CALIFORNIA STATE UNIVERSITY, NORI'HRIIX:E
EVALUATION OF A PARENT EDUCATION PRcx;RM-1
IN A HEALTH .MAINTENANCE ORC'::zANIZATION
A graduate project submitted in partial
satisfaction of the requirements
for the degree of
Master of Public Health
by
Philip Lee Bauman, M.S. W.
Jun:e
1981
The Project of Philip Lee Bauman is approved:
Michael V. Kline, Dr. P. H.
Carmi t_!ee CI;~i~on
Jac~VJinkelman, H. s. D.
ii
ACKNCWLEDGEMENTS
I would like to express my gratitude to the following
people for their contributions to this project.
I wish to express my greatest appreciation to Mei-Ling
Schwartz, M.P.H. for her guidance and corrol:oration.
help this study would not have cane to fruition.
Without her
My thanks to
Walter Rothschild, M.D. for his sup:r:ort and confidence.
My sincere thanks to the multidisciplinary educational
team of Edward Rissman, M.D., Anthony Rich, M.D., Irene Hartsell, Ph.D.,
Sondra Goldstein, Ph.D., Judy McAdoo, M.S.W., and Bea Flcx:m, R.N. for
their invaluable contributions.
Appreciation is extended to Dr. Michael Kline, Chairman
of this project ccmnittee, who over the years has served as a constant
source of encouragement, guidance and wa:r:mth.
to
t.~e
I also express thanks
other :me..'Tlbers of the ccrnmittee, Professors .nnthony Jl.lcocer
and Jack WinkeJman.
And of utrrost im:r:ortance is my rrost special thanks to
my wife, Joan, and children, ~nclrea and Pet:er. Joan especially for
her unyielding oatience and tolerance.
iii
TABLE OF CCNI'ENTS
Page
ii
APPROVAL • • • • •
iii
ACKNCWLEDGEMENTS • .
vi
LIST OF TABLES
vii
ABSTRACT
Chapter
1.
2.
INTRODUCTICN
1
Background of the Problem •
Purpose of the Study
Assumptions
• . . . • • .
Hypothesis of the Study •
Limitations of the Study
Definition of Terms • . •
2
REVIEW OF THE LITERATURE
9
3
4
5
5
6
Concepts of Parenting
History and Rationale for Parent Education
Methods and Models of Parent Education Programs .
Evaluation of Parent Education Programs
Surrrnary
3•
• • • • •
16
21
23
.1'1ETIIODOI.CX;Y
25
Population
Research Design
• . • • •
Statistical Design of the Study
Statistical Hypotheses of the Study .
Developnent of the Educational Intervention
25
26
26
27
Construction of the Test Instruments
Data Collection
• • . • • •
Statistical Analysis of the Data
28
29
31
31
ANALYSIS
33
Program
4.
• • • • • • ·•
9
13
AND
. • • • • • • • • • • • •
DISCUSSION OF
THE
Treatment of the Data
Descriptive Data
Data Analysis
DATA
33
33
39
iv
Chapter
5.
Page
SUMMA,RY 1 CCNCIDSION AND RECO.r--1MENDATIONS
42
Conclusions of Statistical Analysis
Additional Conclusions
Reccmnendations • • • .
43
.
BIBLICGRAPHY
~
.
44
45
46
50
APPENDICES ••
50
APPENDIX A
PROPOSAL
51
CURRICULUMS
54
CURRICULUM HANOOTJrS
62
71
APPENDIX B
WRITTEN A'ITITUDE TEST
72
WRITTEN KNCl'JI...EI::GE TEST
74
PROGRAM SATISFACTION Qt.JESTIONNAIRE
80
PRCX;RAM
82
CONSENT FORM
v
LIST OF TABLES
Table
Page
1.
Statistical Design of the Study
27
2.
Canparison of DEm::lg"raphic Characteristics of
Experimental and Control Groups
34
3.
Individual Mean Scores for Attitude
38
4.
Individual Mean Scores for Knowledge
39
5.
Analysis of Written Attitude and Knowledge Mean
Scores by t-Test for the EY.r~irrental Group
40
Analysis of Written Attitude and Knowledge
Scores by t-Test for the Control and
Experimental Groups . • • • • • . • • •
41
6.
vi
ABSTRACT
EVALUATION OF A PARENT EDUCATICN PROGRAM
IN A HEALTH MAINTENANCE ORGANIZATICN
by
Philip Lee Bauman
Master of Social Work
Master of Public Health
The purpose of this study was to evaluate the effectiveness of a parent education intervention program for parents of preschool age children.
The review of the literature treated the
following areas and their relevance to this study:
concepts of
parenting, the history and rationale for parent education programs,
methods and models of parent education programs and the evaluation
of parent education programs.
A multi-disciplinary educational team desiqned and
implemented an educational intervention program for "Parenting. "
The educational intervention proqram focused on:
psychological
developnent, parent-child carrnunication, behavior management
application, physical, social and enotional develO}:m:mt and problem
solving.
TWo test instruuents were constructed by the educational
team for assessing changes in attitutde and knowledge about parenting.
vii
These tests were administered to the group experiencing the
educational pro:Jraffi (experimental group) before and after the
educational program.
Another group 'Which was not exposed to the
program (control group) was administered the tests at a different
time and a different location.
Derrographic carparisons were made
between the tM:l groups.
The findings of this study revealed little difference in
the den:::>graphic characteristics of the tM:l groups.
There was a
significant difference in the mean scores at the .10 level of
significance for the following:
1.
The pre and post knowledge scores for the experimental
group.
2.
The pre-attitude score for the experimental group, and
the attitude score for the control group.
3.
The pre-knowledge score for the experimental groUP and
the knowledge score for the control group.
4.
There was no significant difference in mean scores
for the pre and post-attitude tests for the exoerirnental group.
The multi-disciplinary educational team determined that
this study developed tools that would be useful in the evaluation
of present and future parent education intervention programs.
viii
Chapter 1
INTRODUCTION
Over the past decade there has been increased interest in
the relationship between parents and t-heir children.
New knowledg-e
about child development has accumulated rapidly over the past·decade
with a growing awareness of the importance of the first five years of
life in social and co:pritive developnent.
Despite these recent devel-
opnents, few parents are adequately prepared for parenthood.
This is
ironic, given the imrortance of the parental role in early childhood
deveJ o:pnent.
The parental role is an important factor in the child's
personality developnent and adjustrr,ent to later adult life.
There has been increased evidence that early intervention
programs may be able to reduce parental concerns and improve child
functioning.
The knowledge gained fran such a program can benefit
new parents who may have many concerns about developnent and behavior
of their children.
Enchanced parental understanding of their children
might reduce parental stress, reduce parental conflict, reduce sis:rnificant behavior p:roblans, and decrease the number of children \\rho
appear to function less well than they conld (35) (44).
As a psychotherapist, working w:i..thjn the Department of
Psychiatry of a lars;e health rnaitenaD.ce organization, the Investigator
bec:ame aware that many children identified as "problems" v1ere the outgrowth of their parent's deficiency of Ynowledge in child developnent
and age appropriate behaviors of child!.en.
This lack of knowledge
was further ca:npounded by parental lack of krK:wledge regarding their
own appropriate parental role development.
1
2
Many of the Investigator's co-v.Drkers in the deoartrnent had
similar impressions.
Approximately one-fifth of the persons seen in
the department are children, or parents of children cnming for child
related problems.
In many instances, the therapeutic hour is spent
in an educational manner discussing the above mentioned areas.
Colleaques in other departments such as Medical Social Services,
reported similar experiences.
Contact time spent with parents and
children in the clinic and on the phone involved teaching and
relating infonnation reqarding the child develon:nent, behavior and
behavior management.
Similarly, in the Department of Pediatrics,
pediatricians and nurse practitioners find
th~selves
frequently
fielding questions that are not related specifically to child illness
and disease, but involve child developnent and behavior.
There is a
general impression among health professionals in the medical canplex
that most questions and problens are treated at randcrn and scrne are
feared to go unaddressed.
The consensus among health professionals
is that a parent education program may serve as an alternative and
preventive measure to the existing situation.
It was the qeneral
impression that the Health Maintenance Organization could more
effectively and successfully achieve parent education through a parent
education program utilizinq a team approach.
It was suggested this
could also reduce the inappropriate use of all the other deparbnents
in the medical ccrnplex.
Background of the Problem
Four problems became apparent when a health education intervention program was seriously considered as an alternative or solution
3
to the existinq situation.
First, there was a. need to fo:r:m a TITillti-
disciplinary health team which could develop the program.
Secondly,
there was a need to develop a curriculum with explicitly stated goals,
objectives, and measurable behavioral outcanes for selected content
areas.
Thirdly, in order to assess if the pr:oqram is accc:mplishing
its intended aims, an evaluative tool needed to be constructed.
And
finally, there ":ras a need to determine if such an alternative program
is cost effective to the clinic.
The evaluation of programs with reqard to program effectiveness and rost effectiveness becanes an important aspect of the total
program when clinic administration becomes acutely rost conscious
and danands proof of program effectiveness.
One of the major short-
canings of so m:my "excellent" health programs within this Health
Maintenance Organization is that they are never really evaluated in
these two aspects.
Consequently, a multidisciplinary health team was fo:r:med and
this team developed
~
curriculum with all the essential canponents.
An evaluation tool was also constructed by this t.eam to assess the
program's effectiveness in achieving program goals.
Purj::x:)se of the Study
The purpose of this study is to evaluate the effectiveness
of a parent education intervention program for parents with preschool
age children.
It will attenpt to assess if an educational program
can be effective in bringing about a chanqe in attitude and knowledge
about "effective parenting. "
The study will also attempt to detennine
if there is a difference between those parents who elect to attend
4
an educational program and those parents who do not attend.
Assumptions
The thesis is built up:m the following assumptions.
These
assumptions are as follows:
1.
Changes in attitude and Jmowledqe are capable of
changing overt behavior.
When parents deronstrate
change in their attitude and Jmowledge about their
children, their overt behavior towards their
children will probably change.
2.
Effective parenting is a learned behavior.
Conflict
and stress in parent-child interaction can be reduced
when parents acquire Jmawledge about child development and parenting skills.
Knowledqe will increase
parental rompetence and self esteem in the parental
role.
3.
A multidisciplinary team approach to parent education
will maximize a change in effective parentinq.
There
are many different kinds of professionals •.vho 'WOrk in
the area of child and parent education and no one
profession can claim expertise in the area of parent
education.
All these professions have sanethinq to
offer parent education and their ronjoint efforts can
produce the maximum benefit.
4.
A well developed, educational intervention program can
bring about a change in parental attitude and know-
5
ledge.
Health education is a means of brinainq
about change that can be scientifically documented.
Hypotheses of the Study
1.
The Educational Intervention Proc:rram will not increase
a parent's attitude and knowledge about effective
parentin<J.
2.
Parents who choose to attend an educational intervention
procrram do not have the same attitude and knowledge al::cut
effective parenting as parents who do not attend.
Limitations of the Study
The curriculum as developed by the multidisciplinary
educational team is based upon the assumptions of the health
education curriculum team and the specific needs of the parents at
the Kaiser Pennanente facility in Panorama City, California.
There-
fore, the generalizability of the program's effectiveness is not
assumed to extend outside this population.
The degree of change in attitude and knowledge ¥Jill be
measured inrnediately after the intervention proqram.
This study is
limited to the change in these dimensions for this time period only.
The change in parental "inappropriate utilization" of
medical services will not be addressed in this study.
"Inappropriate
utilization" of services has cost effective implications.
However,
this will be assessed at a later time.
The educational intervention program v.rill be limited to
Kaiser Pennanente subscribers only.
'The experimental and control
6
groups participating in the program will lack randomization due to
the selection process of these tw::> groups.
The educational intexvention program does not intend to,
or assl.IDle to, treat participants as an alternative to another
deparbnent or p.rocrram within the health maintenance organization.
Therefore, there may be a limitation as to the true effectiveness
of the program itself.
It is quite possible that participants will
receive educational information or quidance fran another department
simultaneously.
The measurement tools vmich have been designed by the rnul tidisciplinary curriculum team specifically for this program lack
standardization.
The attitude and knawledqe tests are not standardized
through a procedure such as a Delphi panel.
Therefore, this procedure
may present sane limitations regarding the validity of the study.
Definition of Terms
1.
Effective Parenting
The ability to parent with a
minimum of parental stress, with a minimum of parent
child conflict, and with a ITLLnirnurn of child behavior
probla:ns.
2.
