a constant factor for all sub­

jects, it was not viewed as the ideal way in which to

150

initiate contact with hyperkinetic children who were later

expected to learn relaxation techniques. This association

may have communicated, both to parents and children, the

concept of "sickness." It is further believed that this

may have created a negative set for the children and may

likely have generated parental expectations associated with

treatment.

The physical setting in which treatment was conducted

is another area where optimal conditions were lacking. Spe­

cifically, the office in which sessions were conducted was

void of decor or fixtures which one would normally desire

for a setting in which relaxation procedures were to be

learned. Again, this was a constant factor for all subjects,

but the drabness could do little to enhance the potential

for relaxation.

Also of concern is the potential for generalization

beyond the experimental setting. The location of the train­

ing and the manner in which such training was conducted do

not relate to either an academic or home situation. As

stated previously, the research design did not incorporate

family or academic environments into treatment procedures.

In fact, an attempt to keep parents as unknowledgeable as

possible regarding the study minimized the probability that

effects would transfer beyond the laboratory setting. That

is, parental reinforcement was lacking. However, parental

151

and/or teacher involvement constitute grounds for further

research projects and within the framework of this investi­

gation, no obvious alternatives to insure generalization

were available.

Practical Application of Relaxation Training

Strong, positive conclusions regarding practical appli­

cation of relaxation training are still lacking at this

point. The current investigation found changes related to

treatments, but this, in part, was seen as a function of the

TMI and its relationship to subject suggestibility. One

might then suspect the existence of modes of communicating

suggestions other than through relaxation training. Also,

the failure to generalize to the academic environment is a

point of pragmatic concern. Most attempts to implement a

plan of relaxation training will likely involve a laboratory­

like environment and in so doing will share some of the same

limitations seen in this investigation.

The most basic shortcoming of relaxation training, as

examined in this investigation, is that it comprised a uni-

modal approach to a multifaceted syndrome. The hyperkinetic

syndrome demands a multimodal treatment approach which in­

volves a more total plan of intervention. Following the

WARD model, intervention should include the family, academic,

and internal environments of the children. This would

152

involve the orientation and counseling of parents, utiliza­

tion of behavioral therapy techniques both at home and

school, special educational programs, and perhaps medical

intervention. Integrated into these are specific treatment

modes. Such may include relaxation, but should relate to

the home and the academic environments in such a way that

generalization from a laboratory setting does not minimize

treatment potential.

Suggestions for Further Research

The current investigation has added to the body of

knowledge concerning the effectiveness of relaxation train­

ing as a mode of treatment for the hyperkinetic child. How­

ever, many questions remain, and the potential for continued,

systematic research is evident. A number of specific sug­

gestions for the continuation of this line of research are

offered.

To begin with, it is highly recommended that subject

selection become somewhat more scientifically oriented and

that less reliance be placed on parental ratings. Specif­

ically the vigilance task has proven to be a reliable and

objective manner by which to discriminate hyperactive from

non-hyperactive children. Also, a larger sample size is

highly recommended for future studies.

A number of variations in the actual treatment are also

advisable in order to gain more information concerning

153

treatment effects. The results of the current study, as

compared to those by Braud (197 4) and Lupin et al. (in

press), for example, would suggest that duration of treat­

ment should exceed four weeks. Varied lengths of treatment

might be examined to gain knowledge regarding the minimal

length of time to gain positive effects, the optimal length

of treatment, etc.

It was pointed out earlier that the setting in which

the current research was conducted lacked many features, such

as attractive physical surroundings, which were believed to

be conducive to effective relaxation training. For future

research these factors should be corrected and all effort

should be made to enhance the potential for relaxation.

Training within the school and/or home setting is also

advisable as these are the two locations in which improved

behaviors are most highly desired. The varied effects of

teaching relaxation in a laboratory as opposed to a "real

life" situation might also constitute a variable for

empirical investigation.

This study, and all of the related studies appearing

in the literature, utilized taped relaxation procedures as

the basis of treatment. It is recommended that this proce­

dure be compared to live, untaped relaxation training in

order to evaluate relative effectiveness.

154

The current study resulted in tentative findings

regarding the effects of the TMI. It is suspected that this

is an important addition to relaxation training. Conse­

quently, continued investigation of this variable is sug­

gested. TMI might be examined, not only as an addition to

relaxation training, but also as a treatment in itself or as

an addition to an attention factor. Varied forms of sug­

gestion should be examined to determine, for example, just

how specific, in nature suggestions must be to elicit change,

Specifically, suggestions regarding academic performance,

behaviors, and feelings of self worth could be varied among

treatment groups under investigation. Also, since suggest­

ibility appears to be a primary issue, measures such as

hypnotic suggestibility might be utilized to differentiate

groups which could then be compared following exposure to

relaxation and TMI.

It is felt that parental reinforcement of relaxation

skills will maximize effects and facilitate generalization

beyond the laboratory setting. However, this conclusion is

largely subjective and, as yet, has not been incorporated

into a research design. Investigation of parental involve­

ment in relaxation treatment would be a meaningful contri­

bution to this body of literature.

Finally, the utilization of additional behavioral mea­

sures, is recommended. It is felt that a good selection of

155

behavioral measures related directly to the school and home

environments would enhance the significance of research

findings in' this field. Many dependent measures which have

been employed with hyperkinetic children seemingly have

little relationship to actual behaviors, and thus lack

meaning. Incorporation of more meaningful behavioral mea­

sures into this area of research will be a major contribution

CHAPTER V

SUMMARY AND CONCLUSIONS

Hyperkinesis is a complex cluster of behaviors charac­

terized primarily by motoric restlessness, poor attention,

and exaggerated levels of activity. These behaviors have

frequently been related to secondary effects including aca­

demic failures, poor interpersonal skills, and lowered self

concept.

In spite of recent interest and scientific research,

many questions regarding the etiology, diagnosis, and treat­

ment of hyperkinesis remain unanswered. The trend has been

to simply medicate these children with stimulant drugs and

thus reduce some of the symptoms. However, it has been noted

that medication does not always work advantageously. Poten­

tial physical hazards and also ethical considerations have

generated questions regarding the continued use of chemical

agents. Consequently, attempts have recently been made to

utilize alternative treatment approaches with hyperkinetic

children.

This current investigation was advanced to further

evaluate one alternative treatment method, progressive relax­

ation training, which has, upon preliminary investigation,

appeared to be of value in the treatment of hyperkinesis.

