International Theraplay Conference, June 23-24, 2005 University of Chicago, Gleacher Center, Chicago, IL, USA Ulrike Franke Herbert H. G. Wettig H-MIM

International Theraplay Conference, June 23-24, 2005University of Chicago, Gleacher Center, Chicago, IL, USA

Ulrike Franke • Herbert H. G. Wettig

H-MIMThe Heidelberg Marschak Interaction Method

to assess the mother-child interactive behaviorQuality criteria: construct validity – effect size - sensitivity – retest-reliability

Research results of a controlled longitudinal study 1998-2005 in Germany

Theraplay InstitutUlrike Franke und Herbert Wettig, Leonberg Germany

2005

Theraplay Institut Germany 2005

H-MIM The Heidelberg Marschak Interaction Method

2

Overview• Introduction

– Objective: The assessment of the mother-child interactive behavior

• The Heidelberg Marschak Interaction Method (H-MIM)– H-MIM: A culturally-dependent modification of the MIM

• Method– 2 Field-studies with repeated measurement in therapy settings– Sample size and sample structure – Course of time of measurement and different kinds of test instruments

• Results An example: Toddlers and preschool children with attention disorders– Hypothesis

about the validity of H-MIM to assess the mother-child interactive behavior– Construct validity of the H-MIM: Clinical and statistical significance

of the change of mother-child interactive behavior in the process of treatment– Effect size: The size of change in children’s interactive behavior after treatment – Sensitivity of the H-MIM: Significance of the change of the interactive behavior– Retest-reliability of the H-MIM: No statistically significant differences in scores– Generalization of the results: Internal and external validity of H-MIM



3

Introduction

• Objective: The assessment of mother-child interactive behavior– Target group: Children who are difficult to treat in therapy

due to for example ADD, ADHD, Aggressiveness, or Autism, that the usual kinds of diagnostic tests of abilities or intelligence yield little information or are nearly impossible to use, and their care givers.

– Diagnosis of difficult children should focus not only on the child, but also on the system, e.g. the interactive behavior with the care giver or the personal environment in which the child lives, thinks, and acts.

– Theraplay aims to change the interactive behavior of such children who are difficult to treat with other kinds of therapies.

– H-MIM was used to assess the mother-child interactive behavior atthe beginning of treatment and the outcome at the end of the treatment.



4

The model of affect regulation of the Heidelberg Marschak Interaction Method (H-MIM)

Literature: Ritterfeld & Franke, 1994, reported in Forum Logopädie, 16 (1), 2002, p. 20

• Three important factors of interaction between the child and his of her care giver. (on basis of research results found until 1994 in German printed journals of psychology, sociology, and cultural sciences)

• Positive consequence:– Attunement of emotions and acceptance of the care giver’s guidance

gives the child a chance to learn affect regulation and interaction with parent’s support.• Negative consequence:

– If emotional attunement is missing and the care giver tries to guide the child, the guidance does not touch the limbic system, the learning areas of the hippocampus, and the prefrontal cortex of the child.

– In this case affect regulation can not be achieved, because without attunement, the “emotional” neural network of the right hemisphere of the brain is not reached.

1. Attunement of the emotionsbetween the care giver and the child

2. The child’s acceptance of guidance by the care giver

relationship-orientatedattachment

task-orientatedlearning

Self-esteem and self-confidence of the child

3. The child‘s affect regulation: Coping with stress



5

H-MIMCulturally-dependent modification of the MIM

• H-MIM is an adaptation of the MIM to fit the typical European pattern of parent-child relationships.

• H-MIM was used to observe/assess the mother-child interactive behaviorof clinically symptomatic toddler and preschool children,2:6 to 6:11 years of age, with their care givers.

• H-MIM focuses on three important factors of social interactive behavior between children and their care givers:– Attunement of the emotions in the parent-child interactive behavior,– The child’s acceptance of guidance by the care giver (e.g. mother or father),– Learning to regulate affects and to cope with stress, supported by the care giver.

• To observe the dyadic system of e.g. the mother-child interactive behavior the mother gets 5 cards with tasks to be solved together with her child.

• The relevant tasks are chosen out of a catalogue of different tasks– 2 different tasks measuring the fitting of the emotions of the dyad, out of 18 possible ones,– 2 different tasks measuring the child’s acceptance of the care givers guidance, out of 22,– 1 task measuring the child’s ability to cope with stress, out of a catalogue of 4 such tasks.

• The kind of tasks depend on the hypothesis/diagnose of the child’s disorder.