Educational Intervention
A parent education curri-
culum with goals, objectives and outcomes for each of
the following content areas:
child developnent, roth
physiological and social; psychological developnent and
psychological needs; parent/child interaction and
camnmication; behavior m:maganent; and ccmnunity
,
7
p •
resources.
The methods employed include lecture,
discussion, reccmnended books: handouts and behavior
management training and application.
3.
Learned Behavior
The manner in which a parent acts
or operates tcwards his/her child followinq the education intervention.
4.
Multidisciplinary Team
The group of health profession-
als who have generated and who are conducting the
parent educational intervention program.
They represent
the disciplines of psychiatry, psycholoqy, social work,
pediatrics, nursing and occupational therapy.
5.
Attitude
A feeling or emotion a parent has towards his/
her own ability to parent.
6.
Knowledge
Understanding the following areas of
infonnation:
child developnent, both physiological
and social; psychological develq:ment; parent/child
ccnrnunication and interaction; behavior management;
and ccmnunity resources as taught by the multidisciplinary educational team.
7.
Behavior
The manner in which a parent acts of behaves
toward his/her child in the management of the child.
Behavior is defined as effective or ineffective,
dependent upon the desired outcome.
8.
Inappropriate Utilization of .Medical Services
The
use of various medical deparbnents by a parent for
infonnation, guidance or catharsis when those depart-
8
ments' ftmctions are to provide services other than
those being sought.
9.
Change
A specified siqnificant level of difference
scored between a pre and post test or between a pre and
p::>st condition.
10.
Cost Effective
~1hen
the total cost of a health educa-
tion intervention program is less than the total cost of
providing "inappropriate medical services."
Chapter 2
REVIEW OF THE LITERATURE
The Literature Review exaroined four areas that are relevant
to this study.
They are:
( 1) concepts of parenting, ( 2) the history
and rationale for parent education, (3) methods and m::rlels of parent
education programs, and (4) the evaluation of parent education
programs.
Concepts of Parenting
Essential to the problem of constructing a parent education
program and an evaluation tool for the program is the need to define
and understand the concept of "parenting. "
The rnul tidisciplinary
health education team needed to explore and assess the concept in
order to focus and proceed with goal formulation in the construction
of the program.
Once the cx:mcept was clearly understood, the team
was able to proceed in designing the curriculum and the evaluating
tool.
A central issue to the topic of parent education is the
concept of parenting.
many tenns.
Parenting is a process that is referred to by
It is sometimes called child rearing, parental guidance,
child guidance or child training.
The psychiatric dictionary refers
to this process as "child training" and defines it as follows:
"the
training given by the adult to the child in order to develop in it
behavior habits and personality characteristics conforming with the
implicit or overtly formulated standards of the cultural group to
which the child belonos" (33: 96).
Kanner defines the same process as
9
10
"It (child training) is built up in the capital stock of instinctive
modes of behavior and makes use of associative memory by suppressing
scrne instincts, accentuatinq others and fo:rming new a::xnbinations.
The
human trainer deals in rewards and punishrn_ents and thereby merely
imitates what nature shows him, for in its wild state the animal also
learns by success and failure•· (36).
Child training or child guidance implies parental guidance
as well.
"Many of the proble:ns which parents find the:nselves burdened
with are the products of their own past experiences for just as truly
as with the child, the personality adjustment of the parents must be
interpreted in terms of cause and effect in their own experience" (38).
The logical deduction fran this statement is t.'llat parent training or
parenting is the simultaneous process of training parents as well as
parents training their children.
People have many reasons, both conscious and unconscious,
for wanting to become parents.
Sane people have children as their
way of makina a contribution to society.
obtain a form of imnortali ty ( 5:19) .
Others have children to
The manner in which we rear
our children is not a happen chance process.
It is scrnethina that is
learned and there has been a long evolution in developnent of our
parenting role as we see it today.
Dr. Sp::>ck r:oints out that over the centuries men have had
different concepts of humanity as \..ell as concepts of mankinds purpose
on earth.
This, in turn, has directly influenced t.'1e manner in which
children were reared and treated by their parents.
For example, in
the Middle Ages and in American colonial times, it was assumed that
11
humanity's main fnnction in the v..orld, over and al::cve making a living,
was to serve
C~
by carrying out his purposes as revealed by religion.
Consequently, not only did children never have an idea that life was
for their fulfilJment, they were constantly exhorted to overcc:rne their
base nature in order to grow up to be pleasing in
('~' s
eyes. · In the
past one hnndred years, sane peoples have taught that their pun::ose
is to serve their conntry.
This was true in France during Narx>leonic
times and in the British and German ffilpires.
This is nCM true in rnanv
ccmnunistic conntries of the world such as the Union of Soviet Socialist
Republics.
This is also true of derocratic conntries such as Israel.
In sane parts of the v..orld children are born and raised to serve the
aims of the family or God.
In the United States, few children are raised to believe
that their purpose or destiny is to serve their conntry, family or C'.,od.
We emphasize the value of being free to set one's own aims or purpose.
American parents also tend to consider the child as .imrx>rtant, and sanetimes more important, than themselves.
That is why we are sanetimes
referred to as the "Child Centered Society."
Because Americans are a
people who have abandoned old v..orld traditions, many family traditions
and child rearing practices have also been abandoned.
Consequently,
we are a people vlho have had to create methods of child rearing or,
rrore than likely, have reared children with few, if any, cn.ridelines.
Consequently, we have turned to professionals, advisors, books and
new theories for help and guidance (51:11-13).
Lloyd
d~ause,
a psychohistorian, presents a different view
of the evolution of parenting ( 22: 3-54) .
He believes the central force
12
for change in child rearing approaches in history is neither technological nor econc:mical.
De.l\iause believes there is a "psychogenic" change
in personality that occurs beb..veen successive generations of parentchild interactions.
His theory is built upon several hypotheses.
He
believes the origin of this evolution lies in the ability of successive
generations or parents to regress to the psychic age of their chiloien
and 'WOrk through the anxieties of that aqe in a better manner the
second time they encounter them than they did during their
hoods.
c:Jif\111
child-
Therefore, he contends the history of childhood is a series of
closer approaches beb..veen adult and child with each closing of psychic
distance producing fresh anxiety.
The reduction of this adult anxiety
is the main source of child rearing practices of each age.
The obverse of the hypothesis that history involves a
general irnprovenent in child care is that the further back one goes in
history, the less effective parents are in meeting the developing needs
of the child.
De.Mause explains that adults have one of three major
reactions available to them in their interaction with the child.
The
parent or adult can (1) use the child as a vehicle for projection of
the rontent of his own unconscious (projective reaction).
This is
sanethina that was rrore prevalent in ancient times and consequently
resulted in infanticide and abandonment.
The parent or adult can
(2) use the child as a substitute for an adult figure important in his
own childhood (reversal reaction).
This kind of reaction to the child
can result in an ambivalent and/or intrusive response by the par-ent.
This cx:>uld result in indifference to the child or exploitation such
as sexual or physical abuse.
And the parent can ( 3) empathize with the
13
child's needs and act to satisfy then (empathic reaction).
This kind
of a response from the parent would lead to a socializing and helping
response to the child.
It appears that this last reaction is the
response that prevails today (22:3-54).
History and Pationale for Parent Education
Despite the fact that the multidisciplinary health education
team had deterwined that a parent education program would be beneficial
to the Health Maintenance Orqanization, it was imperative to rationally
and scientifically justify our contentions to administration.
Tb.is
necessitated delving into previous programs and studies and presenting
the opinions of experts who have previously worked in this field.
Parent education is not a new idea.
United States since the early 1800's.
It has existed in the
Parent education groups have
been found to exist as far back as 1815 (6:32-45) (53).
Mother's
t.lfagazine first appeared in 1832, .f\'!Other 's Assistant in 1841, and
Parent's Magazine ran frcm 1840 through 1850 (not the same
Magazine as we kno:.v today).
The federal government had a major role
in furthering the developnent of parent education.
Conference on Child Welfare was held in 1909.
was created in 1912.
Parent~
The White House
The Children's Bureau
In 1914, the Department of Agriculture
established the county horne denonstration agency (20:151-58).
In 1918,
the United States Public Health Service began health oriented programs
of parent education (7).
In 1932, the Nhit.':c' House Conference published a report that
was based upon the response to a questionnaire mailed from the Office
of Education.
It showed that 378 organizations were providing some
14
form of parent education at that time (56).
The Works Project
Administration provided teachers and group leaders for presentation
of information on child behavior.
Many major universities beqan
developinq and evaluating parent education programs at that time
also.
Arrong those schools were Columbia, Minnesota, Iowa and Cornell.
In the 1960's, as a result of the awareness of the extent
of child abuse, there was a renewed interest in parent education as a
p:>ssible means of decreasing this problen.
Possibly, through parent
education, abusive parents could learn to lower their expectations,
improve their coping mechanisms and their abilities in interpersonal
relationships (37).
In 1972, the United States Office of Child
Develoanent launched a joint program to help schools set up new or
further develop existing programs on parent education.
The Office of
Child Developnent in coo-peration with the Office of Education and
National Institute of
~1ental
Health granted money to develop and design
parent education projects outside the schools.
Within the past three
years, there has been a general proliferation of parent education
proqrams (50:35-37).
Sane consider parent education as just a "vogue" or
politically "in" thing.
Despite this attitude, Sherret presents
excellent reasons that :rrore than justify the need for parent education.
They are:
(1) teenage pregnancy and all of its concanitant
canplications are on the increase despite the leqalization of abortions
and the advent of the birth control pill; (2) single parent families
are on the increase because of the cliMbing divorce rate and because
manv parents choose to renain
unmarried~
( 3) abusive parents who are
15
lacking in infonnation arout child rearing;
(4) traditional learning
and support systems are not as available as they once were because of
the increased rrobili ty of families, the deenphasis on the nuclear
family; (5) professionals believe that parents can be taught;
(6) increased evidence regarding the importance of the first years of
life as a time of critical development; (7) cycle of abnormal parenting (we parent as v-re were parented); (8) the need to increase family
stability, quality of life and enhance the cognitive, social, enotional
and physical develop:nent of children (50} •
Pediatricians, psychologists, nurses, social workers, health
educators, etc. all call upon their respective professions to beqin to
aid parents in their understanding and dealings with
(12) (11:537) (42:42) (43).
L~eir
children
Cerreta points out that "the basic concept
of parent education makes a good deal of intuitive sense.
It follovvs
that parent behavior simply v-rill effect child behavior" (11).
Behavioralists have shown increases in children's positive behavior
and decrease in negative behavior after parent participation in child
management proqrarns.
O'Dell, a psychologist, has done extensive research into
training parents in behavior modification.
He points out that parental
training and education are important agents in preventive mental and
medical health.
"Parents have the primary influence during the
fonnative years and they are in the best position to prarote healthy
adjustment of their children" (43).
Johnson and Katz, in their reviev-r of the literature of
using parents as change agents for their children, enphasize that
.16
"parents are highly motivated to receive training, inasmuch as they
are the ones most directly affected (or punished) by their children 1 s
destructive behavior" (35:181-2).
Glidewell considers the prevention
of disorders in childhocx1 to be the hiqhest priority in the ccmnunity
mental health arena.
He points out the imfX)rtance of parental training
and education as aqents in preventive health prcx;rrams ( 29) .
The
American Academy of Child Psychiatry considers primary prevention of
emotional disorders of children to be very significant.
The Y.7.hite
House Conferences on Children and Youth have continually stressed the
role of prevention in mental health as a priority and have stressed
prevention through education.
Methods and Models of Parent Education Prcx;rrams
Prior to beginning the construction of our prcx:rram it was
also necessary to review the literature in order to investigate and
examine cont:.emporary models and methods of parent education.
This
enabled the team to generate many new ideas, and it was also helpful
in validating our notions and concepts of p3.rent education.
Many
similarities were found between the team 1 s ideas and those of contemporary educators.
The approaches to parent education are a PJtpourri of
techniques and methods which aim at maximizing parenting abilities
and potentials.
The Child Abuse Project of the Education Ccmnission
of the United States de£ ines parent education as "any type of education
program, involvanent or intervention designed to increase parental
canpetence and self esteen in the parenting role" (23).
The diversity
of parent education prog-rams reflects the heteroqeneity of the
17
of the populations tcwards '.vhan parent education is directed.
Target populations for parent education range from preparent programs to parent programs and to programs for teachers of
parent education.
The parent programs can be sul:xlivided into the
following categories:
( 3) single
parent~~;
(1) teenage parents, (2) primagravida,
, (4) foster and adoptive parents, ( 5) parents of
children with handicaps, and ( 6) abusive and neglectful parents.
