1. International Theraplay Conference, June 23-24, 2005 University of Chicago, Gleacher Center, Chicago, IL, USA Ulrike Franke Herbert H. G. Wettig H-MIM The Heidelberg Marschak Interaction Method to assess the mother-child interactive behavior Quality criteria: construct validity – effect size - sensitivity – retest-reliability Research results of a controlled longitudinal study 1998-2005 in Germany Theraplay Institut Ulrike Franke und Herbert Wettig, Leonberg Germany 2005

2. 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 childrens 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. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 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 at the beginning of treatment and the outcome at the end of the treatment.

4. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 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 givers guidance gives the child a chance to learn affect regulation and interaction with parents 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 emotions between the care giver and the child 2. The childs acceptance of guidance by the care giver relationship- orientated attachment task-orientated learning Self-esteem and self-confidence of the child 3. The childs affect regulation: Coping with stress

5. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 5 H-MIM Culturally-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 behavior of 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 childs 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 childs acceptance of the care givers guidance, out of 22, –1 task measuring the childs ability to cope with stress, out of a catalogue of 4 such tasks. The kind of tasks depend on the hypothesis/diagnose of the childs disorder.

6. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 6 Purposes for which the H-MIM is frequently used in 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 speak when 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 at separation 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. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 7 Method Two field studies with 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. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 8 Diagnostic data sampling methods (A number of other diagnostic instruments, tests, and questionnaires were used as well) Data about mother and child Questionnaire collecting socio-demographic data, case history Data about the severity of the childs symptoms Repeated measurement of the severity of the symptoms using CASCAP-D the German Version of CASCAP - Clinical Assessment Scale for 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 tasks using H-MIM the Heidelberg Marschak Interaction Method (Ritterfeld & Franke, 1994) 6-point interval scale: disagree = 1...2...3...4...5…6 = fully agree

9. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 9 Course of time of the Controlled Longitudinal Study (CLS) Time points of the controlled longitudinal study (CLS) –t 0 = at the beginning of a 16-week waiting time (only the waiting time control group W is observed) –t 1 = at the beginning of the treatment with Theraplay –t 6 = at the termination of the treatment with Theraplay –t 7 = follow-up: 2 years after the end of the therapy (Time points during the process of therapy t 2 – t 5 are not reported here.) Normal, clinically non-symptomatic control group (N) –t 1 = at the beginning of a 16-week waiting time –t 6 = at the end of the 16-week waiting time

10. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 10 Course of time of the Multi-Center-Study (MCS) Multi-Center-Study (MCS) 2 times of measurement (pre - post) –t 1 = at the beginning of the treatment with Theraplay –t 6 = at the end of the therapy with Theraplay

11. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 11 Method of the Controlled Longitudinal Study (CLS) Controlled Longitudinal Study (CLS) 1998 – 2003 N = 60 toddler and preschool children with dual diagnoses of 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. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 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. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 13 Sample Size of 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. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 14 Sample Size of 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. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 15 Sample structure of 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; Girls 74%; 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 C ontrol group N (matched sample) CLS: Social status and upbringing_ N=50 toddler and preschoolers suffering from ADD Social status of the mother 90% married mothers 8% unmarried living together 2% unmarried mothers Social status of the child 90% legitimate children 10% illegitimate children Upbringing of the child 85% both parents 15% one parent 71% in kindergarten

16. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 16 Sample structure of 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 upbringing N=218 toddler and preschoolers ______suffering from ADD_____ Social status of the mother 66% married mothers 10% unmarried living together 9% been separated mothers 1% widowed mothers 13% unmarried mothers (1% n.a.) Social status of the child 77% legitimate children 17% illegitimate natural children 6% adopted/foster children Upbringing of the child 77% both parents 23% one parent 76% in kindergarten

17. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 17 Research results investigating the quality criteria of the Heidelberg Marschak Interaction Method (H-MIM) using studies on toddler 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 childs symptoms of attention disorders

18. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 18 Hypothesis about 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 (t 1 – t 6 ) Period of lasting of the reduced symptom: 2 years after Theraplay treatment (t 6 - t 7 ).

19. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 19 Basis is the change of the childrens attention deficit The effectiveness of Theraplay on children with attention disorders reducing the relevant symptoms over the course of time t 1 – t 6 in comparison with a control group N of clinically non-symptomatic children Multi-Center-Study (MCS) t 1 – t 6 repeated diagnoses of symptoms using CASCAP-D (Doepfner et al., 1999) scale: 4=severe symptom, 3=clear symptom, 2=light symptom, 1=non-symptomatic

20. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 20 Basis is the change of the childrens attention deficit The effectiveness of Theraplay on children with attention disorders reducing the relevant symptoms over the course of time t 1 – t 6 in comparison with a control group N of clinically non-symptomatic children Controlled Longitudinal Study (CLS) t 1 – t 6 – t 7 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. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 21 1 st Criterion of Suitability Construct validity of the H-MIM Construct validity of the H-MIM is to prove the correspondence of the statistical significance of the hypothetically predicted change of the mother-child interactive behavior over the course of time with the really observed change of the mother-child interactive behavior over the same period The change of the mother-child interactive behavior is 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 (t 0 ) until 2 years after individual termination of Theraplay therapy (t 7 ). The change of the symptoms of the childs disorder is evaluated using CASCAP-D –investigated in the Controlled Longitudinal Study (CLS) carried out over the course of time from the beginning of the therapy (t 1 ) until 2 years after individual termination of Theraplay therapy (t 7 ).

22. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 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 ( oo; ) to assess the observed improvement of mother-child interactive behavior on 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 childs acceptance to guidance by the care giver –Mean of the childs 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 childs 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. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 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

24. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 24 Attunement of the childs willingness to accept guidance from the mother in their interaction H-MIM on l eft scale: 6-point interval scale from does not accept = 1...2...3...4...5...6 = to fully accept

25. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 25 Stress task: The childs 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

26. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 26 The childs 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

27. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 27 Frequency of the childs contact-seeking in the mother-child interaction H-MIM left scale: 6-point interval scale from never = 1...2...3...4...5...6 = to frequently H-MIM: mean of 5 items; internal consistence of the items: Cronbachs Alpha =.74

28. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 28 The developing self-confidence of the child in 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

29. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 29 The attunement in the mother-child interactive behavior Left: 6-point interval scale from negative = 1...2...3...4...5...6 = to positive

30. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 30 The childs tolerance of frustration from mother in 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: Cronbachs Alpha =.82

31. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 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 frequently H-MIM: Mean of 5 items; internal consistence of the items: Cronbachs Alpha =.85

32. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 32 The childs ability to speak with his or her mother in the mother-child interaction L eft scale: 6-point interval scale from very low = 1...2...3...4...5...6 = to very high H-MIM: mean of 4 items; internal consistence of the items: Cronbachs Alpha =.88

33. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 33 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 children with dual diagnoses of attention disorder and delay in language development as well as language disorders. The high internal validity of the results of the CLS validates 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.

34. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 34 G eneralizing 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.

35. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 35 2 nd Criterion of Suitability Effect size of the H-MIM Effect size (d) = capacity to recognize significant differences in mother-child interaction around 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 significantly Literature: Bortz & Döring, Forschungsmethoden und Evaluation, 1995; Formula: d = M t1 –M t6 /s t6 = 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 inattentive toddler & preschool children altogether Time of treatment t 1 – t 6 Effect size d Childs willingness to accept guidance from the motherd = |0.59|d = |0.58| Childs willingness to separate from the motherd = |0.74|d = |0.75| Childs ability to speak with the mother in their interactiond = |0.90|d = |0.74| Attunement of the emotions in mother-child interactiond = |0.90|d = |1.88| Frequency of the childs contact-seeking in interactiond = |0.98|d = |0.99| Childs attention, concentration, and interest in interactiond = |1.05|d = |1.11| Attunement of empathy in expressing affectiond = |1.06|d = |1.04| Childs developing self-confidence in the interactiond = |1.08|d = |1.07| Attunement in the mother-childs interactive behaviord = |1,08|d = |1,21| Childs tolerance of frustration from the motherd = |1,20|d = |1,04|

36. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 36 2 nd Criterion of Suitability Sensitivity of the H-MIM Sensitivity = statistical significance of the capacity of H-MIM to recognize significant differences in interaction. Sensitivity (t 1 – t 6 ) = Statistically significant change after treatment with Theraplay Lasting effect (t 6 – t 7 ) = No statistically significant (n.s.) change 2 years after therapy Statistical Significance of H-MIMs capacity to recognize differences in mother-child interaction H-MIM Criterion Observation of the mother-child interactive behavior N = 60 clinically symptomatic toddler & preschool children N = 50 children with attention disorders Treatment t 1 – t 6 2 years later t 6 – t 7 Treatment t 1 – t 6 2 years later t 6 – t 7 prob Attunement in the mother-childs interactive behavior< 0.0001n.s. 0.1686< 0.0001n.s. 0.2766 Frequency of the childs contact-seeking in interaction< 0.0001n.s. 0.1840< 0.0001n.s. 0.1450 Childs attention, concentration, and Interest in interaction< 0.0001n.s. 0.2536< 0.0001n.s. 0.3344 Attunement of empathy in expressing affection< 0.0001n.s. 0.7909< 0.0001n.s. 0.7569 Childs developing self-confidence in the interaction< 0.0001n.s. 0.5728= 0.0004n.s. 0.7507 Childs willingness to accept guidance from the mother< 0.0001n.s. 0.6495= 0.0008n.s. 0.4296 Childs willingness to separate from the mother= 0.0003n.s. 0.8011= 0.0007n.s. 0.5717 Attunement of the emotions in mother-child interaction= 0.0003n.s. 0.2802= 0.0015n.s. 0.1540 Childs tolerance of frustration from the mother= 0.0004n.s. 0.5342= 0.0009n.s. 0.8682 Childs ability to speak with the mother in their interaction= 0.0209n.s. 0.0747= 0.0366n.s. 0.3942

37. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 37 Discussion of the research results Sensitivity and effect size of the H-MIM The Sensitivity of the H-MIM is statistically significant. The childs interactive behavior improved during the course of therapy t 1 – t 6 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 d middle =.58 to d large =1.21. H-MIM confirms the lasting effect of the treatment 2 years after the end of Theraplay treatment interactive behavior of children with attention disorders is stable. There was neither a relapse nor a statistically significant change in interactive behavior between child and care giver.

38. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 38 3 rd Criterion of Suitability Retest-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 (r Pearson >.50) of the results of a repeated measurement (t 1 and t 6 ).

39. 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 = t 1 with retest = t 6 Evidence: The Correlation between test and retest has to be statistically significant Retest-reliability of selected variables: t 1 = test; t 6 = retest H-MIM Criterion Observation of the mother-child interactive behavior Pearson correlation coefficient for retest t 1 – t 6 prob > | r | in H 0 : Rho = 0 N = 60 clinically symptomatic toddler & preschool children N = 50 inattentive toddler and preschool children rProbr Childs ability to speak with the mother in their interactionr =.70p =.0054r =.62p =.0242 Childs willingness to accept guidance from the motherr =.66p <.0001r =.61p =.0003 Attunement of empathy in expressing affectionr =.61p <.0001r =.62p <.0001 Attunement of the emotions in mother-child interactionr =.61p <.0001r =.59p <.0001 Attunement in the mother-childs interactive behaviorr =.56p <.0001r =.52p =.0012 Childs attention, concentration, and Interest in interactionr =.55p <.0001r =.50p =.0014 Frequency of the childs contact-seeking in interactionr =.50p =.0006r =.49p =.0026 Childs willingness to separate from the motherr =.50p =.0008r =.49p =.0030 Childs tolerance of frustration from the motherr =.47p =.0110r =.49p =.0136 Childs developing self-confidence in the interactionr =.18p =.3999 n.s.r =.18p =.4773 n.s.

40. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 40 Discussion of the research results Retest-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 =.70 and are statistically significant with prob. =.0110 up to <.0001, apart from one exception. Exception: Self-confidence of the child in mother-child interactive behavior is 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 (t 1 ) to retest (t 6 ).

41. Theraplay Institut Germany 2005 H-MIM The Heidelberg Marschak Interaction Method 41 Theraplay Institut Ulrike Franke and Herbert Wettig KG D-71229 Leonberg, Germany Obere Burghalde 42 www.theraplay-institut.org Questions to ask the therapist about Theraplay Ulrike Franke SLP-S Speech-Language Pathologist and Supervisor CTT-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: Franke.Theraplay@t-online.de 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: Herbert.Wettig@t-online.de © 1996 Theraplay is legally protected in German speaking countries by Wz. 39518465 in agreement with The Theraplay Institute, Wilmette, IL, USA www.theraplay-institut.orgFranke.Theraplay@t-online.deHerbert.Wettig@t-online.de