6

Purposes for which the H-MIM is frequently usedin German-speaking European countries

• Diagnosis of interactive behavior:– How does the clinically symptomatic child act and react in reality

when alone with his of her care giver (mother or father)?• Diagnosis of developmental speech-language delay or impairment

– For example, does a child with elective mutism speakwhen alone with his or her care giver and not feeling observed?

– How is the receptive language ability of the child when with his family?• Parent-child research

– For example, are there differences in behavior of 5-year olds atseparation and reunion when with their mother or father, respectively?

• Parental advice– Which care giver strategies most supports

the social and communicative development of a symptomatic child?• Youth welfare department decision-making

– Which parents are the best fit for an adoptive or foster child?• Forensic decision-making

– Which parent should be responsible for custody of the child?



7

Method

• Two field studieswith repeated measurement in treatment settings

1998-2005 A Controlled Longitudinal Study (CLS) with a follow-up 2 years after termination of the treatment

2000-2004 A nation-wide Multi-Center-Study (MCS) in 9 quite different treatment facilities

• Objective of the studies: Evaluation of the effectiveness of Theraplay on toddler and preschool children with dual diagnoses of interactive, and speech-language disorders

• Function of the H-MIM: Observation and diagnosis to assess the parent-child interactive behavior in the process evaluating the effectiveness of Theraplay in the course of time



8

Diagnostic data sampling methods(A number of other diagnostic instruments, tests, and questionnaires were used as well)

• Data about mother and childQuestionnaire collecting socio-demographic data, case history

• Data about the severity of the child’s symptomsRepeated measurement of the severity of the symptomsusing CASCAP-D the German Version of CASCAP - Clinical Assessment Scalefor Child and Adolescent Psychopathology (Doepfner et al., 1999)4-point scale: 4 = severe symptom, 3 = clear symptom, 2 = light symptom 1 = clinically non-symptomatic)

• Data about the dyadic parent-child interaction Repeated assessment of the parent-child interaction solving different tasksusing H-MIMthe Heidelberg Marschak Interaction Method (Ritterfeld & Franke, 1994)6-point interval scale: disagree = 1...2...3...4...5…6 = fully agree



9

Course of time of the Controlled Longitudinal Study (CLS)

• Time points of the controlled longitudinal study (CLS) – t0 = at the beginning of a 16-week waiting time

(only the waiting time control group W is observed)– t1 = at the beginning of the treatment with Theraplay– t6 = at the termination of the treatment with Theraplay– t7 = follow-up: 2 years after the end of the therapy

(Time points during the process of therapy t2 – t5 are not reported here.)

• Normal, clinically non-symptomatic control group (N)– t1 = at the beginning of a 16-week waiting time– t6 = at the end of the 16-week waiting time



10

Course of time of the Multi-Center-Study (MCS)

• Multi-Center-Study (MCS) 2 times of measurement (pre - post)

– t1 = at the beginning of the treatment with Theraplay – t6 = at the end of the therapy with Theraplay



11

Method of the Controlled Longitudinal Study (CLS)

• Controlled Longitudinal Study (CLS)1998 – 2003 N = 60 toddler and preschool children with dual diagnosesof developmental language, language or speech disorders, and of interactive disorders, whose treatment was terminated in 2003.The study was carried out in the Phoniatric Paed-Audiologic Center in Heidelberg

2000 – 2005 Follow-up study 2 years after individual discharge from treatment.

• Advantages– High internal validity of the results for language disordered children because…– … carried out only in one region, the catchment area of Heidelberg, Germany– … carried out only in one therapeutic treatment facility,

the Phoniatric Paed-Audiologic Center (PPC) in Heidelberg, Germany– … carried out only with one kind of patients, toddler and preschool children

with dual diagnoses of speech-language and social interactive disorders

• Disadvantage– Generalization of the results onto other cohorts of patients is impossible.– Therefore a nation-wide Multi-Center-Study (MCS) was started in 2000.



12

Method of the Multi-Center-Study (MCS)

• 2000 – 2004 Nation-wide Multi-Center-Study (MCS)

• Sample size N=319 clinically symptomatic toddler and preschool children whose Theraplay treatment terminated up to the end of 2004

• The MCS was carried out in Germany and Austria.• The MCS was carried out in 9 different therapeutic facilities:

– a center of early intervention, the therapeutic clinic– a center of handicapped children, the kindergarten– a child and adolescent psychiatry, the therapeutic clinic– a council welfare department, the kindergarten in a focal area– a phoniatric paed-audiologic center, the therapeutic clinic– a clinic for early intervention on development language delay– a practice of psychological psychotherapy for children and adolescents– several practices of speech-language pathologists, etc.,

• The MCS was carried out by 14 different Theraplay therapists.