Specifically, this study was designed to answer questions

156

157

concerning the effects of relaxation on observable behaviors,

self concept, and psychometric tests which are affected by

poor attention, distractibility, and impulsiveness. Two age

groups, six through eight, and nine through 11, were exam­

ined. Treatment conditions included: (1) systematic relax­

ation training plus a specific TMI: (2) systematic relax­

ation training without TMI; and (3) an attention placebo.

Also, no treatment control groups were incorporated into the

design.

Twenty younger subjects and 20 older subjects were

selected for the study. The subject pool included all hyper­

kinetic children seen by the pediatricians at U.S. Darnall

Army Hospital, Fort Hood, Texas. Basic qualification in­

cluded a diagnosis of hyperkinesis, a minimal score of 19

on the Davids Rating Scales at pretest, a measurable IQ of

80 or more, and parental permission. Also, subjects with

severe physical and/or emotional problems were excluded.

Subjects of each age group were randomly assigned to one

of the four groups.

Subjects in the relaxation groups underwent taped, sys­

tematic relaxation training for 12 sessions over a four-week

period. Those children in the Relaxation + TMI groups

received the same relaxation training, but also were given

encouragement and a very positive set of expectations relat­

ing to treatment effects. The Attention group subjects

158

listened to recorded literature for 12 sessions, also over a

four-week interval. Control subjects were seen only for

pretesting and then posttesting after a four-week interval.

Dependent measures included the Davids Rating Scales

for Hyperkinesis, The Piers-Harris Self Concept Scale, and

three WISC-R subtests (Digit Span, Coding, and Mazes). The

Davids Scales were completed by parents while the subjects

were examined individually on the remaining four measures.

Two additional measures were taken on a posttest only basis.

These were the Conners Rating Scale and the Inferred Self-

Concept Scale, both of which were completed by teachers.

In general, it was hypothesized that: (1) all subjects

receiving relaxation training, with or without TMI, would

show more positive results on the seven dependent measures

than either Attention or Control group subjects; (2) Relax­

ation + TMI subjects would show more positive results on

the seven dependent measures than the Relaxation Only sub­

jects; (3) older children would respond more positively to

the effects of relaxation training (with or without TMI),

as measured by the seven instruments,than would younger

children.

Data were subjected to analyses and specific hypotheses

were examined. Statistically significant results were found

on only two of the seven measures, the Davids Scales and the

Piers-Harris Self Concept Scale. Specifically, both Group

159

and Age effects were noted on the Davids Scales. Relaxation

+ TMI subjects achieved significantly more positive scores

than Relaxation Only or Control subjects. Older children

were responsible for the significantly positive effects of

Relaxation + TMI. Piers-Harris results yielded only Group

effects, with Relaxation + TMI subjects obtaining signifi­

cantly more positive self concept measures than either Con­

trol or Attention subjects.

Neither WISC-R subtests (Digit Span, Coding, and Mazes)

nor follow-up measures (Conners Scale and Inferred Self-

Concept Scale) reflected significant results.

Based on the overall results of this investigation, the

following interpretative conclusions resulted:

1. Findings do not merit the advancement of conclu­

sively positive statements from which to recommend relax­

ation training as a highly successful mode of treatment for

hyperkinesis. While some significantly positive results

were attained, consistency across measures was not evidenced.

2. The results of the investigation did not reflect

dramatic success related to relaxation training. It is

hypothesized that greater success was not evidenced because

relaxation treatment constituted a narrowly focused, uni­

lateral approach to intervention. Maximum effectiveness in

the treatment of hyperkinesis is believed to be possible

only when intervention affects the child's total environment

160

as suggested by the WARD model of hyperkinesis. This would

include family and academic intervention as well as other

treatment modes which affect the child's internal environ­

ment. It is suspected that relaxation training can serve

to complement a more comprehensive treatment program. How­

ever, if relaxation is to have pragmatic utility, it must

not be limited to the laboratory setting. Reinforcement of

relaxation principles within the home and academic environ­

ments should seemingly be ongoing in order to maximize

generalizability. Still, empirical investigation is needed

to validate these suspicions regarding the importance of

teacher and/or parental reinforcement.

3. It was concluded from the investigative results

that relaxation training is enhanced when it is coupled with

specific instructions which encourage participation and out­

line expected positive outcomes (TMI). It is further sus­

pected that the effects of TMI may be specifically related

to the content of the instructions. There appears to be a

need to make highly specific suggestions regarding desired

and expected changes in behavior, self concept, academic

performance, or whatever, in order for change in these areas

to occur. The concept of subject suggestibility is believed

to be an important variable.

4. Investigative results indicate that cognitive devel­

opment of children is a highly important variable. Older

161

children tend to gain far more positive results from relax­

ation and TMI procedures than do younger children.

5. The future of relaxation training as a treatment

mode for the hyperkinetic child is still questionable. Its

ability to serve as a panacea is conclusively rejected and

its function as an adjunct therapy is an area where more

research is still needed.

LIST OF REFERENCES

Abrams, A. L. Delayed and irregular maturation versus minimal brain injury. Recommendations for a change m current nomenclature. Clinical Pediatrics, 1968, 7, 344-349.

Administrative Guide and Handbook for Special Education. Bulletin 711. Austin: Texas Education Agency, 1973.

Alabiso, F. Operant control of attention behavior: A treat­ment for hyperactivity. Behavior Therapy, 1975, 6, 39-42.

Aman, M. G., & Sprague, R. L. The state-dependent effects of methylphenidate and dextroamphetamine. The Journal of Nervous and Mental Disease, 1974, 158(4), 268-279.

Anderson, R. P. A neuropsychogenic perspective on remedi­ation of learning disibilities. Journal of Learning Disabilities, 1970, 3, 143-148.

Anderson, R. P., Halcomb, C. G., & Doyle, R. B. The measure­ment of attentional deficits. Exceptional Child, 1973, 39, 534-539.

Anderson, R. P., Halcomb, C. G., Gordon, W., & Ozolins, D. A, A measurement of attention distractability in LD chil­dren. Academic Therapy, 1974, 9(5), 261-266.

Anderson, R. P., Halcomb, C. G., Ozolins, D. A., & Hopson, J. The effects of auditory distraction on vigilance task performance in learning disabled children. Proceedings of the Southwestern Psychological Association, Annual Meeting, 1974.

Anderson, R. P., Sherman, C. P., & Williamson, G. A. Modify­ing hyperactive behavior patterns in the classroom: Programmatic research. Symposium Presented at the Meeting of the Southwestern Psychological Association Annual Meeting, 1976.