Parent education programs are given by a variety of agencies such as
family service agencies, community centers, youth service agencies,
hospitals and clinics, public health nursing agencies, mental health
agencies and educational institutions of all levels.
content emphasis vary dependent upon needs.
Curriculums and
However, topics commonly
include communication skills, child development and psycholoqy,
responsibilities of parenthood, marriage and family relationships,
human sexuality, discipline, health and first aid, and the use of
a:xrmuni ty resources.
Teaching methods carmonly include lecture,
speakers, group discussion, audiovisual presentations, demonstrations,
modeling techniques and the distribution of printed educational
materials.
Sane programs are run on a continuous basis, others time
limited, and sane for one time only.
A maturational model for the develorment of a ccmprehensive
parent education program for adolescence is presented by Levenson,
et al (39).
A unique aspect of their presentation is the emphasis on
the psychological state of the adolescent mother.
The programs
emphasis is geared toward assisting her through this crucial developmental stage.
Other areas of program emphasis included decision
18
making, sensitization to infant needs, and reinforcEYT1eJlt of positive
mateinal behavior.
Glainsky and Hook describe a parent education
prog-ram for teenage parents at the Durham School in Philadelphia (28).
This program provides nothers the opportunity to continue their
education with a day care program for their infants and
toddl~rs.
MJthers leaiTI to care for their children through child developnent
classes and they can practice what they leaiTI under the supervision
of skilled role models.
The federal goverrment has financed 1:\..D maior
efforts to develop parent education curriculum material for young
people.
The Explorinq Childhood Curriculum is widely used in junior
and senior high schools (24) .
Similarly, the Education for Parenthood
Programs have been designed for use in youth service agencies such as
4-H, Boy Scouts, Girl Scouts, Boys Club and settlement houses (41).
Primagravida is a second :rx>pulation of parents that requires
special educational needs.
For example, in order to reduce the stress
that occurs, during the postnatal period for the primagravida mother,
a non-profit ccmnuni ty organization, Parents After Childbirth Education,
Inc. (P.A.C.E.) initiated postnatal
~Drkshops
for parents and their
infants in the Washington, D.C. area in 1973 (58:396-400).
Women parti-
cipate in a didactic v.Drkshop which explores, through lecture, discussion
and readings, many aspects of nother-infant adjustrnent after childbirth.
The sessions also provide a supportive environment for the sharing of
experiences and emotions.
Another program for new parents utilizes the
United States mail as it 1 s vehicle.
The Pierre Pelican Letters,
developed and copywrited by Lloyd Roland, arrives monthly for the first
year and then at longer intervals through the child 1 s sixth year.
The
19
letters provide valuable information about child rearing for literature
and self motivated parents (4 8) .
Transition into Parenthood is a program at the University of
Hinnesota Hospital which is geared for the parent. in the first month to
six weeks postpartum (52: 90-3) .
care approach.
The program is part of a continuity of
It is inclusive of a broad prenatal program, early and
late pregnancy parent education groups, a family centered philosophy of
maternity care, and postpartum heme visits by the primary nurse frcm
the hospital maternity unit.
Parents of handicapped children are a group with special
needs for parent education.
Programs must take into account the
developnental needs of the children as well as the stress factors for
the parents.
Mayer Children 1 s Rehabilitation Institute in Onaha,
Nebraska, has developed a series of "Assertiveness Training for Parents
of Persons with Handicaps" to increase the parent 1 s abil ties as
advocates for their children and themselves (3:38-9).
developed a project called lATON.
Head Start has
It is a program with a sophisticated
set of bilingual materials to meet the special needs of parents of
handicapped children (47).
A study by
HoL~Bn
explores a program devised
to enhance the normal development of toddlers whose psychological
develq::ment is jeopardized by their mothers 1 arDtional difficulties.
M:>ther 1 s concerns about the "separation-individuation" were addressed
within a time limited group setting.
Following a six month course of
-weekly meetings, mothers were better able to handle their toddlers
(34:167-182).
An account by Bevington, et al, illustrates the way in
20
which the needs of parents of mentally handicapped children can be
assessed and met.
Their paper reports the orqanization, content and
evaluation of a parental involvement course for handicapped children.
The course was designed to fulfill the expressed needs of parents whose
children attend a local authority day school.
The outccme of the study
reveals that parents felt more confident and successful in teaching
their children new skills (4:217-27).
Actual or potentially abusive or neglectful parents are
another target group for parent education.
Parent education classes
or discussion groups may be part of a canposi te of services which may
include therapy for parent and children, health services, 24 hour
crisis child care, developnental services for children and social
services.
Authier mentions that three model centers were developed
in 1970 in Birmingham, Houston, and New Orleans and later replicated
in other cities.
Parent-child centers provide opportunities for
parents and children to have separate educational experiences with the
addition of guided parent-child interaction at the center (3).
In
1974, Family Service of Qnaha-council Bluffs, c:ma.ha, Nebraska. developed
a direct service prc:x]ram for parents who abuse or who feel like
abusing their children.
The program revealed that there was a
significant change in sane of the variables known to be related to
abusive behavior (10).
Hane based programs are an attempt to provide parent
education to high risk, low inccme families.
For example, Hane
Start is a t:rrree year Head Start daronstration program designed to
bring comprehensive child development services to children and
21
faiT~ilies
in their own hcmes.
It provides the same services as Head
Start, hCMever, concentrating on the role of parents in the gra.-Tth and
developnent of their children.
There are currently sixteen Office of
Child Developnent funded Heme Start demonstration projects which serve
about 2,500 children {44).
The University of Florida experimented with
the use of women frcm disadvantaged neighborhoods to teach indigent
mothers of infants and young children
develor:rnent.
~
to stimulate their children's
Arrong many findinqs it was indicated that a parent
education proaram using nonprofessionals and serving mothers living in
difficult urban and rural conditions can be maintained and that this
type of program seems to enhance the developnent of infants whose
mothers are reached in their hcmes {30:57-9).
Evaluation of Parent Education Programs
The viability of the parent education program depends upon
an ability to danonstrate its effectiveness.
The team is aware that
the time of accountability is upon us and that more than good
intentions is required to -justify the intervention program.
Therefore,
the multidiscipliilary health education teatu felt it must evaluate what
it is doing in order to derronstrate that the efforts have \\Drthwhile
effects.
In the process of constructing the evaluation tools, the
team needed to look at the \\Drk of previous educators and how they
evaluated their and/or other's programs.
There are many studies in parent education that incorporate
in their study evaluations of the outcomes (2) {46:54-7) {31).
However,
there are many researchers who believe these evaluations lack validity
22
for they fall short of many important evaluation criteria.
Trcrrnontant
is one such person 'Who discusses several issues that are necessary in
order to adequately evaluate program effectiveness.
Key issues in
evaluatinq the effectiveness of parent education are (1) whan is to be
assessed, i.e.
1
parent and/or child, (2) what is to be assessed, i.e.
1
evidence in chanqe of attitude, knCMledge 1 or behavior, ( 3) when chanqe
is to be assessed, i.e. , inmediately following a program or in sane
time period later (54:40-43).
Johnson and Katz present a comprehensive review of studies
that use pa.rents as change agents for their children.
Among the many
aspects of these studies reviewed is the area of evaluation and methodological considerations.
These two authors emphasize the necessity of
observational data, reliability of measurenent (dependent measures
accampanied by empirically derived estimates of their reliability),
demonstrations of behavior controls, follow up observations and cost
factors (35) .
0 'Dell provides another extensive review of the literature
on training parents in behavior rrodification.
In the realm of research
evaluation, he stresses the need for more accuracy in sampling techniques, behavioral descriptions, replicability of studies, experimental
design validity, more riqorous measurenent techniques, generality and
durability and cost efficiency (43).
Tramontana provides guidelines
for evaluating the effectiveness of parent education programs.
He
reccmnends that future studies on outcane should be broadened to
include assessments in multiple outcomes categories, assessments of
qeneralization and maintenance of change, as well as an assessment
23
of possible adverse effects resulting fran parent education.
He calls
for future studies to include same objective appraisal of actual parent
child interaction (54) .
One excellent study found by this Investigator that appears
to meet most of the fore mentioned criteria is a study by Burch and J'11ohr
evaluating a child abuse intervention prCXJram.
Abusinq parents "Who
became part of an education-developnental treatment program, Positive
Parenting, were compared with a control group of abusers in a pre and
post-testing evaluation process.
Significant and positive change in
the treatment group demonstrated the effectiveness of this intervention
rrodel (10) .
Another good exaTI'ple is a study provided by Peed, Roberts,
and Forehand who evaluated the effectiveness of a standardized parent
training prCXJram in altering the interaction of mothers and their noncompliant children (45:323-350).
Sumnary
The literature review was intended to serve as a chronology
of the theoretical considerations in the multidisciplinary health
education team experienced LD the process of constructBrg the
curriculum and evaluation tool.
Although this study deals primarily
with the evaluation of the effectiveness of this parent education
program, the Investigator believes that understanding the evolution
of the program sheds light on understanding the theoretical and
practical applications of the evaluation tool.
The evaluation tool
is built upon the program's philosophical approach as well as the
individual theoretical approaches of the professionals who make up
24
the multidisciplinary health education team.
Chapter 3
MEI'HOOOr.a:;Y
The purpose of this study was to evaluate the effectiveness
of the Parent Education Program relevant to its achievement of the
intended goal.
This Chapter will discuss the methodology by ·which the
progTam evaluation will be accx:mplished.
The following methodological
considerations will be discussed:
1.
The design and develq:ment of the educational program.
2.
The design, developnent, and administration of the
attitudinal and knowledge tests.
3.
The analysis of the effects of the educational intervention program on the experimental group.
4.
The cx:mparison of the performance of the experimental
and control groups on attitudinal and knowledge tests.
Population
The population of this study will be comprised of KaiserPennanente subscribers who have children five years of age or younger.
Participation in the educational intervention program will be limited
to a first cx:me 1 first serve basis.
There will be no previous evalua-
tion or screening of participants in the study.
Those who choose to
participate in the educational intervention program will be self
referrals who have learned of the program through advertisement 1 \\Drd
of rrouth 1 or by being referred by a health care professional at
Kaiser-Permanente.
group in this study.
This population will constitute the experimental
A population of Kaiser-Pennanente subscribers
25
26
who utilize the Pediatric Well-Baby Clinic, but 'Who have not pCL.vticipated in the educational intervention pros:rrarn, will constitute the
control group of this study.
The experimental and control groups will not be randanized.
However, the populations frcrn 'Which both groups will be drawn· are very
similar in that all individuals will be Kaiser-Permanente subscribers
'Who tend to came from similar socio-economic class backgrounds.
Dernc:xJraphic data is to be obtained fran roth populations and the
matching of characteristics will insure that the qroups are not qreatlv
dissimilar.
Research Design
This study will be designed to assess the difference in the
experimental group's attitude and knowledge as a result of participation in the educational intervention program.
This entails a pre-
and post-test for individuals participating in the program.
An
additional question exists as to 'Whether or not an individual 'Who
elects to participate in an educational program possesses a different
attitude and knowledge about parenting than an individual who does not
enter such a prcx:rram.
This will be acccrnplished by assessing a
difference in attitude and knowledge between the experimental and
control c;:rroups.
Statistical Design of the Study
A written pre-test of attitude (A ) of each individual of
1
the experimental group will be administered at the beginning of the
educational program.
A written pre-test of knowledge (K ) will also
1
27
be canpleted at the same time.
Following the final session of the
educational intervention program (X) , individuals cc:mprising the
experimental group will complete a written post-test of attitude (A )
2
and a written post-test of knowledge (K2 ).
At another time, a control
group of parents who do not experience the educational program will
complete a written test of attitude (A ) and a written test of knowc
Table 1
Statistical Design of the Study
-----------------------------------·----------------------------- - - --··- ----·-------------------------Experimental
X
Control
A
c
K
c
---- --·- ---------=-=-:=:.==============
Key:
A= written test of attitude
K =written test of knowledge
X = educational intervention program
c = control group
The analysis of the differences between pre- and postattitude tests (A :A ) and pre- and post-knowledge tests (K :K2 ) will
1
1 2
yield the results of the educational intervention program.
The
analysis of the attitude tests (A :Ac) and knowledge tests (K :Kc) will
1
1
yeild a difference between these two types of individuals.
Statistical Hypotheses of the Study
In order to obtain evidence which will support or reject
28
the overall study hypotheses presented in Chapter 1, two null hypotheses have been formulated:
H : A
0
1
= A2 ,
K
1
= K2
There is no difference in the means of the pre- and post-attitude and
kno.vledge tests for the experimental group.
Hl: Al
= Ac'
Kl
=
And,
Kc
There is no difference in the means of the attitude and knowledge tests
between the experimental and control groups.