13

Sample Sizeof the Controled Longitudinal Study (CLS)

• N=60 Sample of clinically symptomatic toddler & preschoolers (age 2:6 – 6:11 years of age) with dual diagnoses

of developmental language, language or speech disorders and different kinds of socio-emotional interactive disorders. Of these are

• N=50 toddler & preschoolers with attention deficit (net sample) with dual or multiple diagnoses of language and behavior disorders

Out of these 50 children with dual diagnoses are selected:• N=25 … with attention deficit and hyperactivity• N=21 … with attention deficit and oppositional defiancy • N=17 … with attention deficit and shyness• N=13 … with attention deficit and an autism-like lack of social mutuality• N=25 Waiting time control group (W)

of clinically symptomatic preschool children (randomized sample)• N=30 Normal control group (N)

of normal, not clinically symptomatic toddler and preschool children** ** matched sample in age and sex.



14

Sample Sizeof the Multi-Center-Study (MCS)

• N=319 total sample of clinically symptomatic children (MCS) (age 2:6 – 6:11) with dual or multiple diagnoses, respectively, with different kinds of socio-emotional interactive disorders, and different speech and language disorders. Of these are …

• N=291 net sample of symptomatic toddler & preschool children Of these are

• N=218 toddler & preschool children with attention deficit Of these 218 children with dual or multiple diagnoses are selected:

• N=105 with attention deficit and hyperactivity • N=127 with attention deficit and oppositional defiance• N=105 with attention deficit and shyness, withdrawnness• N= 44 with attention deficit and an autism-like lack of social mutuality



15

Sample structureof the Controlled Longitudinal Study (CLS)

(Mean)

CLS: Average age in year: month_.• 4:03 N=50 toddler & preschoolers

suffering from ADD, total• 4:04 years, N = 37 boys• 3:11 years, N = 13 girls• 4:06 N=30 clinically non-symptomatic

toddler and preschoolers Control group N (matched sample)

CLS: Sex in %, Relation 2,9:1______

Boys; Girls74%; 26% N=50 toddler, preschooler suffering from ADD, total

74% = 37 boys 26% = 13 girls

• 70%; 30% N=30 clinically non-symptomatic toddler and preschool children Control group N (matched sample)

CLS: Social status and upbringing_ • N=50 toddler and preschoolers

suffering from ADD

• Social status of the mother90% married mothers 8% unmarried living together 2% unmarried mothers

• Social status of the child90% legitimate children10% illegitimate children

• Upbringing of the child85% both parents15% one parent

• 71% in kindergarten



16

Sample structureof the Multi-Center Study (MCS)

(Mean)MCS: Average age in year: month_. • 4:03 years, N=218

toddler & preschooler suffering from ADD

• 4:03 years, N = 153 boys• 4:04 years, N = 65 girls• 4:06 N=30 clinically non-

symptomatic toddler & preschool children Control group N (matched sample)

• MCS: Sex in %, Relation 2,3:1

Boys; Girls

70%; 30% N=218 toddler & preschoolers with ADD

70% = 153 boys 30% = 65 girls

• 70%; 30% N=30 clinically non- symptomatic toddler & preschool children Control group N (matched sample)

MCS: Social status and upbringingN=218 toddler and preschoolers ______suffering from ADD_____

• Social status of the mother66% married mothers10% unmarried living together 9% been separated mothers 1% widowed mothers13% unmarried mothers (1% n.a.)

• Social status of the child77% legitimate children17% illegitimate natural children 6% adopted/foster children

• Upbringing of the child77% both parents23% one parent

• 76% in kindergarten



17

Research resultsinvestigating the quality criteria of the

Heidelberg Marschak Interaction Method(H-MIM)

using studies ontoddler and preschool children with attention deficit

to compare over the course of time the change of the mother-child interactive behavior

with the change of the child’s symptoms of attention disorders



18

Hypothesisabout the construct validity of H-MIM

as a diagnostic method to assess parent-child interactive disorders

• Construct validity of the H-MIM• If the treatment with Theraplay®

significantly and lastingly reduces the relevant symptom during the process of treatment*(repeated measurement by CASCAP-D)

• … then the parent-child interactive disorder will improve significantly in the same period of time*(repeated measurement by H-MIM)

* Period of reducing the symptom is from the beginning to the end of Theraplay (t1 – t6) Period of lasting of the reduced symptom: 2 years after Theraplay treatment (t6 - t7).