Anderson, R. P. , Williamson, G. A., & Rushing, C. L. Trends in research with hyperactive children. Paper presented at the meeting of the Southwestern Psychological Asso­ciation, Ft. Worth, April 1977.

162

163\

Anderson, W. W. The hyperkinetic child: A neurological appraisal. Neurology, 1963, 13, 968-973.

Andreychuk, T. Personal Communication, April 1977.

Arehart-Treichel, J. School lights and problem pupils. Science News, 1974, 105(16), 258-259.

Atkinson, B. R., & Seunath, O. H. M. The effect stimulus change on attending behavior in normal children and children with learning disorders. Journal of Learning Disabilities, 1973, 6(9), 42-46.

Barber, T. X. Hypnosis: A scientific approach. New York: Van Nostrand Reinhold Company, 1969.

^Barcai, A., & Rabkin, L. Y. A precursor of delinquency: The hyperkinetic disorder of childhood. Psychiatric Quarterly, 1974, 48(3), 387-399.

Barsh, R. Six factors in learning: Learning disorders I. Seattle: Special Child Publications, 1965, 329-343.

Bradley, C. The behavior of children receiving benzedrine. American Journal of Psychiatry, 1937, 94, 577-585.

Bradley, J. E. School problems and physician. Current Medical Digest, 1968, 25, 147-185.

Braud, L. W. The effects of EMG biofeedback and progressive relaxation upon hyperactivity and its behavioral con­comitants. Unpublished doctoral dissertation. Univer­sity of Houston, 1974.

Braud, L. W., Lupin, M. N., & Braud, W. G. The use of elec­tromyographic biofeedback in the control of hyperactiv­ity. Journal of Learning Disabilities, 1975, 8, 420-425.

Buckland, P., Bourgeois, A., Vickland, A., Flagg, C , & Tollison, P. Internal arousal states of hyperactive primary school children. Proceedings of the South­western Psychological Association Annual Meeting, 1975.

Burks, H. The hyperkinetic child. Exceptional Child, 1960, 27, 18-26.

Burns, E., & Lehman, L. C. An evaluation of summated rating and pair comparison measures of hyperkinesis. Journal of Learning Disabilities, 1974, 7(8), 48-51.

164

Buros, O. K. The seventh mental measurements yearbook. Highland Park: The Gryphon Press, 1972.

Campbell, D. T., & Stanley, J. C. Experimental and quasi-experimental designs for research. Chicago: Rand McNally & Company, 19 63.

Campbell, S. B. Cognitive styles in reflective, impulsive, and hyperactive boys and their mothers. Perceptual and Motor Skills, 1973, 36, 747-752.

Campbell, S. B. , Douglas, V. I., & Morgenstern, G. Cogni­tive styles in hyperactive children and the effect of methylphenidate. Journal of Child Psychology and Psychiatry, 1971, 12, 55-67~! ~

Campbell, S. B., & Douglas, V. I. Cognitive styles and responses to the threat of frustration. Canadian Journal of Behavioral Science, 1972, 4, 30-42.

Carter, J. L., & Synolds, D. Effects of relaxation training upon handwriting quality. Journal of Learning Dis­abilities, 1974, 7(4), 53-55";:

Cermak, S. A., Stein, F., & Abelson, C. Hyperactive chil­dren and an activity therapy model. American Journal of Occupational Therapy, 1973, 26(6), 311-315.

Christensen, D. E., & Sprague, R. L. Reduction of hyper­active behaviors by conditioning procedures alone and combined with methylphenidate (Ritalin). Behavioral Research and Therapy, 1973, 11, 331-334.

Clements, S. D. Minimal brain dysfunction in children: Terminology and identification: Phase one of a three-phase project. National Institute of Neurological Diseases and Blindness Monograph No. 3. 1966 (Public Health Service Publication No. 1415).

Cohen, J. Statistical power analysis for the behavioral sciences. New York: Academic Press, 1969.

Comly, H. H. Cerebral stimulants for children with learning disorders. Journal of Learning Disabilities, 1971, 4 (9) , 484-490.

Conners, C. K. A teacher's rating scale for use in drug studies with children. American Journal of Psychiatry, 1969, 126(6), 884-884.

165

Conners, C. K. Symptom patterns in hyperkinetic, neurotic, and normal children. Child Development, 1970, 41, 668-682.

Conners, C. K. What parents need to know about stimulant drugs and special education. Journal of Learning Disabilities, 1973, 6(6), 13-15.

Conners, C. K., & Eisenberg, L. The effects of methyl­phenidate on symptomatology and learning in disturbed children. American Journal of Psychiatry, 1963, 120, 458-463.

Conners, C. K. , Eisenberg, L., & Barcaia, A. Effect of dextroamphetamine on children: Studies on subjects with learning disabilities and school behavior problems. Archives of General Psychiatry, 1967, 17, 478-485.

Conners, C. K. , Eisenberg, L. , & Sharpe, L. Effects of methylphenidate (Ritalin) on paired-associate learning and Porteus Maze performance in emotionally disturbed children. Journal of Consulting Psychology, 1964, 28, 14-22.

Connoly, D. P. , Besserman, R., & Kirschvink, J. Electro­myography (EMG) biofeedback on hyperkinetic children. The Journal of Bio-Feedback, 1974, 2(1), 24-31.

Conrad, W. G. , Dworkin, E. S., Shai, A., & Tobiessen, J. E. Effects of amphetamine therapy and prescriptive tutor­ing on the behavior and achievement of lower class hyperactive children. Journal of Learning Disabilities, 1971, 4(9), 509-517.

Cowgill, M., Friedland, S., & Shapiro, R. Predicting learn­ing disabilities from kindergarten reports. Journal of Learning Disabilities, 1973, 6(9), 50-55.

Cromwell, R. L., Baumeister, A., & Hawkins, W. F. Research in activity level. In N. R. Ellis (Ed.) Handbook of mental deficiency. New York: McGraw-Hill, 1963.

Davids, Anthony. An objective instrument for assessing hyperkinesis in children. Journal of Learning Dis­abilities, 1971, 4(9), 499-501.

Denhoff, E., Davids, A., & Hawkins, R. Effects of dextro­amphetamine on hyperkinetic children: A controlled double blind study. Journal of Learning Disabilities, 1971, 4(9), 491-498.