The use of the statistical t-test is used to assess differences between the mean scores.
A significance level of .10 has been
determined to be of significance by the multidisciplinary educational
team.
This level is based upon the team's determination th.:xt an
acceptable change in performance would be 15% or less and an unacceptable change in performance w:::mld be 5% or less.
Developnent of the Educational Intervention Program
The educational intervention prog-ram was developed, designed
and implemented by the multidisciplinary health team.
This team is
composed of a pediatrician, a child psychiatrist, a clinical
psychologist, a medical social worker, a psychiatric social worker,
a pediatric nurse practitioner and a health educator.
An educational
curriculum for this program was developed by the team with specific
goals, objectives, and content areas.
Resource material carne fran
the health team as well as books, articles, and other sources.
The
program was specifically desiqned for the parent population seen
at Kaiser-Pennanente as perceived by the health team.
See Appendix
29
A for a complete description of the curriculum.
Construction of the Test Instruments
The goals of the intervention program formed the basis
for the construction of the test im;·truments.
The two dimensions to
be surveyed are a change in attitude and knO\.vledge regarding effective
parenting behavior.
The two instruments are written tests designed
by th.e educational tearn.
(See Appendix B.)
The goals of the program that form the basis for the test
instruments are as follows:
1.
Enhance parents' skills and attitudes towards parenting
by increasing their knowledge in the area of (a) psychological makeup of parents, (b) child's emotional and
social developnent, and (c) parental developnent and
tasks.
2.
Enhance and increase the quality of parent-child
relationship through the understanding of the physical,
social and emotional develo[!"'lental process fran infancy
to childhood.
3.
Enhance the quality of parent-child relationship through
a better understanding and application of appropriate
behavioral management techniques.
4.
Encourage behavioral change of the p3.rent through
intervention.
s.
Enhance understanding and appreciation of the various
stages of a child's developnent.
30
Each health professional on the team constructed questions
from his/her cxmtent area.
by the entire team.
These questions were reviewed and critiqued
Three questions fran each content area were
selected by the team to compose the written knowledge test.
The
written attitude test is a modified semantic differential that has
been previously used in the Kaiser-Pennanente manber health
education department.
The attitude test was further modified by the
team to meet the special needs of this procrram.
At the beginning of the educational intervention series
the pre-attitude and pre-knowledge tests were administered to the
experimental group.
The group was informed that they were pioneers
in this program and that they were subjects of a research study.
were informed that their participation was voluntary.
They
They signed a
waiver of consent which also informed then of their right of refusal
(see Appendix B).
No individual refused to participate in the study.
Following the educational series, the experimental group was administered the same tests.
These tests served as post-attitude and
knowledge measurenents.
The pre-attitude and pre-knowledge test administered to the
experimental group served as the attitude and knowledge tests for the
control group.
These tests \vere administered to the control group
when they came for a medical visit in the pediatric well baby clinic.
A nurse practitioner fran the team asked individuals if they would be
willinq to participate in this study by canpletinq the tests.
were informed that their participation was voluntary.
They
Those who chose
to participate signed a consent fonn and ccxnpleted the tests.
There
31
were several refusals in this group.
Data Collection
Collecting of the testing data for the experimental group
was accxmplished by correcting the pre- and post-attitude and knavledge tests for each individual.
This data was then recorded.
Simultaneously, dauographic information was gathered for each
individual in the group.
Similarly, attitude and knowledge test
scores were collected for the control group and recorded.
Derographic
information was also collected for this group.
A score on the attitude test could range fran being very
optanistic alx:mt parenting ( 80 points) to being very pessimistic
al:x::>ut parenting (16 points).
A perfect score on the knowledge test
would be 17 points and poorest perfonnance \...-ould be 0 points.
A group mean was calculated for each of the pre- and
];X)st-written tests for both the experimental and rontrol groups.
Please see Tables 3 and 4 for details.
Statistical Analysis of Data
Obtaining the means enabled this Investigator to proceed
with the assessment of the data.
The Canputational
Statistics provided the oamputational
data.
p~ucedures
H~']-dbook
of
for analysis of the
The use of the t-test was chosen as the method to test the
significance of difference between the groups.
Four canparisons are
to be made: (1) difference between the written pre- and postattitude test for the experimental group, (2) difference between the
written pre- and post-knowledge test for the experimental group,
32
(3) difference between the written pre-attitude test for the experimental group and the attitude test for the control qroup, and (4)
difference between the written pre-knc:Mrledge test for the experimental
group and the knowledge test for the control group.
Chapter 4
ANALYSIS AND DISCUSSICN OF THE DATA
This Chapter presents the descriptive data and analysis
of the data obtained from the written pre- and rost-tests of the
educational intervention prCXJram group.
Also, a canparative analysis
of the written tests of the group which did not experience the intervention program and the group which did is presented.
The results of
the test. instruments are also tabulated, analyzed and discussed.
Treatment of the Data
The data fran this study is approached in t\\D ways.
Descriptive data of the individual subjects within each group is
rep:>rted in descriptive and table fonn.
The analysis of the mean
pre- and p:>st-test scores for the experimental group is presented.
The analysis of the mean pre-test scores of the experimental group
and the mean test scores of the control group is also presented.
Descriptive Data
Table 2 surrmarized the demographic characteristics of the
experimental and control groups.
group are as follows:
Those categories surveyed for each
age, sex, marital status, number of children,
existence of a step parent, children fran previous narriaoes, nurober
of children adopted, level of education, primary caretaker of children,
ethnic background, inoame level, person filling out form, attendance
at previous parenting programs, and with whcrn are you attending this
program.
33
34
Table 2
Comparison of Demographic Characteristics
of Experimental and Control Groups
ExperimP.ntal
Age
Control
N= 29
N= 29
Under 25 years
4
3
26 - 35 yenrs
]9
20
36 - 45 years
6
6
Male
10
2
Female
19
27
28
28
1
1
One
12
5
Two
12
7
Three
4
7
Four
1
7
46 - 55 years
OVer 55 years
Sex
Marital
Statu~;
Single
Married
Divorced
\\7idc:wed
Number of
Childn~n
Five or more
Is
3
there a Step parent?
Yes
4
3
No
25
26
Yes
4
6
No
25
23
ChHdren in house fran previous marriage?
35
Tr1ble 2
(continued)
Experimental
Chi 1dren adopted
Yes
No
Control
2
29
27
Level of Education
Same grade school
Completed grade school
Same high school
Completed high school
3
5
5
11
13
Completed college
7
4
Same graduate v-Drk
2
2
A graduate desree
4
2
17
10
Sane college
Prim:rry CarPta"k-er of Children
Mother
Father
Both parents
2
11
16
1
1
Relative
Other
EtJhnic Background
Bl_ack
3
Mexir.an-AmPrican
Caucasian
3
25
20
Oriental
2
1
Other
2
2
0 - 10,000
1
1
11,000 - 15,000
3
3
16,000 - 20,000
9
5
16
20
Family Incorre Level
OVer 21,000
36
Table 2
(continued)
Experimental
COntrol
Person Filling OUt This QuestionnaireMJther
18
27
Father
10
2
Other
1
Attenned Previous Parenting Program
Yes
No
2
3
27
26
8
NA
19
NA
2
NA
Attending This Program With V.1horn
Alone
With spouse
Other
Although uncanny 1 (as anticipated by the educational team)
these two groups varied little with regard to their demographic
characteristics.
h'i th the two exceptions of thPre being one third
less wanen in the experimental group than the control group 1 ni_neteen
i'lS
canparen to twenty seven 1 and the greater abundance of parents
having two or less children in the experimental as Op]X)sed to the
control group 1 twenty four versus twelve respectively, the groups are
practically identical in nature.
This Investigator suspects that the greater proportion of
wcrnen found in the control group is attributable to the fact that in
this population wanen tend to be the primary daytime caretakers of
their children.
Consequently 1 when children are brought to the clinic
during the daytime, they are accanpanied by their mothers more often
37
then by thej r fathers.
less children fotmd in
The greater proportion of parents with two or
th~
experimental group is dne to their new
parent status.
In hoth groups the roalority of parents were between the ages
of twenty six and thirty five years of age 1 ninetpen ;:md twenty
IdenticaJ_ nUITlbers of p3.rents were married, twenty eight
respectively.
in both groups.
The experimental group had four step parents and the
control group had three.
In the households of the experimental group
there were four children fran previous marriages and in the control
group thP.re were six.
The households of the experimental group had no
adopted children and the control group had just two.
The greatest
proportion of parents in both groups had as their level of eClucation
as "sane college, " eleven in the experimental group and thirteen in
the control.
The primary caretakers for both groups were identified
as either the "mother" (seventeen and ten ro.spectively) or "both"
(eleven and sixteen respec:tively).
The vast majority of parents in
roth groups were Caucasian, twenty five for the experimental group and
twenty for the control.
The rrode incane level for both groups was the
"over $2J ,000" JPark, sixteen for the experimental and twenty for the
control.
In the experimental group only two persons had previously
attended a parenting program and in the control group only three
persons had att-ended a previous parenting prog-ram.
OVerall, it appears that the two groups differ little in
their basic characteristics.
educational team.
This was the suspicion of the
For the pu:rposes of this stuny, the results were
quite convenient for analysis.
38
The individual scores for the
expPrimen~al
pre- and post-
attitude and knowledge and the control attitude and knowledge are listed
in Tahles 3 and 4.
Mean scores have been ccmputed for 0ach test group.
Table 3
Indjvidual
Me~n
Scores for Attitude
--
!
F.xpE>rimental
Pre
N = 28
Control
Post
N = 28
N
= 30
64
79
61
69
61
70
64
68
62
64
69
58
65
69
64
69
65
59
62
65
61
64
61
67
67
61
66
59
78
66
47
55
67
52
64
60
50
56
56
72
7~
64
65
60
70
74
59
63
64
62
52
70
55
74
71
65
62
57
6S
67
65
58
67
53
58
70
62
62
60
71
61
63
51
62
57
57
61
63
62
59
58
63
60
53
62
58
I
--~-
-
X
=
62.6
X
= 62.75
-
X
= 63.2
II
I
!
l
39
Table 4
Individual Mean Scores for KnONledge
Experimental
Pre
Cont_rol
Post
N = 29
N
= 25
N
= 29
9
14
13
12
13
14
12
4
8
16
l2
11
10
14
13
15
9
12
10
8
12
12
11
15
11
11
13
16
12
13
13
13
15
12
JO
8
13
15
9
11
16
13
13
9
11
11
14
13
13
13
11
14
10
13
13
11
16
15
11
13
11
11
13
4
13
13
13
12
9
10
9
9
9
15
8
13
9
14
14
12
15
8
12
X =
11.8
X=
13.36
X=
10.58
Data Analysis
'T'he ;=malysj s of the data will detennine if thP.re is any
difference between (1) the pre-tests and fX)st-tests of the experimental group, and (2) the attitude and knowledge tests between the
experimental and control groups.
All groups were given the
identical pre·- and fX)st-tests for attitude and knONledge.
As
stated earlier, the level of siqnificance which will detennine thP.
acceptance or
p
=
.10 level.
re~ection
of the null hypotheses has been set at the
The result.s of the tests for within and between group
differences are discussed in this section of the stooy.
40
HYPOI'HESIS:
There is no difference in the Jl1eans of the pre- and post-
a.tt:i_tude and knowledqe tests for the experimental group.
Evidence:
The rPsul ts of the pre- and :r:ost-attitude and knc:MlP.dge tests
are in Table 5.
For attitude toward parenting within this group there
was a mean difference of -1.5, yielding t-value of -.084.
four degrees of freedom, this t-value is a p = . 50.
With fifty
For knowledge of
parenting wjthin this same group there was a mean difference of -1.56,
yielding at-value of -2.57.
At fifty two degrees of freedom this
value is a p =.02.
Table 5
Analysis of Written Attitude and Kn0Wledge
Mean Scores by t-Test
for the Experimental Group
Pre- and Post-Test Means
Mean
Difference
T-Value
d.f.
2-Tail
'Probability
Experimental Group
*
Attitude
- 1.5
Knowledge
- 1.56
.084
- 2.57
54
.50+
52
.02
Ind1cates s1gn1f1cant Chanqe.
Conclusion:
There is evidence not to reject the null hypothesis for
the mean attitude scores.
Hov1ever, there is evidence to reject the
null hypothesis for the mean knowledge scores.
HYPOI'HESIS:
There is no difference in the means of attitude and
knowledge tests between the experimental and control groups.
Evidence:
The results of the tests for both groups is founr'l on
*
41
'I'able 6,
-.6,
The rnenn difference for the attitude test between groups is
yielding a t-value of -1.92.
the value is p - .10.