19

Basis is the change of the children’s attention deficit The effectiveness of Theraplay on children with attention disorders

reducing the relevant symptoms over the course of time t1 – t6

in comparison with a control group N of clinically non-symptomatic children Multi-Center-Study (MCS)

t1 – t6 repeated diagnoses of symptoms using CASCAP-D (Doepfner et al., 1999)scale: 4=severe symptom, 3=clear symptom, 2=light symptom, 1=non-symptomatic

Reduction of the attention deficit after treatment with Theraplay

1,3

4,0

2,4

3,0

1,82,0

1,8

3,2

2,0

1

2

3

4

Start of the waiting time (t 0)

Start of the therapy (t 1)

End of the therapy (t 6)

2 years after therapy (t 7)

Sym

pto

m

1 =

no

n-s

ym

pto

ma

tic

... s

ev

ere

sy

mp

tom

= 4

Mean of N=30 clinically non-symptomatic children (sex and age matched control sample N)Mean of N=90 children with severe attention disorders (symptom reduction is statistically significant prob.<.0001)Mean of N=82 children with clear attention disorders (symptom reduction is statistically significant prob.<.0001)Mean of N=46 children with light attention disorders (symptom reduction is statistically significant prob.<.0001)Mean of N=218 children with attention disorder alltogether (symptom reduction is statistically significant prob.<.0001)



20

Reduction of attention deficit after treatment with Theraplay and lasting effect of the reduction 2 years after Theraplay treatment

1,3

3,0

2,22,0

1

2

3

4

Start of the waiting time(t 0)




Sy

mp

tom

1 =

no

n-s

ym

pto

mati

c .

.. s

evere

sym

pto

m =

4

Mean of the N=30 clinically non-symptomatic children of the control group N at t1Mean of all N=50 children with attention deficit. Reduction of the symptom is statistically significant (t1 - t6 prob.=.0015) The lasting effect 2 years after treatment with Theraplay (t6 - t7). The change of the symptom is statistically not significant.

Basis is the change of the children’s attention deficit The effectiveness of Theraplay on children with attention disorders

reducing the relevant symptoms over the course of time t1 – t6

in comparison with a control group N of clinically non-symptomatic children Controlled Longitudinal Study (CLS)

t1 – t6 – t7 repeated diagnoses of symptoms using CASCAP-D (Doepfner et al., 1999) scale: 4=severe symptom, 3=clear symptom, 2=light symptom, 1=non-symptomatic



21

1st Criterion of Suitability Construct validity of the H-MIM

• Construct validity of the H-MIM is to prove the correspondence of the statistical significanceof the hypothetically predicted change of themother-child interactive behavior over the course of timewith the really observed change of the mother-child interactive behavior over the same period

• The change of the mother-child interactive behavioris assessed using H-MIM– investigated in the Controlled Longitudinal Study (CLS) carried out

over the course of time from the beginning of the waiting time (t0)until 2 years after individual termination of Theraplay therapy (t7).

• The change of the symptoms of the child’s disorderis evaluated using CASCAP-D– investigated in the Controlled Longitudinal Study (CLS) carried out

over the course of time from the beginning of the therapy (t1)until 2 years after individual termination of Theraplay therapy (t7).



22

Description of the 2 scales of H-MIM and CASCAP-D to understand the following figures to validate the H-MIM

• Left scale of a graph: H-MIM ( o——o; —— )to assess the observed improvement of mother-child interactive behavioron a 6-point interval scale: disagree = 1...2...3...4...5...6 = fully agree– Mean of the fitting of emotions of the mother-child interaction– Mean of the child’s acceptance to guidance by the care giver– Mean of the child’s stress by separation and reunification with his mother– Mean of several variables of the process (example: 10 out of 40 items)

• Right scale of a graph: CASCAP-D (o; – – –)Evaluates the reduction of the symptoms of the child’s attention disorder after treatment with Theraplay on a 4-point dimensional scale: 4 = severe symptoms of attention disorders of the children (mean)3 = clear symptoms of attention disorders of the children (mean)2 = light symptoms of attention disorders of the children (mean)1 = clinically non-symptomatic normal children (mean of control group N)



23

Attunement of the emotions of mother and child in their interactive behavior

H-MIM on left scale: 6-point interval scale from very little = 1...2...3...4...5...6 = to marked

Change of the mother-child interactive behavior in the Course of Time

3,84,0

4,85,1

5,45,6

3,0

2,22,0

1,3

1

2

3

4

5

6





Ob

se

rve

d In

tera

cti

on

1 =

no

t ap

pro

pri

ate

... a

pp

rop

ria

te =

6

1

2

3

4

Sy

mp

tom

1 =

no

n-s

ymp

tom

atic

... s

eve

re s

ymto

m =

4

H-MIM: Mean of N=50 children with attention disorders. Change t1 - t6 is statistically significant with prob.=0.0015.H-MIM: Mean of N=30 clinically non-symptomatic children in the course of time t1 - t6 (matched control group N)CASCAP-D: Mean of N=50 children with attention disorders. Change t1 - t6 is statistically significant with prob.<0.0001.CASCAP-D: Mean of N=30 clinically non-symptomatic children at point t1 (sex and age-matched control group N)