166

Douglas, V. I. Effects of medication on learning efficiency research findings review and synthesis. In R. P. Anderson & C. G. Halcomb (Eds.), Learning disability/ minimal brain dysfunction syndrome: Research perspec­tives and applications. Springfield: Charles C. Thomas, 197 6.

Douglas, V. I. Stop, look and listen: The problem of sus­tained attention and impulse control in hyperactive and normal children. Canadian Journal of Behavioral Science, 1972, 4(4), 259-282.

Doyle, R. B. The vigilance task and the measurement of attentional deficits. In R. P. Anderson & C. G. Halcomb (Eds.), Learning disability/minimal brain dys­function syndrome: Research perspectives and applica­tions. Springfield: Charles C. Thomas, 1976.

Doyle, R. B. , Anderson, R. P., & Halcomb, C. G. Attention deficits and the effects of visual distraction. Pro­ceedings of the Southwestern Psychological Association, Annual Meeting, 1973.

Dunn, L. M. Expanded manual for the peabody picture vocabu­lary test. Circle Pines: American Guidance Service, Inc., 1965.

Dykman, R. A., & Ackerman, P. T. Hyperactive boys in adolescents. Symposium Presented at the Meeting of the American Psychological Association, 1975.

Dykman, R. A., & Ackerman, P. T. The MBD problem: Attention, intention and information processing. In R. P. Anderson & C. G. Halcomb (Eds.), Learning disability/ minimal brain syndrome: Research perspectives and applications. Springfield: Charles C. Thomas, 1976.

Dykman, R. A., McGrew, J., Harris, T. S., Peters, J. E., & Ackerman, P. T. Two blinded studies of the effects of stimulant drugs on children: Pemoline, methylphenidate, and placebo. In R. P. Anderson & C. G. Halcomb (Eds.), Learning disability/minimal brain syndrome: Research perspectives and applications" Springfield: Charles C. Thomas, 1976.

Ebaugh, F. Neuropsychiatric sequalae of acute epidemic encephalitis in children. American Journal of Diseases in Children, 1923, 25, 89-97.

Eisenberg, L. , Conners, C. K., & Sharpe, L. A controlled study of the differential application of outpatient psychiatric treatment for children. Japanese Journal of Child Psychiatry, 1965, 6, 125-132.

Epstein, L. C., Lasagna, L., Conners, C. K., & Rodriguez, A. Correlation of dextroamphetamine excretion and drug response in hyperkinetic children. Journal of Nervous and Mental Disease, 1968, 146, 136-146.

Feighner, A. C., & Feighner, J. P. Multimodality treatment of the hyperkinetic child. American Journal of Psy­chiatry, 1974, 131(4), 459-463.

Feingold, B. Hyperkinesis and food additives. Paper pre­sented at the American Medical Association Meeting, New York, June 1973.

Fowlie, B. A parent's guide to amphetamine treatment of hyperkinesis. Journal of Learning Disabilities, 1973, 6(6), 16-19.

Fray, M. Implications of electromyographic feedback for essential hypertensive patients. Unpublished doctoral dissertation, Texas Tech University, 1975.

Furman, S., & Feighner, A. Video feedback in treating hyperkinetic children: A preliminary report. American Journal of Psychiatry, 1973, 130(7), 792-795.

Gaylin, J. Helping learning disabled children. Psychology Today, 1977, 10(11), 96-97.

Glennon, C. A., & Nason, D. E. Managing the behavior of the hyperkinetic child: What research says. Reading Teacher, 1974, 27, 815-824.

Greenberg, L. M., Deen, M. A., & McMahon, S. Effects of dextroamphetamine, chlorpromazine, and hydroxyzine on behavior and performance in hyperactive children. American Journal of Psychiatry, 1972, 129(5), 532-539.

-^ Grinspoon, L. , & Singer, S. B. Amphetamines in the treat­ment of hyperkinetic children. Harvard Educational Review, 1973, 43(4), 515-555.

Guralnick, M. J., & Mott, D. E. Biofeedback training with a learning disabled child. Perceptual and Motor Skills, 1976, 42, 27-30.

168

Haight, M. J., Irvine, A. B., & Jampolsky, G. G. Response of hyperkinesis to EMG biofeedback. Proceedings of the Seventh Annual Meeting of the Biofeedback Research Society, 1976.

Halcomb, C. G. Methodological problems in working with special populations. In R. P. Anderson & C. G. Halcomb (Eds.), Learning disability/minimal brain dysfunction syndrome: Research perspectives and applications. Springfield: Charles C. Thomas, 1976.

Huck, S. W. The analysis of couariance: Increased power through reduced variability. The Journal of Experi­mental Education, 1972, 41(1), 42-45.

Huelsman, C. B. The WISC subtest syndrome for disabled readers. Perceptual and Motor Skills, 1970, 30, 535-550.

Huessy, H. R. , Metoyer, M., & Townsend, M. 8-10 year follow-up of 8 4 children treated for behavioral disorders rural Vermont. Acta Paedopsychiatrica, 1974, 40(6), 230-235.

Hutt, C , Hutt, S. J., & Ounstead, C. A method for the study of children's behavior. Developmental Medicine and Child Neurology, 1963, 5, 233-245.

Jacobson, E. Progressive Relaxation. Chicago: The Univer­sity of Chicago Press, 1929.

Jones, N. M., Loney, J., Weissenburger, F. E., & Fleischmann, D. J. The hyperactive child: What do teachers know? Psychology in the Schools, 1975, 12(4), 388-392.

Kagan, J., Rosman, B. L., Day, D., Albert, J., & Phillips, W. Information processing in the child: Significance of analytic and reflective attitudes. Psychological Monographs, 1964, 78 (1, Whole No. 578).

Kahn, E., & Cohen, L. H. Organic driveness: A brainstem syndrome and an experience. New England Journal of Medicine, 1934, 210, 748-756.

Kass, C. E., & Myklebust, H. R. Learning disability: An educational definition. Journal of Learning Disabil-ities, 1969, 2(7), 377-379.

169

Keogh, B. K. Hyperactivity and learning disorders: Review and speculation. Exceptional Children, 1971, 38(2), 101-108.

Kirk, R. E. Experimental design: Procedures for the behav­ioral sciences. Belmont: Brooks/Cole Publishing Company, 1968.

Laufer, M. W., & Denhoff, E. H. Hyperkinetic behavior syn­drome in children. Journal of Pediatrics, 1957, 50, 463-474.

