The effectiveness of the BOAM-therapy on psychosocial developmental issues in children

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F

ACULTEIT DER

M

AATSCHAPPIJ- EN

G

EDRAGSWETENSCHAPPEN Graduate School of Childhood Development and Education

MASTER

ORTHOPEDAGOGIEK

2015-2016

The effectiveness of the BOAM-therapy on psychosocial developmental issues in children

Masterscriptie Orthopedagogiek, Pedagogische en Onderwijskundige Wetenschappen, Universiteit van Amsterdam

Naam: L. M. L. Oterdoom

Begeleiding: Dr. F. J. A. van Steensel, begeleider Dr. E. Potharst, tweede beoordelaar Amsterdam, september 2016.

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The effectiveness of the BOAM therapy on psychosocial developmental issues in children

The effectiveness of the BOAM therapy on a broad range of psychosocial developmental issues and problem behavior in children (N = 9; 77.8 % boys, M age = 9.0, range = 4-19) was examined. The Child Behavior Checklist (CBCL; problem behavior), the Dutch version of the Behavior Rating Inventory Executive Function (BRIEF; executive functioning), the

Vragenlijst Sociale Vaardigheden van Jongeren (VSVJ; social competence) and personalized daily measurements were used to assess changes in problem behavior during the BOAM therapy. On the individual level, daily measurements were analyzed using Mixed Models analysis and the Reliable Change Index was calculated for the questionnaires. Mixed results were found. For some children the BOAM-therapy seemed effective for various problem areas, however, for other children no significant results were found. On the group level, (1) significant improvements were found for the daily measurements and metacognition, (2) a trend significant result was found for improved general executive functioning, and (3) for the majority of the questionnaires, medium to large effect sizes were found. The BOAM-therapy is a promising therapy irrespective of specific disorders, DSM classifications or comorbidity, which could be a new approach on child problem behavior in mental health care. However, more research on BOAM effectiveness is needed and should include long term follow-ups and a larger sample sizes.

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De effectiviteit van de BOAM-therapie voor psychosociale ontwikkelingsproblemen van kinderen

De effectiviteit van de BOAM therapie voor een breed spectrum van psychosociale

ontwikkelingsproblemen van kinderen (n = 9, 77.8 % jongens, M leeftijd = 9.0, range 4-19) werd onderzocht. De Child Behavior Checklist (CBCL; probleemgedrag), de Behavior Raing Inventory Executive Function (BRIEF; executief functioneren), de Vragenlijst Sociale Vaardigheden van Jongeren (sociale competenties) en gepersonaliseerde dagelijkse metingen werden gebruikt om veranderingen in gedrag door de BOAM-therapie vast te stellen. Op individueel niveau zijn de dagelijkse metingen geanalyseerd met Mixed Models analyses en de Reliable Change Index werd berekend voor de vragenlijsten. Gemengde resultaten werden gevonden. Voor een aantal kinderen leek de BOAM-therapie effectief voor verschillende probleemgebieden, voor andere kinderen werden geen significante resultaten gevonden. Op groepsniveau (1) werden significante verbeteringen gevonden voor de dagelijkse metingen en metacognitie, (2) werd er een trendmatige significantie gevonden voor het executief

functioneren en (3) voor een meerderheid van de (sub)schalen van de vragenlijsten werd een gemiddelde tot grote effect size gevonden. De BOAM-therapie is een veelbelovende therapie die ongeacht stoornissen, DSM-classificatie of comorbiditeit gegeven kan worden en kan daarmee een nieuwe aanpak zijn voor probleemgedrag van kinderen in de geestelijke gezondheidszorg. Meer onderzoek is echter nodig naar de effectiviteit van BOAM, waarbij een langere follow-up en een grotere steekproef nodig zijn.

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The effectiveness of the BOAM-therapy on psychosocial developmental issues in children

The acronym BOAM stands for Basic needs, Order, Autonomy and Meaning. The BOAM theory is a new systemic theory to approach the psychosocial development of children developed by Damiët Truijens. It also provides an explanation of disturbed development. The BOAM theory is developed to help children and families understand the child’s problem and how they can deal with it. It is therefore also an intervention that can be used to treat a variety of problems. The current study will evaluate the first effectiveness of BOAM.