24

Attunement of the child’s willingness to accept guidance from the mother in their interaction

H-MIM on left scale: 6-point interval scale from does not accept = 1...2...3...4...5...6 = to fully accept


3,43,7

4,5

5,0

5,5 5,4

3,0

2,22,0

1,3

1

2

3

4

5

6





Ob

serv

ed I

nte

ract

ion

1

= no

t app

ropr

iate

... a

ppro

pria

te =

6

1

2

3

4

Sym

pto

m

1=

non

-sym

pto

mat

ic -

se

vere

sym

pto

m =

4

H-MIM: Mean of N=50 children with attention disorders. Change t1 - t6 ist statistically significant with prob.=0.0008.H-MIM: Mean of N=30 clinically non-symptomatic children in the course of time t1 - t6 (matched control group N)CASCAP-D: Mean of N=50 children with attention disorders. Change t1 - t6 is statistically significant with prob.<0.0001.CASCAP-D: Mean of N=30 clinically non-symptomatic children at point t1 (sex and age-matched control group N)



25

Stress task: The child’s willingness to separate from the mother when in interaction

H-MIM on left scale:6-point interval scale from unwilling = 1...2...3...4...5...6 = to willing


3,43,6

4,6 4,7

5,2

4,8

3,0

2,22,0

1,3

1

2

3

4

5

6





Ob

serv

ed I

nte

ract

ion

1

= n

ot a

pp

rop

ria

te -

ap

pro

pri

ate

= 6

1

2

3

4

Sy

mp

tom

1 =

non

-sym

ptom

atic

- s

ever

e sy

mpt

om =

4

H-MIM: Mean of N=50 children with attention disorders. Change t1 - t6 is statistically significant with prob.=0.0007.H-MIM: Mean of N=30 clinically non-symptomatic children in the course of time t1 - t6 (matched control group N)CASCAP-D: Mean of N=50 children with attention disorders. Change t1 - t6 is statistically significant with prob.<0.0001.CASCAP-D: Mean of N=30 clinically non-symptomatic children at point t1 (sex and age-matched control group N)



26

The child’s attention, concentration and interest in the mother-child interaction

H-MIM on left scale: 6-point interval scale from very low = 1...2...3...4...5...6 = to very high


2,4

2,9

4,14,3

5,0

5,4

3,0

2,22,0

1,3

1

2

3

4

5

6





Ob

serv

ed I

nte

ract

ion

1

= n

ot a

ppro

pria

te -

app

ropr

iate

= 6

1

2

3

4

Sy

mp

tom

1 =

non-

sym

ptom

atic

- s

ever

e sy

mpt

om =

4

H-MIM: Mean of N=50 children with attention disorders. Change t1 - t6 is statistically significant with prob.<0.0001.H-MIM: Mean of N=30 clinically non-symptomatic children in the course of time t1 - t6 (matched control group N)CASCAP-D: Mean of N=50 children with attention disorders. Change t1 - t6 is statistically significant with prob.<0.0001.CASCAP-D: Mean of N=30 clinically non-symptomatic children at point t1 (sex and age-matched control group N)



27

Frequency of the child‘s contact-seeking in the mother-child interaction

H-MIM left scale: 6-point interval scale from never = 1...2...3...4...5...6 = to frequentlyH-MIM: mean of 5 items; internal consistence of the items: Cronbach‘s Alpha = .74


3,4

3,8

4,7

4,0

3,0

2,22,0

1,3

1

2

3

4

5

6





Ob

serv

ed I

nte

ract

ion

1

= n

ot

ap

pro

pri

ate

- a

pp

rop

ria

te =

6

1

2

3

4

Sy

mp

tom

1

= n

on

-sym

pto

ma

tic

- se

vere

sym

pto

m =

4

H-MIM: Mean of N=50 children with attention disorders. Change t1 - t6 is statistically significant with prob.<0.0001.

CASCAP-D: Mean of N=50 children with attention disorders. Change t1 - t6 is statistically significant with prob.<0.0001.