Laufer, M. W. , Denhoff, E., & Solomons, G. Hyperkinetic impulse disorder in children's behavior problems. Psychosomatic Medicine, 1957, 19, 38-49.

Laybourne, P. C., Jr. Psychiatric response to the minimal brain dysfunction child. In R. P. Anderson & C. G. Halcomb (Eds.), Learning disability/minimal brain dys­function syndrome: Research perspectives and applica­tions. Springfield: Charles C. Thomas, 1976.

Lazarus, A. A. Behavior therapy and beyond. New York: McGraw-Hill Book Company, 1971.

Lovitt, T. C. Self management with children with behavioral disabilities. Journal of Learning Disabilities, 1973, 6, 138-150.

Lupin, M. Peace, harmony, and awareness. Houston: Self Management Tapes, 1974.

Lupin, M. , Braud, L. W. , Braud, W. , & Duer, VJ. F. Effects of relaxation tapes upon children and their parents. Academic Therapy, in press.

Lutey, C. L. Individual intelligence testing: A manual. Greeley: Executary Inc., 1966.

Marshall, P. H., Anderson, R. P., & Tate, P. A. Memory analysis: Short- and long-term memory in learning disabled children. In R. P. Anderson & C. G. Halcomb (Eds.), Learning disability/minimal brain dysfunction syndrome: Research perspectives and applications. Springfield: Charles C. Thomas, 1976.

Marwit, S. J., & Stenner, A. J. Hyperkinesis: Delineation of two patterns. Exceptional Child, 1972, 38, 401-406.

170

McDaniel, E. L. Inferred self-concept scale manual. Los Angeles: Western Psychological Services, 1973.

Meichenbaum, D. H. The nature and modification of impulsive children: Training impulsive children to talk to them­selves. Jouranl of Abnormal Psychology, 1971, 77, 115-126.

Melzack, R. The promise of biofeedback: Don't hold the party yet. Psychology Today, 1975, 9(2), 18-20; 80-81.

Mendelson, W., Johnson, N., & Stewart, M. A. Hyperactive children as teenagers: A follow-up study. Journal of Nervous and Mental Disease, 1971, 153(4), 273-279.

Millichap, J. G. The Hyperactive Child with Minimal Brain Dysfunction: Questions and Answers. Chicago: Year Book Medical Publishers, Inc., 1975.

Minde, K., Lewin, D., Weiss, G., Lavigueur, H., Douglas, V., & Sykes, E. The hyperactive child in elementary school: A 5 year, controlled, followup. Educational Children, 1971, 38(3), 215-221.

Mirsky, A. F., & Rosvold, H. E. Behavioral and physiologi­cal studies in impaired attention. In Z. Votava et al. (Eds.), Psychopharmacological methods: Proceedings of a symposium on the effects of psychotropic drugs on higher nervous activity. Oxford: Pergamon Press, 1963.

Montagu, J. D., & Swarbrick, L. Hyperkinesis: The objective evaluation of therapeutic procedures. Biological Psy­chology, 1974, 2, 151-155.

Morrison, J. R., & Stewart, M. A. A family study of the hyperactive child syndrome. Biological Psychiatry, 1971, 3, 189-195.

Morrison, J. R., & Stewart, M. A. Bilateral inheritance as evidence for polygenicity in the hyperactive child syndrome. The Journal of Nervous and Mental Disease, 1974, 158(3), 226-228.

Morrison, J. R., & Stewart, M. A. Evidence for polygenetic inheritance in the hyperactive child syndrome. Ameri-can Journal of Psychiatry, 1972a, 130(7), 791-792.

171

Morrison, J. R., & Stewart, M. A. The psychiatric status of the legal families of adopted hyperactive children. Archives of General Psychiatry, 1973b, 28(6), 881-891.

Nail, A. Alpha training and the hyperkinetic child—is it effective? Academic Therapy, 1973, 9(1), 15-19.

Offir, C. W. A slavish reliance on drugs: Are we pushers for our own children? Psychology Today, 1974, 8(7), 49.

Page, J. G., Janicki, R. S., Bernstein, J. E., Curran, C. F., & Michelli, F. A. Pemoline (Cylert) in the treatment of childhood hyperkinesis. Journal of Learning Dis­abilities, 1974, 7(8), 499-503.

Piers, E. V. Manual for the Piers-Harris children's self concept scale (The way I feel about myself). Nashville: Counselor Recordings and Tests, 1969.

Pope, L. Motor activity in brain-injured children. Ameri­can Journal of Orthopsychiatry, 1970, 40(5), 783-794.

Powers, H. Dietary measures to improve behavior and achieve­ment. Academic Therapy, 1973-1974, 9, 203-214.

Quay, H., Sprague, R., Werry, J., & McQueen, M. Conditioning visual orientation of conduct problem children in the classroom. Journal of Experimental Child Psychology, 1966, 5, 512-517.

Rappaport, J., & Benoit, M. The relation of direct home observations to the clinic evaluation of hyperactive school age boys. Journal of Child Psychiatry, 1975, 16, 141-147.

Rappaport, J. L., Quinn, P. 0., Bradbarb, R., Riddle, D., & Brooks, E. Imipramine and methylphenidate treat­ments of hyperactive boys. Archives of General Psy­chiatry, 1974, 30(6), 789-793.

Satterfield, J. H., Cantwell, D. P., & Satterfield, B. T. Pathophysiology of the hyperactive child syndrome. Archives of General Psychiatry, 1974, 31, 839-843.

172

Satterfield, J. H. , Cantwell, D. P., Saul, R. E., & Yusin, A. Intelligence, academic achievement, and EEG abnormal­ities in hyperactive children. American Journal of Psychiatry, 1974, 131(4), 391-395.

Satterfield, J. H., & Dawson, M. E. Electrodermal correlates of hyperactivity in children. Psychophysiology, 1971, 8(2), 191-197.

Schnackenberg, R. C. Caffeine as a substitute for schedule II stimulants in hyperkinetic children. American Journal of Psychiatry, 1973, 130(7), 796-798.

Schulman, J. L., Kaspar, J. C., & Thorne, F. M. Brain damage and behavior: A clinical-experimental study. Spring­field: Charles C. Thomas, 1965.

Senf, G. M. Model centers program for learning disabled children: Historical perspective. In R. P. Anderson & C. G. Halcomb (Eds.), Learning disability/minimal brain dysfunction syndrome: Research perspectives and applications. Springfield: Charles C. Thomas, 1976.