The mean difference on the knowledge test was
1.22, yielding a t-value of 1.93.
va.lue of p
=
With fifty si.x degrees of freedan
At fifty six degrees of freedan the
.10.
Table 6
Analysis of Written Attitude and Knowledge
r·1ean Scores by t-Test
for tht:> Control and Experimental Groups
Mean
Difference
T-Val.ue
d. f.
2-'T'ail
Probability
Experimental vs.
Control
Attitude
Knowledge
*
.6
1.22
- 1.92
1.93
56
56
.10
.10
*
*
Innicates significant change
Conclusion:
Ther~
is
eviden~e
to reject the null hypothesis for roth
the mean attir.ude and knowledge test soores.
r.hapter 5
Sill1t,JARY, CONCLUSION AND RECCMMENDATICNS
The purpose of this study was to evaluate the effectiveness of
a parent education intervention program for parents of preschool age
children.
The review of the literature examined the followinq areas
relevant to this study;
concepts of parenting, the history and
rationale for pnrent education programs, methods and models of
parent education programs and the evaluation of parent education
programs.
A mul tidisci.pl i.na:ry educationaJ team developed, designed
and implemented an educational intervention program for "Parenting."
The educational intervention proqram focused on:
psychological
developnent, parent-child carmunication, behavior manage:nent
application, physical, social and emotionnl development and problem
solving.
Two specific test instruments were constructed by the educational team to assess changes in attitude and knowledge about parenting.
These tests were administered the the group experiencing the educational
program (exper:Lmf"ntal grouf>) before and after the educational program.
A group not experiencing the program (control group) was administered
the tests at a different time and a different location.
Demog-raphic
comparisons were made between the two groups.
The findings of this study revealed little difference in the
demographic characteristics of the two groups.
There was a signifi-
cant difference in the wean scores at the .10 level of significance
for the following:
. 42
43
1.
The pre- and post.-kna.vledge soores for the experimental
g"LOUp.
2.
The pre-atti t.ude score for the experimental grol.:'.p aTld the
attitude score for the controJ group.
3.
'l'he pre-knowledge score for the experimental
gro~1p
and
the kna.vledge soore for the oontrol group.
4.
There was no significant difference in mean scores for
the pre- and post-attitude tests for the experimental
group.
Conclusions of Statistical Analysis
1.
The dEmOgraphic characteristics between the tv.D gronps is
essentially the same.
Therefore, it is presmned that the
groups are CCITiparable.
2.
There was no statistically significant difference between
the rnean scores of the prethe experimental group.
ann
post-attitucle test for
'T'his outcane could have resulted
fran (1) the fact that the progrr:rrn was ineffectual, or
(2) the experimental group did not have t.he opp:>rtunity
to utilize the knowledge gained fran the program.
John
Dewey points out that "you do not believe saner.hing
u11.ti l you behave upon it" (32: 53).
3.
There was a statistically significant difference between
the mean scores of the pre- and post-knowledge tests for
the experimental group.
The oonclusion d"Lawn fran this
is that the program was effective in bringing a.l:x>ur a
44
change in knowledge.
4.
There was n. statistically significant difference between
the mean pre-attitude
test for the experimental group and
thP me;m attitude test for the control group.
'This out-
come poses a question regarding an individuaJ 's motivation
for seeking infonnation or knowledge.
It is concluded
that the expPriJnental gro,Jp, which had a more pessimistic
Bttttu~e tnwa~d
pnrepting, perceived that they needed
help in t..his area and therefore sought education.
The
control group 1 having the more optimistic at:ti tude, did
not feel that they needed help or information regarding
parenting.
5.
There was a statistir.ally signi_fir..ant difference between
the mean pre-knowledge test score of the experimental
group and the mean knowledge test score of the controJ
group.
It i.s qnite likely that the experimental group,
which had a greater arrount of knowledge than the controJ
group, is basically a more "educationally aware" group.
They may have a pattern of seeking infonnation and
knowledge which is indicative of the fact that they
elected to attend this program.
Additional Conclusions
This Investigator is cognizant that repeated follow-up
measurement over a lang period of -time is necessary to conclusively
state that these out-.cx:rnes are valid.
There is a need to standardize
45
the test tools.
Because of tirre constraints, testing of the instruments
was not pnssiblP and inaccuracies or faults may exist in these tools.
In a more positive vein, a program evaluation questionnaire
was administered the the educational group (see Appendix B) and the
overalJ rating by the participants was very good t0 exr.ell ent~
member experienced the pro:::rarr. as 1msatisfactory.
No
This perception
by group members may generate in itself a more positive attitude
towards parenting.
Reccmnendations
The following recorrmend"ltions are made based upon this study:
l.
Health educators working with other health professionals
can generate effective health education intervention
programs on parenting that can increase knowledge in
parenting skills.
2.
The educational intervention program developed in this
study should be implenented in health maintenance organizations as an adjunct to other medical services.
3.
Similar studies in the future should attenpt to evaluate
changes i11 attitude and knowledge over an extended pericxl
of time such as six months post educational program,
4.
Similar studies in the fut_ure shoulCl atten:[)t to evaluate
changes in utiliza-tion of medical services as related to
the acquisition of knowledge fran such education programs.
46
'
BIBLicx;RAPHY
1.
Arie 1 s • Philippe. Centuries of Childhood: A social History of
Farnily Life. N.Y. : Vintage Books, 19 62 .
2.
Augelli, J. and Weener, J. Training Parents as 1'1ental Heal D.'1
Agents. Carrm.mity !'"ental Health Journal. Vol. 14, 1978.
3.
Authier, K. Methods and .M::xlels of Pare.'1t Education.
of Clinical Child Psychology, Spring, 1980.
4.
Bevington, P., et al. An Approach to Planning and Evaluation
of a Parental Involve:nent Course. Child: Care, Health and
Developnent, 1978, 4.
5.
Boston ~'Janen 1 s Health Book Collective.
Children. N.Y.: Randan House, 1976.
6.
Bridgeman, R. Postwar Progress in Child ~·Jelfare. Annals of
the .American Acadany of Political and Social Science, 151,
1930,
7.
Education for Child Rearing.
Journal
Ourselves and Our
N.Y.: FrPe Press, 1965.
8.
Bruning, J. and Kintz. Canputationc_l Handbcd< of Statistics.
Ill: Scott, Foreman & Co. , 1968.
9,
Brown, P. and Elliott, R. Control of Aggression in a Nursery
School Cln.ss. Journal of Exoer:imenta1 Child Psychology, 2,
1965.
10.
But:"ch. G. and Mohr, V. Evaluating a Child Abuse Intervention
Program. Social Casework, Vol. 61, No. 2, February, 1980.
11.
Cerreta, M. Parenting Education: Panacea for all Ills?
Journal of School Health, NovEmber, 1979.
12.
Chamberlin, R. Parental Use of Positive Contact in Child
Rearing: Its reli'ltionship to child behavior p:1tterns and other
variables. Pecliatrics, Vol. 56, No. 5, NovEmber, 1975.
13.
Chamberlin, R. Nevv Knowledge in Early Child Developnent: Its
Importance for Pediatricians. American Journal of Disabled
Children. Vol. 126, NovEmber, 1973.
14.
Chamberlin, R. Approaches to Child Rearing: Early Recognition
and Modification of Vicious Circle Parent-child Relationships.
Clinical ·pediatrics, August, 1967.
47
15.
Chamberlin, R.
Can \'Je Identify a Group of Children at Age 2
who are at High Risk for the Developnent of Behavior or
Emotional Problems in Kindergarten and First Grade?
59: 1977.
Pediatrics,
16.
Chamberlin, R. ~anagernent of Pre-school Behavior ProblEfflS.
Pediatric Clinics of North America, Vol. 21, No. 1, February,
1974.
17.
CharPberlin, R. An Evaluation of Efforts to Educate l'~thers
Alxmt Child Developnent in Pediatric Office Practice. American
Jry~nl of Public Health,
Vol. 69, No. 9, 1979.
18.
Cobb, Sidney. Social Support as a ~iloderator of Life Stress.
Psyc!1osanatic Jvledicine, Vol. 38, No. 5, Septernber-october, 1976.
19.
Cc:wen, E . .- et al. A Preventive Mental Health Program in the
School Setting: Description and Evaluation. The Journal o~
P~ychology,
1963 (56) .
20.
Croake, J. and Glover, K. A. History and Evaluation of Parent
Education. The Family Co-ordinatory, April, 1977.
21.
D'Angelli, J. and Wiener, J. Training Parents as tft.ental Health
Agents. Ccmnunity Hental Health Journal, Vol. 14 (1), 1978.
22.
deMause, L. The History of Childhood.
Press, 1972.
23.
Education Cormnission of the States, Child Abuse Project.
Education for Parenthood: A Primary Prevention Strategy.
Education Ca:nmission of the States, ReJX)rt No. 93! 1976.
N.Y.: Psychohistory
Denver:
24.
Education Developnent Center. Exploring childhood:
overview and catalog of mat-.erials.
25.
Friedman, A. and Friedmcq1, D. Parenting: A Developnental
Process. Pediatric Annals, 6:9, September, 1977.
26.
Friedman, David. Parent Developnent.
Vol. 86, No. 1, June, 1957.
27.
Friedman, R.
Family Roots of School Learning and Behavior
Disorders. Springfield, Ill.! Charles Thomas, 1972.
-
28.
Galinsky, E. and Hooks, W. The New Extended Family, Day Care
that Works. Boston: Houghton Mifflin Co., 1977.
29.
Glidewell, J. Priorities for Psychologists in Carrnunity Mental
Health. Issues in Carmunity Psychology and Preventative Mental
Health. N.Y., Behavioral Public..ations, 1971.
Program
california l\1edicine,
48
30.
Gordon, Ira.
Vol. 16, No.
Stimulation via Parent Education.
March-April, 1969.
Children,
2~
31.
Gordon, S. and Lerner, L. Responsive ParentL11g: An Approach to
Training Parents of Problen Children. American Journal of
Ccmnunity Psychology, Vol. 7 (l), 1979.
32.
Hersher, L. Four Psychotherapies.
Croft, 1970.
33.
Hinsie and Shatzky. Psychiatric Dictionary.
University Press, J953.
34.
Holman, s. An Early Intervention Program for Developnentally
at-Risk Toddlers and Their !v'bthers. Clinical Social Work
Journal, Vol. 7, No. 3, Fall, 1979.
35.
Johnson, C. and Katz, R. Using Part=>..nts as Change Agents for
Their Children: A Review. Journal of Child Psychology and
Psychiatry, Vol. 14, 1973.
36.
Kanner, L.
1935.
37.
Kempe, C. The Battered Child.
Association, 1962~
38.
Lee, P. and Kenworth. Mental Hygiene and Social Work.
Commonwealth Fund Publications, 1929.
39.
Levenson, P. , et al. Adolescent Parent Education: A ~-Bturational
!v'bdel. Child Psychiatry and Human nevelq::ment, Vol. 9 (2) ,
Winter, 1978.
40.
Hcinerny, T. and Charrberlin, R. Is It Feasible to Identify
Infants who are at Risk for Later Behavior Problens? Clinical
Pediatrics, VeT . 17 , No. 3 .
41.
Morris, L. (Ed.) Education for Parenthocd: A program, curriculum,
and evaluation guide. U.S. Dep.3.rtrnent of Health, Education and
Welfare: Publication No. (OHDS), 77-30125, 1977.
42.
Murphy, N. Training Professionals to Support and Increase the
Ca:npetency of Young Parents. Journal of Nursinq Education,
Vol. 17, No. 7, September, 1978.
43.
O'Dell, S. Training Parents in Behavior Jvbdification.
Psychological Bulletin, Vol. 81, No. 7, 1974.
44.
0 'Keefe, R. Hane Start: Partnership with Parents.
January-February, 1973.
Child Psychiatry.
:N.Y. : Appleton-century
Springfield:
N.Y. : Oxford
Charles
c.
Thanas,
The Journal of American Medical
N.Y.:
Child Today,
p '
49
45.
Peed, S., Roberts, M. and Forehand, R. Evaluation of the
effectiveness of a standardized parent training program in
altering the interaction of mothers and their noncompliant
children. Behavior M:xlification, 1977.
46.
Renz, L. and Cohen, M. Interpersonal SkiJl Practice as a
Canronent in Effective Parent Training. Ccnmuni ty Hental
Health Journal. Vol. 13(1), 1977.
47.
Riley, M. Project IA'ION II:
The Texas Tech Press, 1977.
48.
Ro.vland, L. Pierre the Pelican (Series of 28).