CASCAP-D: Mean of N=30 clinically non-symptomatic children at point t1 (sex and age-matched control group N)



28

The developing self-confidence of the childin the mother-child interaction

H-MIM on left scale: 6-point interval scale from rather shy = 1...2...3...4...5...6 = to rather self-confident


4,34,5

5,1 5,15,3

5,6

3,0

2,22,0

1,3

1

2

3

4

5

6





Ob

serv

ed I

nte

ract

ion

1

= n

ot a

pp

rop

ria

te -

ap

pro

pri

at =

6

1

2

3

4

Sy

mp

tom

1

= n

on-s

ympt

omat

ic -

sev

ere

sym

ptom

= 4

H-MIM: Mean of N=50 children with attention disorders. Change t1 - t6 is statistically significant with prob.=0.0004.H-MIM: Mean of N=30 clinically non-symptomatic children in the course of time t1 - t6 (matched control group N)

CASCAP-D: Mean of N=50 children with attention disorders. Change t1 - t6 is statistically significant with prob.<0.0001.CASCAP-D: Mean of N=30 clinically non-symptomatic children at point t1 (sex and age-matched control group N)



29

The attunement in the mother-child interactive behavior Left: 6-point interval scale from negative = 1...2...3...4...5...6 = to positive


4,74,4

5,2 5,1

5,6 5,6

3,0

2,22,0

1,3

1

2

3

4

5

6





Ob

se

rve

d In

tera

cti

on

1

= n

ot a

ppro

pria

te -

app

ropr

iate

= 6

1

2

3

4

Sy

mp

tom

1

= n

on

-sym

pto

ma

tic -

se

vere

sym

pto

m =

4




30

The child’s tolerance of frustration from motherin the mother-child interaction

Left scale: 6-point interval scale from not at all = 1...2...3...4...5...6 = to very well H-MIM: Mean of 3 items, internal consistence of the items: Cronbach’s Alpha = .82


3,83,6

4,74,94,8

5,1

3,0

2,22,0

1,3

1

2

3

4

5

6





Ob

ser

ved

In

tera

ctio

n

1 =

no

t ap

pro

pri

atl

- a

pp

rop

ria

te =

6

1

2

3

4

Sy

mp

tom

1 =

no

n-s

ymp

tom

atic

- s

eve

re s

ymp

tom

= 4

H-MIM: Mean of N=50 children with attention disorders. Change t1 - t6 is statistically significant with prob.=0.0004.

H-MIM: Mean of N=30 clinically non-symptomatic children in the course of time t1 - t6 (matched control group N)

CASCAP-D: Mean of N=50 children with attention disorders. Change t1 - t6 is statistically significant with prob.<0.0001.

CASCAP-D: Mean of N=30 clinically non-symptomatic children at point t1 (sex and age-matched control group N)



31

Attunement of empathy in expressing affection in the mother-child interactive behavior

Left scale: 6-point interval scale none = 1...2...3...4...5...6 = to frequentlyH-MIM: Mean of 5 items; internal consistence of the items: Cronbach’s Alpha = .85


3,2 3,3

4,3 4,4

5,1 5,1

3,0

2,22,0

1,3

1

2

3

4

5

6





Ob

serv

ed I

nte

ract

ion

1

= n

ot a

pp

rop

ria

te -

ap

pro

pri

ate

= 6

1

2

3

4

Sy

mp

tom

1

= n

on-y

mpt

omat

ic -

sev

ere

sym

ptom

= 4




32

The child’s ability to speak with his or her motherin the mother-child interaction

Left scale: 6-point interval scale from very low = 1...2...3...4...5...6 = to very highH-MIM: mean of 4 items; internal consistence of the items: Cronbach’s Alpha = .88


1,4

1,9

3,12,8

5,3 5,3

3,0

2,22,0

1,3

1

2

3

4

5

6





Ob

se

rve

d In

tera

cti

on

1

= n

ot a

ppro

pria

te -

app

ropr

iate

= 6

1

2

3

4

Sym

pto

m

1 =

no

n-s

ymp

tom

atic

- s

eve

re s

ymp

tom

e

= 4

H-MIM: Mean of N=50 children with attention disorders. Change t1 - t6 is statistically significant with prob.=0.0366.

H-MIM: Mean of N=30 clinically non-symptomatic children in the course of time t1 - t6 (matched control group N)

CASCAP-D: Mean of N=50 children with attention disorders. Change t1 - t6 is statistically significant with prob.<0.0001.CASCAP-D: Mean of N=30 clinically non-symptomatic children at point t1 (sex and age-matched control group N)



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Discussion of the research results Construct validity of the H-MIM

• The Construct Validity of the H-MIM is confirmed.based on the sample of N=50 toddler and preschool childrenwith dual diagnoses of attention disorder and delay in language development as well as language disorders.

