international theraplay conference, june 23-24, 2005 university of chicago, gleacher center,...
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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
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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
Theraplay Institut Germany 2005
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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.
Theraplay Institut Germany 2005
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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
Theraplay Institut Germany 2005
H-MIM The Heidelberg Marschak Interaction Method
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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.
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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?
Theraplay Institut Germany 2005
H-MIM The Heidelberg Marschak Interaction Method
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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
Theraplay Institut Germany 2005
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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
Theraplay Institut Germany 2005
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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
Theraplay Institut Germany 2005
H-MIM The Heidelberg Marschak Interaction Method
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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
Theraplay Institut Germany 2005
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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.
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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.
Theraplay Institut Germany 2005
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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.
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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
Theraplay Institut Germany 2005
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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
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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
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H-MIM The Heidelberg Marschak Interaction Method
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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
Theraplay Institut Germany 2005
H-MIM The Heidelberg Marschak Interaction Method
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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).
Theraplay Institut Germany 2005
H-MIM The Heidelberg Marschak Interaction Method
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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)
Theraplay Institut Germany 2005
H-MIM The Heidelberg Marschak Interaction Method
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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)
Start of the therapy (t 1)
End of the therapy (t 6)
2 years after therapy (t 7)
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
Theraplay Institut Germany 2005
H-MIM The Heidelberg Marschak Interaction Method
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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).
Theraplay Institut Germany 2005
H-MIM The Heidelberg Marschak Interaction Method
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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)
Theraplay Institut Germany 2005
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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
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)
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)
Theraplay Institut Germany 2005
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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
Change of the mother-child interactive behavior in the Course of Time
3,43,7
4,5
5,0
5,5 5,4
3,0
2,22,0
1,3
1
2
3
4
5
6
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)
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)
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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
Change of the mother-child interactive behavior in the Course of Time
3,43,6
4,6 4,7
5,2
4,8
3,0
2,22,0
1,3
1
2
3
4
5
6
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)
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)
Theraplay Institut Germany 2005
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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
Change of the mother-child interactive behavior in the Course of Time
2,4
2,9
4,14,3
5,0
5,4
3,0
2,22,0
1,3
1
2
3
4
5
6
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)
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)
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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
Change of the mother-child interactive behavior in the Course of Time
3,4
3,8
4,7
4,0
3,0
2,22,0
1,3
1
2
3
4
5
6
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)
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)
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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
Change of the mother-child interactive behavior in the Course of Time
4,34,5
5,1 5,15,3
5,6
3,0
2,22,0
1,3
1
2
3
4
5
6
Start of the waiting time (t 0)
Start of the therapy (t 1)
2 years after therapy (t 7)
2 years after therapy (t 7)
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)
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The attunement in the mother-child interactive behavior Left: 6-point interval scale from negative = 1...2...3...4...5...6 = to positive
Change of the mother-child interactive behavior in the Course of Time
4,74,4
5,2 5,1
5,6 5,6
3,0
2,22,0
1,3
1
2
3
4
5
6
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)
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
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)
Theraplay Institut Germany 2005
H-MIM The Heidelberg Marschak Interaction Method
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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
Change of the mother-child interactive behavior in the Course of Time
3,83,6
4,74,94,8
5,1
3,0
2,22,0
1,3
1
2
3
4
5
6
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)
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)
Theraplay Institut Germany 2005
H-MIM The Heidelberg Marschak Interaction Method
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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
Change of the mother-child interactive behavior in the Course of Time
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
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)
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
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)
Theraplay Institut Germany 2005
H-MIM The Heidelberg Marschak Interaction Method
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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
Change of the mother-child interactive behavior in the Course of Time
1,4
1,9
3,12,8
5,3 5,3
3,0
2,22,0
1,3
1
2
3
4
5
6
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)
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)
Theraplay Institut Germany 2005
H-MIM The Heidelberg Marschak Interaction Method
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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.
Theraplay Institut Germany 2005
H-MIM The Heidelberg Marschak Interaction Method
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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.
Theraplay Institut Germany 2005
H-MIM The Heidelberg Marschak Interaction Method
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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|
Theraplay Institut Germany 2005
H-MIM The Heidelberg Marschak Interaction Method
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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
Observation of the mother-child interactive behavior
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
Theraplay Institut Germany 2005
H-MIM The Heidelberg Marschak Interaction Method
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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.
Theraplay Institut Germany 2005
H-MIM The Heidelberg Marschak Interaction Method
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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).
Theraplay Institut Germany 2005
H-MIM The Heidelberg Marschak Interaction Method
39
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
Observation of the mother-child interactive behavior
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.
Theraplay Institut Germany 2005
H-MIM The Heidelberg Marschak Interaction Method
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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).
Theraplay Institut Germany 2005
H-MIM The Heidelberg Marschak Interaction Method
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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