Family Publication Center, 1976.
49.
Schleicher, Isabel . Teaching Parents to Cope with Behavior
ProblEmS. American Journal of Nursing. May, 1978.
50.
Sherrets, S. , et al. Parent Education: :Rationale, History, and
Funding Sources. Journal of Clinical Child Psychology, Spring,
1980.
51.
Spack, B.
52.
Stranik, M. and Hogberg, B. Transition to Parenthood.
Journal of Nursing. , January, 1979.
53.
Sunley, R. Early 19th Century American Literature on Child
Rearing. In M. Mead and Wolfenstein (Eds. ) , Childhood in
Contemporary Culture. Chicago: University of Chicago Press, 1955.
54.
Tramontana; M. Evaluation of Parent Education Programs.
of Clinical Child Psychology, Spring, 1980.
55.
Wahler, R. and Winkel, G. Mothers as Behavior Therapists for
their CM7n Children. Behavior Res. Ther, Vol. 3! 1965.
56.
White House Conference on Child Health and Protection, Sec. 3:
Education and Training. N.Y. : Century, 19 32.
57.
Willouqhby, J. A Simple Behavior Questionnaire for Preschool
Children. Pediatrics, Vol. 134 , December, 1964.
58.
Zinner, E. and Hertzman, R. P .A.C.E.: A .r-1odel for Parent
Infant Support Groups during the First Months of Life.
Clinical Pediatrics, Vol. 17, No. 5, May, 1978.
The parent child lxlok.
Baby and Child Care.
LUbl::ock:
New Orleans:
N.Y. : Sim:m and Schuster, 1945.
American
Journal
APPENDIX A
50
51
Proqram
Activity
September 17, 1980
Date
PROPOSAL
Name of Person Sul:mitting Proposal:
Department:
Member Health F.ducation
Subject Jl'latter:
I.
Mei-Ling Schwartz
Phil Bauman
Extension:
3018
Parent Education Program
Statanent of Purpose
The Deparbnent of Pediatrics, Psychiatry and Social Services
receive requests from parents and staff for education and
counseling of parents in healthy child rearing practices.
ThP.re exists i'it this time no fonnal unifom and consistent
program or process within the medical ccrnplex to meet this
need. Many of these concerns becane referrals to the
Department of Psychiatry as "psychiatric problems" and/or
r- are treated as crisis intervention in the Departments of
· Social Services and Pediatrics. This suqgests the need for
a nore appropriate intervention program. Robert Chamberlin,
M.D. (1974) a pediatrician who has done extensive research
in behavioral problans of pre-school children, states that
evidence strongly suggests that a traditional psychiatric
nodel treatment is inappropriate for pre-school behavior
disorders. He suggests parental guidance is a more effective approach and denonstrates several educational interventions. Stanley ()jell of Nova University who has done
extensive reasearch into training parents in behavior modification, points out that parental training and education
are irnportant agents in preventive medical anc'l mental health
programs. Parents have the primary influence during the
formative years and they are in the best p:>sition to promote
healthy adjustment of their children. Johnson and Katz (1972)
in their review of studies using parents as change agents for
their children, Emphasize that parents are highly rrotivated
to receive training, inasmuch as they are the ones most directly
affected (or punished) by their children's destructive
activities.
This program
be canprised
and behavior
who wrote an
proposes a parental education program which is to
of lecture. discussion, recarmended books, handouts
managanent training and application. J. Glidewell,
article, "Priori ties for Psychologists in
52
Ccmmmity Mental Health, " considers the prevention of disorders in
childhood to be the highest priority in the community mental health
arena. Parental training and education are imr:ortant agents in
preventive health programs. The American Academy of Child
Psychiatry considers primary prevention of emotional and behavioral
disorders of children to be of significant value. The ~Vhite House
Conference on Children and Youth has continually stressed the role
of prevention in mental health as a priority.
II. Justification
A significant percentage of referrals of pre-school children to
the Departments of Pediatrics, Pediatric Social Services and
Psychiatry revolve around specific parenting concerns. At present,
there does not exist any consistent and unifonn program to meet
these reg_uests. Concerns are treated at randan and/or go
unaddressed. A great number of patients attending the prenatal
educational prcx::rram at Kaiser have requested continuation in
th8ir education in the area of parenting and parent-child
concerns. Within the Deparbnent of Psychiatry 1 many school age
children ~uJ.d have benefited fran earlie..r 1 simpler, preventive
techniques as oprx>sed to the lengthy corrective treatment
process that they na.v must undergo.
III. Goals and Objectives
There are several overall goals. First, the program is to serve
'What the planners consider to be urnnet needs within the medical
canplex. Secondly, is to decrease "inappropriate" referrals to
the Deparbnents of Pediatrics, Pediatric Social Services and
Psychiatry. (A final and rrost important goal is to bring about
preventive health treatment through change in p:1rental knowledge 1
attitude and ultimately behavior in relationship to their
children.)
IV. Target Population
Participants for this program \vill be any parent-to-be and/or
any p~""ent of pre-school age child or children. Open referral
fran the Departments of Pediatrics, Psychiatry, Social Services
and Obstetric-Gynecology as well as those that are self referred.
v.
Program Format
The program is canposed of four sessions, two hours per session,
given one evening per week. It uses a multidisciplinary team
approach in educating parents to the physical, psychological
and social developnent of the pre-schooler.
53
The team consists of the follaving manbers:
Psychiatrist:
A. Rich, M.D.
Pediatrician:
E. Rissman, M.D.
Psychologist:
s. Goldstein, Ph.D.
Pediatric Nurse Practitioner: Bea Floan, R.N.
Psychiatric Social Worker :
Phil Bauman, L. C. S. W.
t-1edical Social 'YJorker:
Judy 111cAdoo, L. C. S . W.
Health Education Coordinator: Mei-Ling Schwcrtz, !v'l. P. H.
VI.
Session I:
Psychological Development and ParentChild Crnmunication
Phil Bauman, L.C.S .vJ.
Clinical Social vJorker
Session II:
Behavior f.'Janagenent Application
Sondra Goldstein, Ph.D.
Clinical Psychologist
Session III & IV:
Physical, Social and Eh:·c _;Lonal Development
and Problem Solving
Panel: l. A. Rich, .M.D., Child Psychiatrist
2. E. Rissman, M.D., Pediatrician
3. Judy McAdoo, L.C.S.W .
.Medical Social vJorker
4. Bea Floan, R.N., Pediatric
Nurse Practitioner
Educational Strategies
The following are a a::mbination of educational methods which will
be used to achieve program goals and objectives.
A.
Cognitive-knowledge comprehension
l.
2.
3.
4.
B.
Affective
1.
2.
C.
Lecture - discussion
Peer group learning
Audiovisual aids
Inquiry learning (p.roblan solving, values clarification)
Inquiry learning
Peer group learning
Behavioral
l.
2.
3.
Inquiry learning
Skilled developnent
Behavior rnanaqanent
PSYCHOu:x;ICAL DEVELOPMENT OF THE CHilD
--------------·--·---·--·----·-·--...- ................,_...............................................
OOAIS
OBJECTIVES
1. Identify the varying
ego states and their
interaction.
To enhance parent •s
skills and attitudes
towards parenting
by increasing their
2. Differentiate and
knowledge in the
develop stage-approarea of
priate behavior of
(a) psychological makethe child and
up of parent
parent.
(b) child's emotional
and social devel3. Ability to identify
opnent
and describe the
(c) parental rules
first three stages
and tasks
of a child's life
and the corresponding parental
tasks.
4. Ability to recognize behavior in
children which
decrease the amount
of parent-child
conflict.
____ _________
..
CONTENT
RESOURCES
1. Berne, Eric: Transac1. Psychological makeup
tional Analysis in
a. Ego as seen in TA
~chotherapy.
Terms P.A.C. and
2. Chamberlin, Robert:
their interactions
Management of Pre(psychological vs.
school Behavior
social)
Problems, Pediatric
b. Typical parental
Clinics o{ North
needs and conflicts
America, Vol. -21, No.
bebv\?en parent1, February, 1974.
child, parentparent.
3. Chamberlin, R.:
Approaches to Child
2. Stages of social, emoReari.11g: Early
tional development and
Recognition and Modicorresponding parental
fication of Vicious
tasks.
Circle
Parent-child.
a. Infant-Trust
Pediatrics, August,
b. Toddler-Autonany
1967.
c. Preschool Iniative (see hand- 4. Friedman, David &
Alma: Parenting: A
out)
Developmental Process,
3. Dysfunctional Patterns
Pediatric Annals, 6:9,
a. Punishing-Resistant
September, 1977.
Cycle
5. White, Burton: The
b. OVerprotective,
First Three Years-of
overpermissive,
Life.
dependent, mani6. Resource Specialist,
pulating vicious
Phil Bauman, L.C.S.W.
cycle.
c. Psychological ramification of these
patterns.
V1
.+::-
BEHAVIORAL 1'1ANAGEMENT
GOALS
OBJECI'IVES
enhance the quality
of parent-child relationship through
better understanding
and application of
appropriate behavioral managerrent
techniques.
1. Parents would be able
To
To encourage behavioral change of the
parent through
intervention.
to recognize behavioral
patterns of child and
apply appropriate
behavioral rnanaganent
techniques.
2. Parents would identify
those behavioral techniques which are effective and those 'Which
were ineffective.
3. Parents would define
and differentiate
different behavioral
te:rms.
4. Parents would identify
the purposes of these
beraviors and apply
appropriate responses.
5. Parents would apply
appropriate behavioral
management techniques
to specific target
behaviors.
CONTENT
1. Desirable and undesir-
able behavioral
pattern of child.
a. Excess vs deficits
b. Age - appropriate
c. Situation appropriate
2. Ineffective techniques
Verbalization by mEmbers of the group of
scme ineffective
behavioral techniques.
3. Be.havioral :Managanent
Terroinology and Application
a. Behavior
b. Behavior observation
c. Reinforcement
d. Neqative reinforcement
e. Punishment
f. Extinction
g. Reinforcement schedules
4. Adlerian Concepts
a. Att.ention getting
b. Power st:rugg le
c. Assumed disability
d. Revenge
RESOURCES
Parents Are Teachers
Becker, Wesley,
Research Press
Living with Children
Gerald Patterson
Copinq With Children's
Misbehavior
Rudolph Druckers, M.D.
Discipline Without Tears
Rudolph Druckers, M.D.
Pearl Cassel
U1
U1
BEHAVIORAL MANAGEr-1ENT (Continued)
"
GOAlS
OBJECTIVES
CONTENT
RESOURCES
5. Specific Techniques
a. Selecting tarqet
behavior
b. Selecting behavior
management techniques
c. Applying techniques
Ul
0"1
GOALS
OBJECI'IVES
""
""""""
"--
""
CONI'ENT
"""""""······--"----------"·------------
RESOt.JOCES
Mahler, }'largaret: On
1. Parents will recog1. Mahler's concept
To enhance and increase
Human Symbiosis arrlthe
the quality of parentnize the social
a. Autonomy - indiviVicissitudes of Indivichild relationship through
developnental produality
duation. International
the understanding of the
cess of the child.
1. stages - autism University Press, 1963.
physical, social and
symbiosis- diffemotional developnental
2. Parents v.-ould be able
erentiation,
Resource Specialist:
process fran infancy to
to differentiate
Anthony Rirh, M.D.
practicing,
behaviors which are
childhood.
reapproachrnent,
Pediatric Nurse Practinormal and the behavcanplex functioner
ior of those that are
Pediatrician
tioning.
disturbed.
3. Parents will recognize when to seek
help.
b. Separation
Holman, Sandra; An Early
Intervention Program for
Developmentally at Risk
2. Types of Play and
Toddlers and Their
Meaning
~~others , Clinical Social
a. autocratic
Work Journal: Vol. 7!
b. transitional object Nl.IDlber 3, ·Fall, 1979.
c. parallel play and
c..hecking back
d. cooperative
c. School pl-nbia
3. Socialization and
Identification
4. Progression and
regression when seen,
lags.
5. Pathology vs. normality.
U1
-J
PHYSICAL DEVEI.OPHENT AND CONCERNS
GOALS
OBJECI'IVES
Tb enhance understanding and appreciation
of the various st.ages
of a child's develop-
CONTENT
C':eneral Approach: Problern Solving
(Analyze problems using the following
outline}
1. Identify the problern - What's going on
you don't like?
ment.
2. Analyze thP. behavior - What does the
behavior do for the rllild?
3. Assess your influence - Is this
behavior scmething you have control
over?
4. Judgment -What should be done arout it?
1. Recognize different signals
for crying and v.rays to resp:md
to them.
