Application of a relational frame theory account of psychological flexibility in young children

Full reference: Ruiz, F.J., & Perete, L. (2015). Application of a relational frame theory account of psychological flexibility in young children. Psicothema, 27(2), 114-119. https://doi.org/10.7334/psicothema2014.195

Study type: Single-case experimental design (A-B design) with one-year follow-up

Background and objectives

Acceptance and Commitment Therapy (ACT) is a contextual behavior therapy grounded in Relational Frame Theory (RFT), a functional-contextual approach to human language and cognition. ACT is built on the principle that psychological well-being improves when psychological flexibility (PF) increases—that is, the capacity to remain in contact with present private experiences without needing to avoid or escape from them, and to adjust behavior according to what the situation requires in order to pursue valued goals. Although ACT has been successfully applied with adults and is beginning to be applied with adolescents, at the time of this study there were no published studies on its application with young children.

The authors propose that an RFT-based approach to PF can facilitate the adaptation of ACT to work with young children. According to this approach, PF consists of a generalized repertoire of framing one's own ongoing behavior, including thoughts and feelings, through deictic relations (I-HERE, BEHAVIOR-THERE) and hierarchical relations (I contain BEHAVIOR). This relational framing reduces the discriminative functions of the behavior and allows the derivation of augmental rules that specify abstract, delayed, probabilistic, and positively reinforcing consequences, as well as behaviors consistent with them.

The primary objective of the study was to illustrate how ACT can be adapted to work with young children in accordance with the RFT-based approach to PF, using a clinical case of a 5-year-old boy with problematic anger episodes.

Method

Participants

The participant was Samuel, a five-year-and-one-month-old boy who lived with his parents and his two-year-old brother. Samuel was at the appropriate stage of social development and grade level for his age, being enrolled in Preschool during the study period.

Samuel's parents reported that he presented excessive anger at home, which was problematic because they feared provoking his disproportionate reactions. They reported that most of his anger episodes appeared when things were not done the way he wanted. They had attempted to avoid these episodes by not bothering Samuel (e.g., doing things the way Samuel liked before he could get angry, not scolding him when he misbehaved), but this strategy was not fully successful. Samuel also made annoying comments when he felt jealous. Samuel complained that he got angry too frequently and that he was unable to stop doing so. After every episode, he used to promise not to do it again because "it is better to be happy than to be angry."

The second author is Samuel's mother, who was a last-year teaching student in an online university program in which the first author was a professor. Because both authors lived in different and distant cities, all assessment and intervention procedures were implemented by the second author at home under online supervision of the first author.

Design

A single-case experimental design (A-B) was used with a one-year follow-up. The baseline extended for two weeks before the intervention began. Baseline trend analysis was conducted to identify whether significant changes occurred during this phase. The intervention was implemented during the three-week period following the baseline.

Intervention / Conditions

The intervention comprised two components implemented within three weeks:

1. ACT Protocol Based on RFT: Consisted of four 20-minute sessions that commenced on the first day of the intervention and were conducted approximately every three days so that training was implemented within the initial ten days. Sessions were videotaped and supervised by the first author to ensure correct implementation. The protocol included multiple-exemplar training in which Samuel was asked to: (a) relationally frame his ongoing experience through deictic relations (I-HERE, EXPERIENCE-THERE) by describing its form, painting it on paper, and noticing that the experience was THERE on the paper while he was HERE; (b) relationally frame the experience through hierarchical relations (I contain EXPERIENCE) by responding to several questions (e.g., Who is having that thought/sensation? Who is bigger: Samuel or the thought/sensation?); and (c) transform the discriminative functions of ongoing experiences by relating them to rules that progressively specified positive, symbolic, and longer-term consequences (augmentals). Training commenced with neutral and slightly aversive private experiences to promote errorless discrimination, then proceeded with more aversive events and finished with trials in which rage reactions were elicited.