The BOAM theory assumes that development, behavior and its interaction takes place in four dimensions (Truijens, 2015). The first dimension is the development of the Gestalt within the child, which is achieved by ordering and it forms a regulating reference frame. The second dimension is behavior, resulting from the Gestalt development. The third dimension covers the parent-child relationship and the fourth dimension is the system. In each

dimension, problems can occur. This thesis focuses on the first and second dimension, of which the first dimension – and how it is related to other existing theories - is explained in more detail below.

The first dimension of BOAM can be sketched as a tree that represents the developing psychosocial mind, which provides meaning to the world – the functioning psyche (Figure 1). Psychosocial development starts at the roots of the tree, the basic needs. The BOAM theory assumes that five essential basic needs need to be fulfilled in order to start the psychosocial development. The five basic needs are a system (a group to belong to, e.g. the family),

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nurture, structure/predictability, attention and protection. If the five basic needs are

(continuously) fulfilled, a person can climb up to the tribe of the tree: order. A person will try to order the surrounding physical world and to process sensory input. The ordering of the physical world means a child knows where it stands: what, when, where, with whom and how things are done (Truijens, 2015; based on the book of Collette de Bruijn, 2014). After

someone (continuously) succeeds in ordering the physical world and sensory input, one will climb up to the branches of the tree – the crest: one reaches the level of autonomy. At this level a person can start psychosocial planning/ordering. This includes for example

understanding of the own psyche, someone else’s psyche and empathy. When a person manages to understand and succeeds in the psychosocial ordering, the next level of autonomy comes in play, the leaves. Autonomy includes increasing independence, the executive

functions (stemming from the physical order) and increasing social skills (stemming from psychosocial order), as well as the ability to ask for help if needed. Next, the final level of development of the psyche can be reached: meaning. At this level the basic needs are met and the sensory input, the physical world and the psychosocial aspects of life are successfully ordered. The psyche is ready for self-actualization (flowers of the tree) and a person can become servient (the fruits from the tree). The BOAM theory can be used to describe normal psychosocial development, but it also provides an explanation for a disturbed psychosocial development. That is, The BOAM method theorizes that a child builds a Gestalt of the world through this ordering process combined with the influence of nature and nurture. However, disruptions in the ordering process can result in a weak or even dysfunctional Gestalt. A ‘healthy Gestalt’ forms a reference frame of life through which the world is experienced by the child, however, a ‘weak or dysfunctional Gestalt’ becomes an unsuitable reference frame to understand the world and may result in problem behaviors.

The BOAM theory points out different causes for problems with the psychosocial development in the first dimension. One of these causes is being labeled as ‘ordering problems’, which are caused by three related underlying key issues: (1) sensory

overstimulation, (2) the complexity of the physical world and psychosocial demands and lastly (3) an overcharge relative to the developmental level of a person’s capacities and the psyche (Truijens, 2015). According to Truijens (2015) these causes are more prominent these days as Western societies have developed rapidly into more complex forms with an excess of sensory stimulation. This, combined with information processing problems, can easily lead to children failing in the ordering process which can result in psychosocial problems. Traumatic

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Figure 2. The hierarchical order of needs forming Maslow’s pyramid.

events during the lifetime of a child are the second cause of an impaired psycho-social development.

BOAM and its relation to other existing theories

The BOAM theory is based on both Maslow’s pyramid (Maslow, 1943) and the Gestalt psychology (Koffka, 1935; Lewin, 1939). Maslow’s theory stems from the 1940’s and is still used in motivational psychology. Maslow (1943) described several basic propositions and formulated a theory of human motivation based on clinical observations, experiments and these propositions. BOAM can be linked to Maslow’s theory in several ways. First, the new BOAM theory is based on the same principle of basic needs and a prepotent hierarchical order of needs, which is translated to different stages of psychosocial ordering in the BOAM theory. Maslow (1943) argued that there are five related and hierarchical sets of goals – the needs (Figure 2). The hierarchy is based on prepotency. Sufficient and chronical fulfillment of the most important need clears the way for fulfilling the overlying need. The needs are best represented by a pyramid. On the broad bottom of the pyramid the most important needs are displayed: the physiological and safety needs. As one climbs up the pyramid fulfilling needs, the needs become narrower in the pyramid. This represents the decreasing number of people reaching the needs higher up the pyramid (Maslow, 1943). A difference in Maslow’s theory and BOAM in this manner is that the BOAM theory assumes the bottom three steps of Maslow’s pyramid to be all basic needs and crucial for potential development. The second link is both BOAM and Maslow regard self-actualization as the ultimate goal in