C:rying
1. Meaning of newl::x::>rn and infant crying corrrmmication.
2. Check list for when the baby cries.
3. Patterns of crying (time, relationship
to feeding, consistency or duration
of crying, relationship to environment: physical or emotional).
4. Parental feeling arout crying (upset,
exasperation, anger-guilt, fatiguesleepiness) .
5. Examples of problern - situations.
lJl
00
----------·----·--··
COALS
PHYSICAL DEVELOPMENT AND CONCERNS (Continued)
. - ··--·-··--·-- ... ········- ......-. ·---- ···- ·--·-·----·-. ------------------·----·
.....
OBJECTIVES
2. Parents will recognize different
sleeping patterns at different
age level.
3. Parents will develop different
feeding patterns appropriate
for t.heir child.
CO.\JTENT
Sleeping
1.
Range of normal for baby: 8 - 20 hours
per day.
2.
Bedtime routines - consistent patterns
3.
Where to sleep (which roan, whose
bed/crib)
4.
Avoid rituals which infant or child
cannot duplicate on his awn
(rocking to sleep, pacifier or
bottle in bed, nursing until baby
is asleep).
5.
Nightmares (Dr. Rich to elaborate) ,
sleep walking
6.
Problems and approaches of management
(at various ages.
Feeding
1.
Breast or bottle.
2.
Demand or structure feeding schedule.
3.
Holding baby - no propping of bottle.
4.
Spitting up.
5.
V.ben to start solids .
6.
How to give new foods.
7.
Appetite decline at about age 12 nnnths.
lJ1
\.0
PHY_?ICAL DEVEIDP:t-1ENT AND CONCERNS (Continued)
-------
GOAI.S
-- -------------------------------------------------------------------------
OBJECI'IVES
CONTENT
8. Teaching your child not to be a picky
eater (at least as much as we have
control over this).
9. Feeding problEms and concerns.
10. "Clean the plate club".
11. Deserts and snacks.
4. Parents will identify ways to
respond to a child's separation.
Separation
1. Establishing routine early (in play pen,
etc)
--
2. Fear of strangers at 7 - 9 rronths.
3. Baby sitters - develop checklist for
sitters, your address, phone numbers
for plice, fire, rescue - where you
can be reached, other people who can
be called.
4. Neat clean "breaks" when leaving.
5. Pre-school - ideal age (if you have
the option) .
6. Parent's feelings alxmt leaving child
alone or with someone else.
0)
0
PHYSICAL DEVElOPMENT AND CONCERNS (Continued)
------~---~--
-~-----
---·····
OOAIS
OBJECTIVES
·--------------------~0~~-~----------------
5. Parents will identify ways of preventing accidents in the hane.
6. Parents will identify ways of
keeping medicine out or reach.
7. Parents will recognize what to do
in case of an Emergency.
8. Parents will recognize when to
seek medical help.
Safety
----1. Anticipating developmental progress
and possible hazards it can create
(rolling over, crawling) .
2.
Electrical outlets, cords and
applicances.
3.
r,;;edicines.
4.
Cleaning solutions.
5.
Syrup of Pecac - to induce vcrni ting.
6.
Activated charcoal - absorb poisons
in intestine.
7.
Car seat that is appropriate for age
and size.
8.
Pets - age factors.
0'1
I-'
62
BEHAVIOR
~1ANAGEMENT
HANDOUI'
I.
Social Reinforcers
Nod
Smile
Pat on shoulder, head, knee
V'Jink
Signal or gesture to signify approval
Touch cheek
Fulfill requests
Tickle
Give Assistance
Say
yes
good
fine
very good
very fine
excellent
marvelous
at-a-boy
good boy (girl)
right
that's right
correct
wonderful
I like the way you do that
I 'm pleased wi t.'1 (proud of) you
that's good
wow
oh boy
very nice
good work
great going
good for you
that' s the wav
muc::h better
O.k.
you're doing better
that's perfect
that's another one you got right
you're doing very well
look how well he (she) did
watch what he (she) did. IX:> it again
63
II.
Reinforcing Activities
Blow up a balloon; let it go
Jump down from high place into arms of adult
Play with typewriter
Watch train go around track
Run other equipnent, such as string pull toys, light switch
Listen to own voice on tape recorder
Build up, knock down blocks
Push adult around in swivel chair
Pull other person in wagon
Look out windov.r
Play short garre: ticktacktoe, easy puzzles, connect the dots
Blow bubbles: soap, gum
Read one canic book
Write on blackboard: v.mi te or colored chalk
Paint with water on blackboard
Pour water through funnel, from one container to another, and so on
Comb and brush own or adult's hair
I..Dok in mirror
Play instrument: drum, whistle, triangle, piano, and so on
Use playground equipnent: slide, swings, jungle gym, merry-goround, seesaw
Draw and color pictures.
III.
Reinforcement
and Timeout Procedures:
An Illustration
Zeilberger, Sampen and Sloane (1968) reported using a timeout
procedure with a four-and-a-half-year-old nursery school child
by the name of Rorey. Rorey' s objectionable behaviors were
screaming, fighting, disobeying, and bossing in the home
situation. The parents requested assistance fran the school's
behavioral specialist. They were subsequently instructed to
follow, under the specialist's supervision, the following
treatment:
1. Immediately after Rorey acts aggressively or disobediently,
take him to the timeout ('ID) roc:m. (One of the family bedroans
was modified for this use by having toys and other items of
interest to a child removed.)
2. As Rorey is taken to the TO roan for aggressive behavior,
say "you cannot stay here if you fight." As P..orey is taken to
the TO roan for disobedient behavior, say "you cannot stay
here if you do not do what you are told." Make no other
ccmnents.
3. Place Rorey in the TO roan swiftly and without conversation
other than the above. Place him inside and shut and hook the
door.
64
4. Leave Rorey in the TO roan for tv.o minutes. If he tantrums
or cries, time the t.\\0 minutes from the end of the last tantrum
or cry.
5. When the time is up take Rorey out of the TO rcx:rn and back
to his regular activities without further comment on the
episode, i.e. , in a matter-of-fact m:mner.
6. Do not give Rorey explanations of the prog-ram, of wpat you
do, of his behavior, or engage in discussions of these topics
with him. If you desire to do this, have such discussions at
times when the undesired behaviors have not occurred, such as
later in the evening. Keep these brief and at a minimum.
7. Ignore undesirable behavior which does not merit going to
the TO rcx:xn. "Ignore" means you should not ccmnent up:m such
behavior, not attend to it by suddenly lcx:>king around vlhen it
occurs.
8. Ignore aggressive or disobedient behavior which you find
out about in retrospect. If you are present, treat disobedient behavior to other adults the same as disobedient
behavior to you.
9. Reinforce desirable ccx:>perative play frequently (at least
once every five minutes) without interrupting it. Carments
such as "my, you're all having a gcx:rl time" are sufficient,
although direct pra1se which does not interrupt the play is
acceptable.
10.
Always reward Rorey when he obeys.
11. Special treats, such as cold drinks, C<X>kies, or new toys
or activities, should be brought out after perioo.s of desirable
play. It is always tempting to introduce such activities at
times when they will interrupt tmdesirable play, but in the
long run this strengthens the undesired behavior.
12.
Follow the prog-ram 24 hours a day.*
The employment of this timeout procedure, which was a:rnbined
with the use of pranpts (step 2), extinction (steps 7 and 8)
and reinforcement (steps 9, 10, and 11}, decreased Rorey' s
objectionable behaviors.
* Reprinted fran J. Zeilberger, S. E. Sampen, and H. N. Sloane,
Modification of a child's problem behaviors in the home with the
mother as a therapist. Journal of Applied Behavior Analysis,
1968, 1, 49. Copyright 1968 by the Society for the Experimental
Analysis of Behavior, Inc.
65
PARENTING PROGRAM
CONTENT OtiTLD;jE FOR SESSION III AND IV
Go...neral Approach: Problem Solving
(Analyze problems using the follCM.Ting outline)
l.
Identify the problem - What 1 s going on you don 1 t like?
2.
Analyze the behavior - h11at does the behavior do for the child?
3.
.n..ssess your:- influence - Is thj s behavior something you have
control over?
4.
JudgmP.nt - What should be done about it?
Crying
1.
Meaning of newhorn and infant. crying - carm.unicat.i.on.
2.
ChECk list for when the baby cries.
3.
Patterns of crying (time, relationship to feeding, consistency
of duration of crying, relationship to environment: physical
or arotional) .
4.
Parental feeling about crying (upset, exasperation, anger-guilt,
fatigue-sleepiness) .
5.
Examples of problem - situations.
Sleeping
l.
Range of normal for baby:
8 - 20 hours per day.
2.
Bedtime routines - consistent patterns.
3.
Where to sleep (which roc:m, whose bed/crib) .
4.
Avoid rituals which infant or child cannot duplicate on his
own (rocking to sleep, pacifier or bottle in bed, nursing
until baby is asleep) .
5.
Nightmares, (Dr. Rich to elaborate) sleep walking.
6.
Problems and approaches of management (at various ages) .
66
Feeding
1.
Breast or bottle.
2.
Demand or structure feeding schedule.
3.
Holding baby - no propping of bottle.
4.
Spitting up.
5.
\'ilhen to start solids .
6.
How to give new foods.
7.
Appetite decline at about age 12 nonths.
8.
Teaching your child not to be a picky eater (at least as much as
we have control over this) .
9.
Feeding r:>roblans and concerns.
10. "Clean the plate club".
11. Desserts and snacks.
Separation
l.
Establishing routine early (in play pen, etc.)
2.
Fear of strangers at 7 - 9 months.
3.
Baby sitters - develop checklist for sitters, your address, phone
numbers for police, fire, rescue - where you can be reached,
other people who can be called.
4.
Neat clean "breaks" when leaving.
5.
Pre-school - ideal age (if you have the option).
6.
Parent's feelings about leaving child alone or with scrneone else.
Safety
1.
Anticipating developmental progress and possible hazards it can
create (rolling over, crawling) .
2.
Electrical outlets, cords and appliances.
3.
Medicines.
67
Safety (continued)
4.
Cleaning solutions.
5.
Syrup of Ipecac - to induce vari ting.
6.
Activated charcoal - absorb poisons in intestine.
7.
Car seat that is appropriate for age and size.
8.
Pets - age factors.
68
RULES FOR RA.ISTIJG KIDS
The Eight Basic Rules
Rule 1:
There are battles you can win and battles you can't win.
Never fight the battle you can 't win.
Rule 2:
Always follow through and
that you can't keep.
re
consistent; don't make a threat
Rule 3:
Don't get involved with kids ' behavior unless necessary;
revvard good behavior and ignore bad.
RuJ.e 4:
Don't put up roadblocks to kids' feelings, especially anger.
Rule 5:
Don't make kids feel like a failure; condemn the act, not
the kid.
Rule 6:
Set outer limits glvlng kids as much freedom as possjble ~nile
Pncouraging thP.m to take responsibility for their actions.
Rule 7:
T:ry to fiC]1.ITe out what the behavior is doing for tbe kid.
Rule 8:
Teach kids in two ways, by t.elling them and b.f showing than
by exa!l"ple.
Adopted f~an "Rules for Raising Kids" by Robert I. Lesowitz, H.D.,
Springfield, Illinois.
69
PESaJRCES
BABY SI'ITING
Agencies:
~aggie's
990-8622
Better Care
997-1421
Inter-city
995-1303
Child Care Resource Center
989-8297
Church or Synagogue
Referrals from friends
Start a baby sitting coop with friends.
CHIID OOUNSELING
For Kaiser members with psychiatric be1efits, call
Permanente Psychiatric Clinic nearest you:
G~e
Kaiser
884-3724
368-6275
908-2985
Woodland Hills
Granada Hills
Van Nuys
For Kaiser members without psychiatric coverage:
vJest Valley
-
Central Valley
-
East Valley
-
San Fernando Valley Child Guidance Clinic
993-9311
Los Angeles Cmmty Mental Health Clinic
Sylmar - 362-1561
Hope Crnmunity Mental Health Clinic
896-1161
For more infoTIP.ation al:::out other Canmunity Child Clinics or
referrals to private therapists, call Kaiser Medical Social
Service - 908-2977
CHIID DAY CARE REFERRAlS
Child Care Resource Center
Valley Jewish Community Center
989-8297
786-6310
HOI'LINES
Child Abuse Hotline
ZE2-1234
A 24 hour listening and helpline for parents worried
about any child - their awn or a neighbor's - call
should be placed through operator.