Shouse, M. N., & Lubar, J. F. Management of the hyperkinetic syndrome in children concurrent with sensorimotor rhythm (SMR) biofeedback training. Proceedings of the Seventh Annual Meeting of the Biofeedback Research Society, 1976.

Silver, L. B. A proposed view on the etiology of the neuro­logical learning disability syndrome. Journal of Learn­ing Disabilities, 1971, 4(3), 123-133.

Simpson, D. D., & Nelson, A. E. Attention training through breathing control to modify hyperactivity. Journal of Learning Disabilities, 1974, 7(5), 274-283.

Solomons, G. Guidelines on the use and medical effects of psychostimulant drugs in therapy. Journal of Learning Disabilities, 1971, 4(9), 470-475.

Sprague, R. L. Counting jars of raspberry jam. In R. P. Anderson & C. G. Halcomb (Eds.), Learning disability/ minimal brain dysfunction syndrome: Research perspec­tives and application's"^ Springfield: Charles C. Thomas, 1976.

Sprague, R. L., Barnes, K. R., & Werry, J. S. Methylphenidate and thioridazine: Learning, reaction time, activity, and classroom behavior in disturbed children. American Journal of Orthopsychiatry, 1970, 40, 615-628.

173

Spring, C., Greenberg, L., Scott, J., & Hopwood, J. Electro­dermal activity in hyperactive boys who are methyl­phenidate responders. Psychophysiology, 1974, 2(4), 436-442.

Steinberg, G. G. , Troshinsky, C., & Steinberg, H. R. Dextroamphetamine-responsive behavior disorder in school children. American Journal of Psychiatry, 1971, 128(2), 174-179.

Stewart, M., Pitts, F., Craig, A., & Dieruf, W. The hyper­active child syndrome. American Journal of Ortho­psychiatry, 1966, 36, 861-867.

Strauss, A. A., & Kephart, N. C. Psychopathology and educa­tion of the brain-injured child: Progress in theory and clinic. (Vol. II). New York: Grune & Shatton, 1955.

Strauss, A. A., & Lehtinen, L. E. Psychopathology and edu­cation of the brain-injured child. Vol. I. New York: Grune & Stratton, 1947.

Sulzbacher, S. Drug effects in learning and behavior of children. Paper presented at the University of Oregon Medical School, Portland, Oregon, July 1971.

Sykes, D. H. , Douglas, V. I., Weiss, G., & Minde, K. K. Attention in hyperactive children and the effect of methylphenidate (Ritalin). Journal of Child Psychology and Psychiatry, 1971, 12, 129-139.

Tarver, S. G., & Hallahan, D. P. Attention deficits in chil­dren with learning disabilities: A review. Journal of Learning Disabilities, 1974, 7(9), 36-45.

Toffler, A. E. The effect of intervention on children classi­fied as minimal brain damage by psychological testing which has been confirmed or disconfirmed by EEG evalu­ation. Dissertation Abstracts International, 1972, 32, (10-B), 6062-6063.

Waizer, J., Hoffman, S. P., Polizos, P., & Engelhardt, D. M. Outpatient treatment of hyperactive school children with imipramine. American Journal of Psychiatry, 1974, 13(5), 587-591.

Walker, S., III. Drugging the American child: We're too cavalier about hyperactivity. Psychology Today, 1974, 8(7), 43-48.

174

Wechsler, D. Manual for the Wechsler Intelligence Scale For Children - Revised. New York: The Psychological Corporation, 1974.

Weiss, G., Werry, J. s., Minde, K. K., Douglas, V. I., & Sykes, D. H. Studies on the hyperactive child - V: The effects of dextroamphetamine and chlorpromazine on behavior and intellectual functioning. Journal of Child Psychology and Psychiatry, 1968, 9, 145-156.

Weiss, G. , Minde, K. K., Werry, J. S., Douglas, V. I., & Nemeth, E. Studies on the hyperactive child - VIII: Five-year follow-up. Archives of General Psychiatry, 1971, 24, 409-414. ~~

Weithorn, C. J. Hyperactivity and the CNS: An etiological diagnostic dilemma. Journal of Learning Disabilities, 1973, 6(1), 46-50. " ~

Werry, J. S. Developmental hyperactivity. Pediatric Clinics of North America, 1968, 15(3), 581-599.

Werry, J. S., & Aman, M. G. Methylphenidate and haloperidol in children: Effects on attention, memory, and activity. Archives of General Psychiatry, 1975, 32(6), 790-795.

Whitehead, P. L., & Clark, L. D. Effects of lithium carbon­ate, placebo, and thioridazine on hyperactive children. American Journal of Psychiatry, 1970, 127(6), 824-825.

Wiens, A. N. , Anderson, K. A., & Matarazzo, R. G. Use of medication as an adjunct in the modivication of behav­ior in the pediatric psychology setting. Professional Psychology, 1972, 3(2), 157-163.

Williamson, G. A., Anderson, R. P., & Sherman, C. P. Atten­tion training for hyperkinetic children in a classroom setting. Texas Tech University Journal of Education, in press.

Wolpe, J., & Lazarus, A. A. Behavior Therapy Techniques. New York: Pergamon, 1966.

Wunderlich, R. C. Treatment of the hyperactive child. Academic Therapy, 1973, 8(4), 375-390.

Zukow, A. H. Helping the hyperkinetic child. The Journal of the National Education Association: Today's Education, 1975, 64(4), 39-41.

APPENDICES

A. Permission Form 176

B. Subject Information Sheet 177

C. Davids Rating Scales for Hyperkinesis 178

D. Task Motivational Instructions 180

E. Conners Behavioral Rating Scale 182

F. Pretest Mean Scores 184

G. Non-adjusted and Adjusted Posttest Mean Scores 186

H. Analysis of Variance Source Tables for the Conners Factors 188

I. Analysis of Variance Source Table Peabody Picture Vocabulary Test 190

175

176

APPENDIX A: PERMISSION FORM

^' / give my permission for

my son/daughter to participate in a project conducted under

the supervision of Ray H. Brown, a doctoral candidate in

psychology. It is my understanding that the purpose of

this project is to evaluate the behaviors of overly active

children who are not being medicated for their overactivity.

The project has been explained to me and the understanding

is that the procedures are safe and, in fact, may lead to

newer, non-medical methods of treating hyperactive children.

Baring no unforeseen interruptions, an attempt will be made

to see that my child can participate for the full term of

the project. Also, I grant permission for the examiner to

contact my child's teacher and/or principal in the fall in

order to gain further behavioral information.