   • Session 1: Discrimination of sensations (Trials 1-5) and thoughts (Trials 6-9), including difficult postures, cold water bottle, sensation of eating candy, tickling on shoulder, sensation of drinking a beverage, and memories of positive activities with father and mother.

   • Session 2: Similar to Session 1 but involving new exemplars including sensations of jumping, playing hide-and-seek, having dinner at a burger bar, cooking with Dad, eating chocolate, remembering the three king's parade, thinking about sleeping at Uncle David's home, thinking about spending the weekend at a farmhouse, thinking about going to the beach on holidays, and thinking about catching spiders with Mom.

   • Session 3: Elements that usually provoked anger episodes were introduced. The mother explained to Samuel: "I propose something for you: we are going to play some games and sometimes, I will bother you in some way so you will feel rage. You have two options then: you can choose to get angry at me or you can paint the rage in your mind and not get angry. If you don't get angry, you will show the anger that you are the boss and that you are in charge of it." Trials included: beginning to play videogames and then being interrupted, making a construction with toy blocks and being interrupted near completion, eating a chocolate bread roll, and writing words in a notebook that the mother erased.

   • Session 4: Similar to the previous session but included more aversive elements than on previous occasions. Trials included: playing a racing car videogame where the mother covered the screen with her hands, feeling like eating a chocolate bar, and writing his name and date where the mother corrected some letters and finally tore the page out and tore it up.

2. Token Economy: A token economy was implemented to establish a motivational context to help Samuel derive rules specifying consequences for not behaving fused with rage after framing his experience through deictic and hierarchical relations. Parents were instructed to avoid paying attention to Samuel's anger episodes and to wait until he calmed down to provide social reinforcement. During the first week, a token was given to Samuel if he did not get angry in specific situations: (a) when awakening, (b) dressing, having breakfast and going to school, (c) having lunch, (d) tidying his bedroom, and (e) having a shower and putting on pajamas. Each token could be exchanged for reinforcers such as his mother reading him two stories instead of one, choosing his dinner and dessert, and watching a chapter of a TV show he liked. The token economy was faded during the following two weeks, progressing from multiple daily tokens to a single daily token by the end of the third week.

Outcome measures

Assessment of anger episodes: The second author was instructed to register all of Samuel's anger episodes when he was with his parents throughout the study and to videotape some anger episodes that occurred during baseline (e.g., at home, the mall, etc.). The register included: hour, antecedent stimuli, anger intensity, Samuel's actions during the episode, other peoples' actions, and episode duration (in minutes). Anger episodes were defined as persisting complaints, crying, and tantrums (e.g., yelling, throwing things, etc.). Anger intensity was assessed by the mother on a 1-10 scale, where 1 and 10 reflected, respectively, the smallest and biggest anger episode she had ever seen in Samuel.

Assessment of the derived relational responding repertoire: During the two weeks of baseline, Samuel's mother was instructed to implement several exercises to evaluate his relational repertoire. Abilities in relational framing through coordination, opposition, distinction, comparison, and deictic relational cues were assessed. Abilities in relational framing through hierarchical relations were evaluated with exercises like the following: Samuel's mother put eight animal toys on the floor, among them six horses, and asked: "Are there more horses or toys?". Initially, Samuel responded incorrectly, but after providing explanations of the correct responses, Samuel began to answer correctly. His new abilities in hierarchical relational framing were considered sufficient to implement the intervention.

Data analysis

The nonparametric Tau-U statistic (Parker, Vannest, & Davis, 2011) was used to explore the presence of significant undesirable trends in the baseline phase and to quantify the effect of the intervention. Tau-U is a non-overlap effect size that does not require meeting the assumptions of parametric methods (e.g., normality, constant variance, etc.). It was derived from Kendall's rank correlation and the Mann-Whitney U between-groups test. Tau-U scores range from -1 to 1 and can be interpreted as the percentage of data that improved between two phases of a study. Tau-U values were calculated using the online calculator provided by Vannest, Parker, and Gonen (2011).