• The high internal validity of the results of the CLSvalidates the H-MIM, but only for this particular population.

• The results have low external validity due to their limitation– to one therapeutic facility (the PPC in Heidelberg),– to one specific population of patients (language delay or disorder),– to one Theraplay therapist (Ulrike Franke).

• The results can not be generalized to other populations of disordered children and adolescents.

• Further studies are needed to evaluate the H-MIM to generalize the results on other populations of patients.



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Generalizing of the validity of the H-MIM Validity is the important point as long as the H-MIM is reliable.

Generalizing asks for high external validity of the H-MIM.

• Controlled Longitudinal Study (CLS)– High internal validity of the H-MIM

due to high homogeneity of the population of patients (PPC)– Low external validity of the H-MIM

due to a lack of variation of the spectrum of disorders– These results may not be generalized!

• Nationwide Multi-Center-Study (MCS)– Low internal validity of the H-MIM

due to great heterogeneity of the populations of patients of 9 different therapeutic facilities, treated by 14 different therapists,in two different German speaking countries Germany and Austria

– High external validity of the H-MIM due to a well distributed mean variation over several cohorts of patients,different therapeutic facilities, and different Theraplay therapists

– These results can be generalized to other populations of patients.



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2nd Criterion of SuitabilityEffect size of the H-MIM

Effect size (d) = capacity to recognize significant differences in mother-child interactionaround d=0.20 = low…, around d=0.50 = middle…, around d=0.80 = high effect size

d<1.00 = extremely high effect size to differentiate significantlyLiterature: Bortz & Döring, Forschungsmethoden und Evaluation, 1995;

Formula: d = Mt1–Mt6/st6 = population-near deviation (www,phil.uni-sb.de/jakobs/seminar/vpl/….htm

Capacity of the H-MIM to recognize significant differences in mother-child interaction

H-MIM Criterion

Observation of the mother-child interactive behavior

N = 60 clinically symptomatic toddler &

preschool children

N = 50 inattentivetoddler & preschoolchildren altogether

Time of treatment t1 – t6 Time of treatment t1 – t6

Effect size d Effect size d

Child’s willingness to accept guidance from the mother d = |0.59| d = |0.58|

Child’s willingness to separate from the mother d = |0.74| d = |0.75|

Child’s ability to speak with the mother in their interaction d = |0.90| d = |0.74|

Attunement of the emotions in mother-child interaction d = |0.90| d = |1.88|

Frequency of the child’s contact-seeking in interaction d = |0.98| d = |0.99|

Child’s attention, concentration, and interest in interaction d = |1.05| d = |1.11|

Attunement of empathy in expressing affection d = |1.06| d = |1.04|

Child’s developing self-confidence in the interaction d = |1.08| d = |1.07|

Attunement in the mother-child’s interactive behavior d = |1,08| d = |1,21|

Child’s tolerance of frustration from the mother d = |1,20| d = |1,04|



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2nd Criterion of SuitabilitySensitivity of the H-MIM

Sensitivity = statistical significance of the capacity of H-MIM to recognize significant differences in interaction.

Sensitivity (t1 – t6) = Statistically significant change after treatment with Theraplay Lasting effect (t6 – t7) = No statistically significant (n.s.) change 2 years after therapy

Statistical Significance of H-MIM’s capacity to recognize differences in mother-child interaction

H-MIM Criterion


N = 60 clinically symptomatictoddler & preschool children

N = 50 childrenwith attention disorders

Treatmentt1 – t6

2 years latert6 – t7

Treatmentt1 – t6

2 years latert6 – t7

prob prob prob prob

Attunement in the mother-child’s interactive behavior < 0.0001 n.s. 0.1686 < 0.0001 n.s. 0.2766

Frequency of the child’s contact-seeking in interaction < 0.0001 n.s. 0.1840 < 0.0001 n.s. 0.1450

Child’s attention, concentration, and Interest in interaction < 0.0001 n.s. 0.2536 < 0.0001 n.s. 0.3344

Attunement of empathy in expressing affection < 0.0001 n.s. 0.7909 < 0.0001 n.s. 0.7569

Child’s developing self-confidence in the interaction < 0.0001 n.s. 0.5728 = 0.0004 n.s. 0.7507

Child’s willingness to accept guidance from the mother < 0.0001 n.s. 0.6495 = 0.0008 n.s. 0.4296

Child’s willingness to separate from the mother = 0.0003 n.s. 0.8011 = 0.0007 n.s. 0.5717

Attunement of the emotions in mother-child interaction = 0.0003 n.s. 0.2802 = 0.0015 n.s. 0.1540

Child’s tolerance of frustration from the mother = 0.0004 n.s. 0.5342 = 0.0009 n.s. 0.8682

Child’s ability to speak with the mother in their interaction = 0.0209 n.s. 0.0747 = 0.0366 n.s. 0.3942



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Discussion of the research resultsSensitivity and effect size of the H-MIM

• The Sensitivity of the H-MIM is statistically significant.The child’s interactive behavior improved during the course of therapy t1 – t6 statistically significant.