Signature:

Date:

177

APPENDIX B: SUBJECT INFORMATION SHEET

Child's Name

Date of Birth Age

Grade (Next Year) School (Next Year)

Sex Race Birth Order of

Father: Name

Age Occupation (Job Description)

Military Rank Highest Grade Attained in School

Address Phone

Mother: Name

Age Occupation (Job Description)

Address Phone

Highest Grade Attained in School

Birth History: Premature Caesarian

Weight at Birth Short Labor Long Labor

Forcep Birth Difficulty at Birth

History of Head Injury • History of Seizures

EEG Abnormality Allegeries Hypoglycemia_

Medicated for Hyperactivity Before

Name of Medication

Dosage

Other Pertinent Information

178

APPENDIX C: DAVIDS RATING SCALES FOR HYPERKINESIS

TABLE 1. Rating scales for hyperkinesis

Child's Name Bij th Date

Rater ' s Name Date of Rating

Please rate the child on each of the characteristics (or behavior) listed on the following scales. Place a check mark at the point on the scale indicative of your estimate of the degree to which the child possesses the particular characteristic.

As you make each rating, judge the child in comparison with other children of the same sex and age. That is, the ratings should indi­cate your estimate of the child's behavior in comparison with the behavior displayed by other "normal children."

For each of the characteristics, which are defined below, place a check mark at one of the six points on the scales running from "much less than most children" to "much more than most children." Do not mark the midpoint on any of the scales. Even though it may sometimes be difficult to make a judgment, please make a rating on one or the other side of the scale.

!• Hyperactivity - Involuntary and constant overactivity; advanced motor development (throwing things, walking, running, etc.); always on the move; rather run than walk; rarely sits still.

Much Less Than Less Slightly Slightly More Much More Than Most Children Less More Most Children

2. Short Attention Span and Poor Powers of Concentration - Concentra­tion on a single activity is usually short, with frequent shifting from one activity to another; rarely sticks to a single task very long.

Much Less Than Less Slightly Slightly More Much More Than Most Children Less More Most Children

3. Variability - Behavior is unpredictable, with wide fluctuations in performance; "sometimes he (or she) is good and sometimes bad."

Much Less Than Less Slightly Slightly More Much More Than Most Children Less More Most Children

4. Impulsiveness and Inability to Delay Gratification - Does things on the spur of the moment without thinking; seems unable to tolerate

179

any delay in gratification of his (her) needs and demands; when wants anything, he (she) wants it immediately; does not look ahead or work toward future goals; thinks only of immediate present situation.

Much Less Than Less Slightly Slightly More Much More Than Most Children Less More Most Children

5- Irritability - Frustration tolerance is low; frequently in an ugly mood, often unprovoked; easily upset if everything does not work out just the way he (she) desires.

Much Less Than Less Slightly Slightly More Much More Than Most Children Less More Most Children

6. Explosiveness - Fits of anger are easily provoked; reactions are often almost volcanic in their intensity; shows explosive, temper-tantrum type of emotional outbursts.

Much Less Than Less Slightly Slightly More Much More Than Most Children Less More Most Children

7. Poor School Work - Has difficulty participating successfully in school work; cannot concentrate on school work; has some specific learning difficulties or blocks (e.g., poor in arithmetic, poor in reading, etc.); poor visual-motor coordination (e.g., awkward gestures, irregular handwriting, poor in drawing, etc.).

Much Less Than Less Slightly Slightly More Much More Than Most Children Less More Most Children

180

APPENDIX D: TASK MOTIVATIONAL INSTRUCTIONS

In this program you will learn a great deal about your­

self and about your behaviors. Do you ever wish that you

could change your behavior so that you get in less trouble?

Most children have wished they could better control their

behavior and always act as they know they should. You can

do this if you will listen carefully and do just what these

tapes say. You will be surprised how well you can behave

and be still and quiet when you are supposed to and how much

less you will find yourself getting into trouble. Most

everyone who has done what these tapes say has learned how

to relax and have also improved themselves very much. The

tapes will tell you how to relax and will ask you to use

your imagination. Most children can do this very easily

and I'm sure you can too. Try very hard and I think that

you will be very pleasantly surprised about how good you do

and how much you can improve yourself. All I want is for

you to try hard, because I want you to learn to relax, to

learn to like yourself better than ever before, and as

you do this you will begin to get along with other people

better than you ever have before. Also, by trying real

hard you will help us learn more about how to use this pro­

gram to help others like yourself. So try real hard and

you can soon see how helpful this program will be to you.

181

your family, your classmates, and your friends. You will

find that changes will happen just as if by magic.

182

APPENDIX E: CONNERS BEHAVIORAL RATING

Rate 1 - 4

PROBLEM AREA NOT AT JUST A QUITE VERY ALL LITTLE A BIT MUCH

1. Sits fiddling with small objects

2. Hums and makes other odd noises

3. Falls apart under stress of examination

4. Coordination poor

5. Restless or overactive

6. Excitable

7. Doesn't pay attenion - Inattentive

8. Difficulty in concentrating

9. Oversensitive

10. Overly serious or sad

11. Daydreams

12. Sullen or sulky

13. Selfish

14. Disturbs other children

15. Quarrelsome

16. "Tattles"