developmental needs. Third, the BOAM theory also endorses Maslow’s view on threats towards the fulfillment of needs. Maslow’s

pyramid of the hierarchical order of needs can be applied on developmental impairment and psychopathology. According to Maslow (1943) thwarting of fulfilling the needs poses a psychological threat and this threat can lead to psychopathology and explains resulting problem behavior. The different ordering stages and basic needs in the BOAM theory can also be exposed to threats which can

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and can explain psychopathology.

Maslow’s theory was partially inspired by the Gestalt psychology (Maslow, 1943), as is the BOAM theory. Important convictions regarding social and developmental psychology and psychopathology originated from the Gestalt movement, which have gone largely unnoticed in the evolution of psychology (Silverstein & Uhlhaas, 2004; Wagemans et al., 2012). For a full summary of the concepts and methods of the Gestalt movement see King, Woody and Viney (2016). The Gestalt psychology is a theoretical movement which originates from the 1920s and tries to understand and explain the fundament of the human ability to obtain and maintain meaningful perceptions in a seemingly chaotic world

(Wagemans et al., 2012). Awareness is organized in structures with a characteristic coherence and an inner center. These structures were called ‘Gestalten’. Key to these Gestalten is that they are different (note: not greater) from the sum of the parts and they result from ongoing global processes in the brain (Wagemans et al., 2012). Here, a first link between BOAM and Gestalt psychology can be drawn: BOAM also holds the Gestalt, which consists of global processes in the brain, responsible for ordering the surrounding physical and social world in order to create a meaningful ordering in a chaotic world.

One of the founding fathers of the Gestalt psychology and renowned professor in child psychology in his time, was Kurt Lewin (King et al., 2016). An important concept in Lewin’s (1939) work is the situation of the adolescent he described, which can be broadened to the situation of a developing child. This situation can be represented as the position of a person during movement from one region to another (e.g., home, school, the neighborhood, sport clubs). This movement includes the widening of the life-space (geographically, socially and in time perspective) and the cognitive unstructured character of new situations. Emotional tension and therefrom arising behavior, can be explained due to unclearness and instability in the life-space (Lewin, 1939). The widening life-space demands increasingly higher levels of cognitive structuring of the individual, e.g. planning, (Lewin, 1939) and thus a further

developed Gestalt. BOAM believes that unclearness and instability are unfulfilled basic needs that need to be met for a child to be able to develop. When this condition is not met,

emotional tension will rise and therefrom problem behavior will occur. Lewin (1939) argues that the free movement of a child is limited due to serval causes, one of which is regions being beyond the social or intellectual capacity of a person. This is where Truijens (2015) believes it can go wrong with the Gestalt development in children: the overcharging of children and (too) complex physical and social environments. Children are expected to function well in regions

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which are actually not accessible in terms of their Gestalt development, resulting in ordering problems and problems in the first two dimensions of the BOAM theory.

The second important concept in Lewin’s work is environment and interaction. Here the systemic view of BOAM on problems and the third dimension of the BOAM theory are linked. According to Lewin (1939), the environment – or fields – is of significant importance to understand behavior. For example: instability of the psychological environment leads to greater instability of the person. Lewin (1939) states that the occurrence of a certain type of behavior as well as the meaning of this specific behavior depends on the environment, because all the different parts of the field are mutually interdependent. Furthermore, Lewin (1939) argues that to understand the character and behavior of an individual, observations of the group (e.g., a family) are of greater significant importance than observations of the individual. He ends this argumentation saying “it would not be surprising to me if such a sociological procedure would become a key technique even for problems of individual psychopathology” (Lewin, 1939, p. 849). Thus, according to Gestalt psychology, to

understand the individual character, behavior and psychopathology, one must primarily look at the environment, systems surrounding the individual. BOAM also embraces Lewin’s view on the environment and surrounding systems of a child. The BOAM theory sees behavior occurring as an answer to prior behavior, reactions and interactions between group members and also influencing the interaction between the family members. In order to resolve

developmental problems and problem behavior, the whole system needs to be reflective on the behavior in the system.