• The Effect Size (d) of the H-MIM is very large.The change of the mother-child interactive behavior of children with attention disorders is from dmiddle =.58 to dlarge =1.21.

• H-MIM confirms the lasting effect of the treatment 2 years after the end of Theraplay treatmentinteractive behavior of children with attention disorders is stable. There was neither a relapse nor a statistically significant changein interactive behavior between child and care giver.



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3rd Criterion of SuitabilityRetest-reliability of the H-MIM

• Reliability is here understood as the trustworthiness of a method,to measure reliable what should be measured.

• Retest-Reliability is the proof of statistically relevant co-variation (rPearson > .50) of the results of a repeated measurement (t1 and t6).



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Retest-reliability of the H-MIM Controlled Longitudinal Study (CLS). Total sample N=60; ADD sample N=50

Method: Retest-reliability of selected variables comparing test = t1 with retest = t6

Evidence: The Correlation between test and retest has to be statistically significant

Retest-reliability of selected variables: t1 = test; t6 = retest

H-MIM Criterion


Pearson correlation coefficient for retest t1 – t6 prob > | r | in H0: Rho = 0

N = 60 clinically symptomatic

toddler & preschool children

N = 50inattentive toddler

and preschool children

r Prob r Prob

Child’s ability to speak with the mother in their interaction r = .70 p = .0054 r = .62 p = .0242

Child’s willingness to accept guidance from the mother r = .66 p < .0001 r = .61 p = .0003

Attunement of empathy in expressing affection r = .61 p < .0001 r = .62 p < .0001

Attunement of the emotions in mother-child interaction r = .61 p < .0001 r = .59 p < .0001

Attunement in the mother-child’s interactive behavior r = .56 p < .0001 r = .52 p = .0012

Child’s attention, concentration, and Interest in interaction r = .55 p < .0001 r = .50 p = .0014

Frequency of the child’s contact-seeking in interaction r = .50 p = .0006 r = .49 p = .0026

Child’s willingness to separate from the mother r = .50 p = .0008 r = .49 p = .0030

Child’s tolerance of frustration from the mother r = .47 p = .0110 r = .49 p = .0136

Child’s developing self-confidence in the interaction r = .18 p = .3999 n.s. r = .18 p = .4773 n.s.



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Discussion of the research resultsRetest-reliability of the H-MIM

• The Reliability of the H-MIM is confirmed.• The retest-reliability of the H-MIM

to assess mother-child interactive behavior is proven by relatively high correlation coefficients.

• Pearson correlation coefficients range from r =.49 up to r =.70and are statistically significant with prob. = .0110 up to < .0001,apart from one exception.

• Exception: Self-confidence of the child in mother-child interactive behavioris not statistically significant. The correlation coefficient is low (r =.18).Hypothesis: There is such a great difference between the associated symptoms of children with attention disorders, such a hyperactivity, oppositional defiance, shyness, or an autism-like lack of social mutuality that differently disordered children change their position in the group from test (t1) to retest (t6).



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Theraplay InstitutUlrike Franke and Herbert Wettig KG

D-71229 Leonberg, Germany Obere Burghalde 42www.theraplay-institut.org

Questions to ask the therapist about Theraplay Ulrike Franke

SLP-S Speech-Language Pathologist and SupervisorCTT-T Certified Theraplay Therapist and Trainer (TTI)

RPT-S Reg. Play Therapist and Supervisor (APT)Phone ++49-6202-54051 Fax ++49-6202-54958

e-mail: [email protected]

Questions to ask the researcher about research results Herbert H.G. Wettig Diplompsychologe

Clinical Psychologist, Researcher Phone ++49-7152-27061 Fax ++49-7152-22602

e-mail: [email protected]

© 1996 Theraplay is legally protected in German speaking countries by Wz. 39518465in agreement with The Theraplay Institute, Wilmette, IL, USA

http://www.theraplay-institut.org/





mailto:[email protected]

mailto:[email protected]

Documents

International Theraplay Conference, June 23-24, 2005 University of Chicago, Gleacher Center, Chicago, IL, USA Ulrike Franke Herbert H. G. Wettig H-MIM