Results

Figure 1 shows that during the baseline, Samuel's anger episodes were relatively frequent (median = 1 per day, range 0-2), long (median = 10 minutes per day, range 0-30), and intense (median = 6.5, range 0-10). According to Tau-U, no statistically significant trends during baseline were identified (duration: Tau-U = .209, p = .226; number: Tau-U = .229, p = .185; intensity: Tau-U = -.058, p = .753).

However, all Tau-U values for the intervention effect were statistically significant. For episode duration: median = 0, range 0-1, Tau-U = .574, p = .002. For number of episodes: median = 0, range 0-8, Tau-U = .542, p = .004. For intensity: median = 0, range 0-7, Tau-U = .476, p = .014. These results indicate substantial and statistically significant improvements across all three dimensions of anger behavior measured.

During the one-year follow-up, Samuel only had one anger episode per month, on average, and these were considerably less intense than before. Samuel also stopped making annoying comments when he felt envious and angry.

Discussion and conclusions

This article presented a case study with a 5-year-old boy who showed problematic anger episodes, according to his parents. The intervention consisted of two components. The first component was a brief ACT protocol based on the previous RFT account of psychological flexibility and was applied in four 20-minute sessions. The protocol aimed at shaping psychological flexibility by providing multiple-exemplar training in which the child was asked to relationally frame his ongoing experiences through deictic and hierarchical relations and to transform their discriminative functions by means of relating them to rules that progressively specified longer term and symbolic, positive consequences for not acting fused with the private experiences. The protocol proceeded from practicing with private neutral experiences to more aversive ones in order to promote errorless discrimination. The second component of the intervention was a token economy that was introduced to establish a motivational context that would help Samuel derive rules specifying the consequences for not behaving fused with rage after he had framed his ongoing experience through deictic and hierarchical relations. The consequences for not acting fused with rage were subsequently of longer term and more symbolic (e.g., telling his grandmother that he was in charge of the rage, behaving like a big boy, etc.).

To the best of the authors' knowledge, this is the first published application of ACT with a young child. This paucity of ACT studies could be due to the difficulty of adapting ACT as described in middle-level terms to clients of this age. In this sense, the RFT definition of psychological flexibility seems to facilitate the adaptation of ACT in young children because it specifies the relational repertoires necessary to shape psychological flexibility (e.g., deictic and hierarchical relational framing and rule-following in accordance, at least, with comparative, deictic, and causality relations) and it provides guidelines about how defusion and values exercises can be implemented.

Some limitations of this study are worth mentioning. First, due to the design of the study, it was not possible to isolate the effect of the ACT protocol from that of the token economy. Further research might analyze the differential effect of incorporating the brief ACT protocol to the sole implementation of a token economy or exploring the efficacy of the ACT protocol alone. Second, the assessment and training of the relational repertoire was not conducted systematically. Further research might design and validate measures of young children's relational abilities in order to better specify whether they have the prerequisite repertoires to receive the ACT intervention. Third, the intervention was implemented and evaluated by Samuel's mother, so experimenter bias is a threat to this study. However, this also shows that the ACT protocol can be implemented with minimal training by parents and teachers in a natural context for children, which is especially important because behavioral interventions with young children are often applied by the parents.

In conclusion, this study provides a preliminary demonstration of the feasibility of ACT protocols based on an RFT account of psychological flexibility in young children. Further research should analyze the potential of this approach to design ACT interventions specifically tailored to children's problems such as anxiety, behavioral disorders, and attention and hyperactivity deficit disorder.

Significance and contribution

This study contributes significantly to the field of child therapy and contextual behavioral science by demonstrating how Relational Frame Theory can operationalize psychological flexibility in a manner that permits its practical application with young children. While ACT has been successfully developed with adults and is beginning to extend to adolescents, this work provides the first specific guidelines on how to adapt behavioral-contextual procedures (such as cognitive defusion and values clarification) through multiple-exemplar training that leverages preschool learning capacities. The effectiveness of such a brief intervention suggests potential for improving accessibility of acceptance and flexibility-based procedures for pediatric populations.