Additionally, Lewin’s co-founding father of the Gestalt psychology, Koffka, has focused in much of his work on Gestalt psychology combined with developmental

psychology, especially on perception, learning and memory (King et al., 2016). Koffka (1935) claimed that every Gestalt has order and meaning, and the quality of the gestalt cannot be expressed in terms of quantity, but in terms of meaning. Koffka attributed this characteristic specifically to the human mind. The BOAM theory can also be linked to Koffka’s work. First of all, Koffka referred to the human gestalt as having order and meaning, which corresponds with the role of the gestalt in the BOAM theory. Second, the role of the sensory input on learning and development is emphasized in Koffka’s work. Koffka believed early learning is established through ‘sensorimotor’ learning, meaning a child learns by means of sensory sensations and sensory input (King et al., 2016). In the BOAM theory processing sensory input is a key part of becoming able to order the world to become meaningful, and also one of the parts where development can go wrong. The BOAM theory assumes overstimulation of

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the senses can thwart the ordering process. Third, Koffka's (1935) ideas about conscious experiences can be linked to BOAM, especially how BOAM tries to solve (developmental) problems. Koffka believed specific environmental experience and events initiate activity in the brain, which he called a memory process. When this memory process is ended, Koffka argues a memory trace remains present in the brain and the brain will influence all

comparable situations to occur in the future. The conscious experience from humans will be more in accordance with the trace itself than with the process (Hergenhahn & Henly, 2014). Because of the memory traces, it is difficult to act differently in familiar situations. BOAM also theorizes much of the behavior takes place unconsciously. By creating awareness of behavior and interaction processes, a person will become able to change the process rather than reacting through the memory traces. In the BOAM treatment self-reflection and awareness are therefore a central solution to resolve problems.

Current study: problem definition, research question and hypotheses

To summarize the above, BOAM is a new theory that shares several characteristics with both Maslow’s theory and the Gestalt movement. It tries to explain psychopathology and child problems from the fulfillment of prepotent needs, the ordering or making sense of the world through the Gestalt, the environment and reciprocal processes in behavior and

communication with others. This new approach to psychopathology and child problems may lead to a new, innovative treatment from which children and parents may benefit and who may not have benefitted from established treatments. That is, existing treatments often focus on individual DSM diagnoses (Van Heycop ten Ham, de Vos, & Hulsbergen, 2014), which can be time and cost ineffective, because of visiting multiple therapists and receiving serval therapies. In addition, a large Comorbidity Survey in the USA revealed that almost 52% of adolescents being diagnosed with mental disorders, were having multiple diagnoses (Costello, He, Sampson, Kessler, & Merikangas, 2014) and as disorders or symptoms of different

disorders can persevere each other (Hagen, 2014), the treatment of one disorder may be less effective when there is a non-treated comorbid disorder. The BOAM method is searching for a common underlying cause of the symptoms of a variety of different disorders. This means that children with a variety of psychosocial problems and children with an impaired

development, regardless of meeting DSM disorders, can be treated. These children and their parents will likely benefit from the holistic view of BOAM, because symptoms,

developmental issues and the functioning of the family system are all addressed in one treatment. This is specifically relevant because an effective treatment with a matching theory

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for a wide range of psychosocial problem behavior in children would be a big step in helping children and their parents with an impaired development.