17. Acts "smart"

18. Destructive

19. Steals

20. Lies

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

3

3

3

3

3

3

3

3

3

3

3

3

3

3

3

3

3

3

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

183

PROBLEM AREA NOT AT JUST A QUITE VERY ALL LITTLE A BIT MUCH

21. Temper outbursts

22. Isolates himself from other children

23. Appears to be unaccepted by group

24. Appears to be easily led

25. No sense of fair play

26. Appears to lack leadership

27. Does not get along with opposite sex

28. Does not get along with same sex

29. Teases other children or inter­feres with their activities

30. Submissive

31. Defiant

32. Impudent

33. Shy

34. Fearful

35. Excessive demands for teacher's attention

36. Stubborn

37. Overly anxious to please

38. Uncooperative

39. Attendance problem

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

184

APPENDIX F: PRETEST MEAN SCORES

TABLE 1

DAVIDS SCALES—PRETEST MEAN SCORES

Treatment Group

Relax + TMI

Relax Only

Attention

Control

Column Marginal

Younger Children

28.40

29.00

31.20

30.40

29.75

Older Children

28.20

32.00

24.60

28.40

28.30

Row Marginal

28.30

30.50

27.90

29.40

TABLE 2

PIERS-HARRIS SCALE—PRETEST MEAN SCORES

Treatment Group

Relax + TMI

Relax Only

Attention

Control

Column Marginal

Younger Children

59.60

51.20

61.20

54.20

56.35

Older Children

46.00

56.40

54.20

54.40

52.75

Row Marginal

52.80

53.80

57.70

54.30

TABLE 3

CODING—PRETEST MEAN SCORES

Treatment Group

Treatment Group

Relax + TMI

Relax Only

Attention

Control

Column Marginal

Younger Children

Younger Children

8.40

6.80

7.20

8.20

7.65

Older^ Children

Older Children

3.80

6.40

8.60

8.80

6.90

Row Marginal

Row Marginal

6.10

6.60

7.90

8.50

185

TABLE 4

MAZES—PRETEST MEAN SCORES

Treatment Group

Relax + TMI

Relax Only

Attention

Control

Column Marginal

Younger Children

9.80

7.80

9.60

11.00

9.55

Older Children

7.60

8.80

10.60

12.60

9.90

Row Marginal

8.70

8.30

10.10

11.80

TABLE 5

DIGIT SPAN—PRETEST MEAN SCORES

Treatment Group

Relax + TMI

Relax Only

Attention

Control

Column Marginal

Younger Children

7.20

6.80

8.20

9.60

7.95

Older Children

9.20

8.20

8.60

7.60

8.40

Row Marginal

8.20

7.50

8.40

8.60

186

APPENDIX G: NON-ADJUSTED AND ADJUSTED

POSTTEST MEAN SCORES

TABLE 6

DAVID SCALES—NON-ADJUSTED AND ADJUSTED POSTTEST MEAN SCORES

Treatment Group

Relax + TMI

Relax Only

Attention

Control

Younger Non-adjus

29.20

31.20

28.80

30.20

ted Younger Adjusted

29.64

31.22

27.27

29.23

TABLE 7

Older Non-adjusted

22.80

31.20

23.20

27.60

Older Adjusted

23.38

29.11

26.31

28.04

PIERS-HARRIS SCALE—NON-ADJUSTED AND ADJUSTED POSTTEST MEAN SCORES

Treatment Group

Younger Non-adjusted

Younger Adjusted

Older Non-adjusted

Older Adjusted

Relax + TMI

Relax Only

Attention

Control

64.60

57.80

60.40

53.80

60.33

60.78

54.75

54.19

TABLE 8

59.40

62.60

59.20

55.20

66.87

61.09

59.59

55.42

CODING—NON-ADJUSTED AND ADJUSTED POSTTEST MEAN SCORES

Treatment Younger Younger Group Non-adjusted Adjusted

Older Non-adjusted

Older Adjusted

Relax + TMI

Relax Only

Attention

Control

10.80

8.40

7.80

8.00

9.70

8.87

7.87

7.09

5.80

7.60

10.60

9.40

9.21

8.46

9.30

7.90

187

TABLE 9

MAZES—NON-ADJUSTED AND ADJUSTED POSTTEST MEAN SCORES

Treatment Group

Relax + TMI

Relax Only

Attention

Control

Younger Non-adjusted

11.40

9.80

10.00

10.80

Younger Adjusted

11.34

11.42

10.11

9.73

Older Non-adjusted

8.80

8.00

11.20

12.80

Older Adjusted

10.59

8.78

10.47

10.38

TABLE 10

DIGIT SPAN—NON-ADJUSTED AND ADJUSTED POSTTEST MEAN SCORES

Treatment Group

Relax + TMI

Relax Only

Attention

Control

Younger Non-adjus

8.80

8.40

10.40

9.00

ted Younger Adjusted

9.60

9.62

10.38

7.74

Older Non-adjus

9.60

8.80

9.20

7.40

;ted Older Adjusted

8.69

8.78

8.82

7.91

188

APPENDIX H: ANALYSIS OF VARIANCE SOURCE TABLES

FOR THE CONNERS FACTORS

Source

Group

Age

TABLE 16

ANALYSIS OF VARIANCE SOURCE TABLE CONNERS-DEFIANCE-AGGRESSION

Interaction

SS

194.07

8.05

426.07

Unit (Error Term) 1028.17

df

21

MS

64.69

8.05

142.02

48.96

1.32

.16

2.90

.29

>. 50

.06

Total 1656.36 28 59.16

Source

TABLE 17

ANALYSIS OF VARIANCE SOURCE TABLE CONNERS-DAYDREAMING-INATTENTIVENESS

Group

Age

Interaction

Unit (Error Term)

SS

16.22

1.57

23.30

303.42

df

3

1

3

21

MS

5.40

1.57

7.7

14.45

. 37

. 1 1

.54

>.50

>.50

>.50

Total 344.51 28 12.30

189

TABLE 18

ANALYSIS OF VARIANCE SOURCE TABLE CONNERS-ANXIOUS-FEARFULNESS

Source

Group Age

Interaction

Unit (Error Term)

Total

SS

60.44

3.65

61.44

316.42

441.94

df

3

1

3

21

28

TABLE 19

MS

20.15

3.65

20.48

15.07

15.78

F

1.3

.24

1.36

P

.29

>.50

.28

ANALYSIS OF VARIANCE SOURCE TABLE CONNERS-HYPERACTIVITY

Source

Group

Age

Interaction

Unit (Error

Total

Term)

SS

88.

0.

205.

763.

1058.

^

,29

30

75

67

00

df

3

1

3

21

28

MS

29

68

36

37

.43

.30

.58

.37

.79

F

.81

.01

1.89

P

>.

>.

0.

50

50

,16

TABLE 20

ANALYSIS OF VARIANCE SOURCE TABLE CONNERS-WELL ADJUSTED STATE

Source

Group

Age

Interaction

Unit (Error

Total

Term)

SS

16.37

4.53

41.01

112.75

174.65

df

3

1

3

21

28

MS

5.46

4.53

13.67

5.37

6.24

F

1.02

.84

2.55

P

.41

.37

.08

APPENDIX I 150

TABLE 27

ANALYSIS OF VARIANCE SOURCE TABLE PEABODY PICTURE VOCABULARY TEST

Source

Group

Age

Interaction

Unit (Error Term)

Total

SS

154.50

122.50

1012.50

5154.42

6443.91

df

3

1

3

32

39

MS

51.50

122.50

337.50

161.08

165.08

F

.32

.76

2.10

P

>.50

.39

.12