VALLEY V.JARMLINE
993-9323 -
A 24 hour listening line for parents
70
INFORr-1A.TION AND REFERRAL
Collects information on any public resources in Los Angeles
County. A Counselor will attenpt to put you in touch with
resources to fit your request.
LIBRARIES
Most public library branches have Story Hour for pre-schQol
and school age children. Free. Check phone book for nearest branch library.
NURSERY SCHOOLS
Child Care Resource Center - 989-8297, maintains a list of
licensed nursery schools by geographic area.
PARENT-cHILD CLASSES
(Mammy & Me) - birth through pre-school
Los Angeles County Schools Adult Education Office - 625-6649
(ask for information al::out "Parent-child Observation Class"
near your hane - lON cost.
YM:A or YM:A - Check phone book for branch nearest your hane.
Church or Synagogue often have "~rnmy & ~1e" programs.
RECREATION - Programs for Pre-schoolers
Los Angeles County Department of Parks and Recreation
(Check phone book for local listing. ) They sr:onsor many
programs in crafts and play for pre-schoolers.
YWCA - Y!'-CA- Check phone book for branch near you.
also sponsor many prograr..s for pre-schoolers.
North Valley Jewish Ccmnunity Center
Hest Valley Jew-ish Ccmnuni ty Center
They
360-2211
346-3003
arHER RESOORCES
For questions or problEms in locating a resource of any kind,
call ~1edical Social Service - 908-2977.
APPENDIX B
71
72
Circle the letter on the answer sheet which best describes your opinion.
There are no right or wrong answers, so answer according to your CMn
opm1on. Sane of the statements may sean alike, but all are necessary
to show slight differences of opinion.
Read each of the statements belov;r and rate than as follows:
SA
strongly
agree
1.
2.
3.
4.
5.
6.
A
U
agree
uncertain
SD
strongly
disagree
D
disagree
The way I feel about children's
emotions and behaviors is as
follov;rs:
Confident
SA
A
u
D
SD
Happy
SA
A
u
D
SD
Detached
SA
A
u
D
SD
Confused
SA
A
u
D
SD
Concerned
SA
A
u
D
SD
Enthusiastic
SA
A
u
D
SD
Active
SA
A
u
D
SD
Interested
SA
A
u
D
SD
Uncanfortable
SA
A
u
D
SD
Nervous
SA
A
u
D
SD
children have emotional and
behavioral difficulties.
SA
A
u
D
SD
Children's ernotions and behaviors
are strongly influenced by their
parents.
SA
A
u
D
SD
s~i~.
~
A
u
D
SD
You can do sanething about your
children's emotions and behaviors.
SA
A
u
D
SD
Eirotional and behavioral difficul ties are powerful problems.
SA
A
u
D
SD
~bst
Errotions and behaviors are strongly
influenced by other factors in
73
7.
Errotional and behavioral difficulties always cause mental
illness.
SA
A
u
D
SD
74
PARENT EDUCATION PRCX;RN1
DEPARI'MENT OF ME£11BER HEALTH EDUCATION
PANORN'TA. CITY
PR<X:RAM EVALUATION QUESTIONNAIRE
CONFIDENI'IAL
In order for this questionnaire to be useful! it is important that you
think through each question, then ansvver as carefully and as honestly
as you can. It is very important that we find out what your attitudes
and behaviors are tc:wards parenting so that we can assess to see if
the program meets your needs. All answers and crnrnents are confidential. It will not be filed in your record or shown to your doctor.
If you wish to sign your name, please do so.
Please circle the appropriate answer.
l. What is your present age:
l.
2.
3.
4.
5.
2.
Your sex.
l.
2.
3.
2.
3.
4.
Single.
Married.
Divorced.
Widowed.
Nl.m"lber of children.
l.
2.
3.
4.
5.
5.
Male.
Female.
Your present marital status.
l.
4.
Under 25 years.
26 - 35 years.
36 - 45 years.
46 - 55 years.
OVer 55 years.
One
'IW:>
Three
Four
Five or rrore.
Is there a step-parent?
l.
2.
Yes.
No.
75
6.
7.
8.
Are there children in the house fran a previous marriage?
1.
Yes
2.
No
Are any of the children adopted?
1.
Yes.
2.
No.
~Vhat
1.
2.
3.
4.
5.
6.
7.
8.
9.
Same grade school.
Completed grade school.
Sorre high school.
Cc:rnpleted high school.
Same college.
Canpleted college.
Some graduate work.
A graduate degree.
Primary caretaker of your child/children.
1.
2.
3.
4.
5.
10.
is the highest level of education you have completed?
~t
1.
2.
3.
4.
5.
Mother.
Father.
Both parents.
Relative.
Other ---------------is your ethnic background?
Black.
Mexican-American
Caucasian
Oriental
Other
11. Family' s approximate income.
1.
2.
3.
4.
0 - $10,000
$11,000 - $15,000
$16,000 - $20,000
OVer $21,000.
12. Person filling out this questionnaire.
1.
2.
3.
M:>ther.
Father.
Other
-----------------
76
13.
14.
Have you attended a parenting program prior to this one?
l.
Yes.
2.
No.
Are you attending this prc:x_:rram
1.
2.
3.
15.
Alone
vJi th your spouse
Other
What are your expectations fran this program? (Please list.)
77
Please circle all that apply.
1.
In the majority of situations, children (ages up to five years)
resp::md best to parents when they
1.
2.
3.
4.
2.
When in oonflict with your child and you beccme angry to the ooint
of rage
1.
2.
3.
4.
3.
Soold him and then spank him more.
Tenporarily isolate him or distract him.
Sha-.1 him your anger by yelling at him.
Tell him what you feel about him.
When a child two years old both clings to and pushes away the
parent and is hard to canfort
1.
2.
3.
4.
6.
To adjust to change
To accept sane loss of control while maintaining limits
Trust
None of the above.
When a child is told to do sanething and her persistently and
angrily resists, you should
1.
2.
3.
4.
5.
You are a poor parent
You have lost oontrol of the situation
Your child is really troubled and you have a right to be
angry
Your child deserves the punishment of your 211ger
The most important task a parent must develop with her infant is
1.
2.
3.
4.
4.
Are allowed to make their awn rational decisions.
When they are clearly told what to do by their parents.
Feel they are ready to do sanething.
De~nding upon the situation, all of the above.
He/she is spoiled.
He/she should be disciplined soundly.
He/she is separating fran the parent and being rrore
independent.
Has serious enotional problens.
When a toddler (age two to four years) has a tantrum, he/she
1.
2.
3.
4.
Should
Should
its
Should
Should
be spanked.
generally be ignored and the tantrum allowed to run
oourse.
be allowed at times to have his/her own way.
be held dawn while the parents reason with him.
78
7.
A two year old child who says "no" to nearly everything
1.
2.
3.
4.
8.
A child who often refuses to go to school and complains of pains
\.vhen doctor finds nothing physically wrong
1.
2.
3.
4.
5.
9.
Is stubborn and should be discouraged fran this as soon as
possible.
Is nonnal.
Is trying to make early attEmpts to be independent fran his
parents.
Needs to be allowed his way.
Is lying.
Fears sanething at school.
Is angry with the parent •vhile he is away, so he fears
separation.
Should see a counselor before anything else is done.
Should be forced to attend school and encouraged to talk
of his feelings.
In order to get your child to eat dinner and not dawle, you should
1.
2.
3.
4.
Bribe with dessert.
Plead.
Use a timer and renove the plate after a reasonable time has
passed.
All of the above.
10. Your five year old child starts acting like a much younger child
shortly after your new baby corres hane fran the hospital. For
example, wants to be dressed in the rrorning. You find this very
annoying. This is an example of
1.
2.
3.
Attention getting.
Power struggle.
Abnonnal behavior.
11. A good way to handle the problen mentioned in #10 is
1.
2.
3.
4.
Give the
Give the
Go ahead
Give the
child a lecture not to feel jealous of the baby.
older child sane more special attention.
and dress the child because you sympathize.
older child an opportunity to interact \'lith the baby.
12. You have noticed that your children often fight when you are on the
phone. This is an example of
1.
2.
3.
4.
Power struggle.
Attention getting.
Revenge.
Bratty behavior.
79
True or false (please circle one) .
13.
A two year old will normally play in dirt and be sanewhat cruel and
selfish.
1.
2.
14.
A young child should never be allowed to say "I hate you, I wish
you were dead!" to a parent.
1.
2.
15.
False.
True.
False.
A five year old with frequent severe tantrums should probably have
psychiatric consultation.
1.
2.
17.
True.
If a child has a bedwetting problen after sane important illness,
but was dry before, t...... is is to be expected.
1.
2.
16.
True.
False.
True.
False.
Children should always be spanked when they misbehave.
1.
2.
True.
False.
80
KAISER PERMANENTE NEDICAL CENTER
DEPARI'MENT OF MEMBER HEALTH EDUCATIOO
PANORAMA CITY
PARENTING PROGRAM QUESTICNNAIRE
Participant
(Optional) - - - - - - - - - - - - - - -
Date:
Please circle all that apply:
1.
The reason ( s) I chose to take part in this program was because:
A.
I was having a problem(s) that I believed would be helped by
this program.
B.
I was not having any particular problEm but felt I would like
to leaiTl :rrore about the subject.
C.
My doctor suggested that I take part in the program.
D.
A Nurse Practitioner or Social Worker suggested that I take
part in the program.
E.
2.
3.
Other:
OVerall, I found the program to be:
A.
Infonnative and helpful to rre in dealing with the problan(s).
B.
Infonnative but not necessarily helpful as a problem solving
resource.
C.
Not especially infonnative or worthwhile but not a total waste
of tirre.
D.
Not worthwhile at all.
E.
other:
In response to your answer to question #2 above, please indicate
the factor(s) you feel were responsible for your evaluation of
the program:
A.
The level of expertise of the instructors.
B.
The type of information provided.
C.
The length of the program.
D.
The location of the program.
E.
The size of the class.
F.
other:
81
4.
5.
you feel that your participating in the program has:
(answer all that apply)
Do
A.
Increased your knowledge and skills tcMards parenting.
B.
Reassured you in your present skills towards parenting.
C.
Makes you feel :rrore comfortable in your parental role.
D.
No effect on you to-wards parenting.
E.
Other:
What other areas would you have liked to see presented in the
prog-ram?
Please list:
6.
Overall, hON would you rate:
A.
B.
c.
7.
The program
1.
Excellent
2.
Very good
3.
Good
4.
Satisfactory
5.
Unsatisfactory
The instructors delivering the prog-ram
1.
Excellent
2.
Very good
3.
Good
4.
Satisfactory
5.
Unsatisfactory
The fonnat of the program
1.
Excellent
2.
Very good
3.
Good
4.
Satisfactory
5.
Unsatisfactory
Canments:
(Please feel free to express any feeling you have
towards the program. )
82
SOUlliERN CALIFORNIA P:E:ffi1ANENTE MEDICAL GROUP
DEPA.RI'MEliT' OF' !-.fl'lBER HEALTH EDUCATION
PANORAMA CITY, CALIFORNIA
CONSENT TO ACT AS RESEARCH SUBJECI'
You are invited to participate as a research subject in the
evaluation of this parent education program. Yt\Te hope to learn if this
program is effective in helping you to increase your knowledge and
skill in your role as a parent.
If you choose to participate, the procedure is as follows.
You will be asked to complete a multiple choice questionnaire before
the program begins today. You will be asked to canplete the same
q.Jestionnaire at the conclusion of the lecture series four weeks fran
now.
Information that is gathered fran this study will ranain
confiden-tial as does all your medical infonnation here at KaiserPerrnanente. Your consent to participate in this study will enable
Jl-1e:nber Health Education to evaluate the value of continuing this
kind of program. The actual evaluation is being conducted by a
graduate student at California State University, Northridge.
I understand that if I wish to voice a complaint or concern
about the research, I may direct my canplaint or concern in writing
to Mr. Nonnan Goldman, Nedical Clinic Director, Kaiser-Pennanente,
Panorama City, and/or to the Research Coordinator, AD!'~ 306,
18111 Nordhoff Street, california State University, Northridge,
California, 91330.
I understand that my participation in tl1is study is
voluntary, that I may decline to P.nter this study or may withdraw
fran it at any time without jeopardy, and that my decision whether or
not to participate will not prejudice my future relations with
Kaiser-Perrnanente. I understand that I am not receiving any
oompensation for my participation in this study. I understand that
the investigator(s) may terminate my participation in the study at any
time.
Please feel free to ask any additional questions.
YOUR SIGNATURE INDICATES THAT YOU HAVE DECIDED TO PARI'ICIPATE
HAVING READ THE PRECEEDllJG INFORiv'IATIC!\1.
Date
Signature
Signature of Investigator