Although the BOAM treatment can be given irrespective of diagnosis or type of behavioral problems, one problem area in specific (problems with executive functioning) is a likely candidate to benefit from the BOAM treatment. That is, the information processing problems resulting from ordering problems can cause weak ‘executive functions’ (EF). EF are psychological processes that play an important role in regulating and coordinating

behavior, to plan and to control behavior and attention (Thorell, Lindqvist, Nutley, Bohlin, & Klingberg, 2009). In childhood and adolescence EF are gradually developing (Thorell et al., 2009) and appealing too early to the executive functions has a negative effect on the

development of EF (Diamond, 2013). Weak EF are regarded as a contributing factor to the problems in several disorders, such as Attention Deficit and Hyperactivity Disorder (ADHD; Berkeley, 1997; Dovis, Van der Oord, Wiers, & Prins, 2016), Autism Spectrum Disorder (ASD; Happé, Booth, Charlton, & Hughes, 2006) and anxiety disorders (Eynsenk, 2014). Even Major Depressive Disorder (MDD) has been linked with neuropsychological EF impairments (Snyder, 2013). Several therapies have been developed, focusing on the symptoms of these disorders but often do not treat an impaired executive functioning. In addition, methods for training executive functioning are scarce and those that are being investigated (e.g., Cogmed, Brain Game Brian) show minimal effectiveness for the daily functioning (Thorell et al., 2009). It is theorized that the EF will improve and develop through the BOAM method as this method will create a more psychological and understanding

perspective for all family members (Truijens, 2015). That is, it uses techniques to strengthen the self-reflective abilities and awareness about behavior, interactions and the EF needed to be able to order, on a meta-cognitive level instead of training the EF, behavior or interactions without providing insight in these processes.

The objective of this study is to examine the efficacy of the new BOAM method for a diverse range of psychosocial internalizing and externalizing problems in 4-18 year old children and their parents. This is a pilot study which aims to explore the first signs of

effectiveness. The study describes the results of the first nine treatments carried out according to the BOAM method. BOAM is expected to be effective because BOAM engages the

essence of being and enables children to further develop their Gestalt and it provides insight in behavior in relation to the environment of the child. The current study will focus on the two first dimensions of the BOAM method: the Gestalt development/ordering issues and child behavior.

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Method Participants

The participants of this study were 9 children (N = 9) and their parent(s). Demographic characteristics of the participants are displayed in Table 1. Patients from an academic

treatment center for parent and child in Amsterdam who had subscribed for therapy based on the BOAM-method, were asked to participate in this study. Inclusion criteria were

participation in parent-child treatment based on the BOAM-method with children’s ages between 4-19 years. Exclusion criteria were insufficient proficiency of the Dutch language and addiction or abuse within the family. In return for participating in the study, the families received a feedback report with their scores on the questionnaires after the third measurement. The sample consisted of seven boys (77.8 %) and two girls, with a mean age of 9.0 years (range = 4-19 years; SD = 4.46). Three participants (33.3 %) had a (ASD) diagnosis prior to the start of the BOAM therapy. One child had the comorbid diagnosis of dysthymia. In seven of the nine cases (77.8 %) both parents participated in (a part of) the study. In the remaining two cases only the mothers participated. All participating parents had a Caucasian

background. The mean age of the mothers was 44.9 years (range = 42-50, SD = 3.26), Table 1.

Demographic Characteristics of the BOAM Participants

*Non-biological lesbian mother of twin boys, regarded in this table as father

A

MBO, HAVO/VWO: Dutch educational levels, corresponding with a middle educational level

B

HBO, WO: Dutch educational levels, corresponding with a high educational level

Case Gender Age School Diagnosis Mother Age

Education Father Age

Education

101 M 19 MBOA - 50 HBOB 48 HBO

102 F 7 Primary school - 42 HBO 45 WOB 103 M 7 Primary school - 43 WO 45 WO 104 M 4 Primary school - 42 HBO 39* HBO 105 M 4 Primary school - 42 HBO 39* HBO 106 M 8 Primary school PDD-NOS/ Dysthymia 49 HBO - - 107 M 12 Secondary School ASS 45 WO - - 108 F 8 Primary school

ASS 48 MBO 44 HBO

109 M 12 Primary

school

- 43 HAVO/VWOA 46 HBO

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with seven (77.8 %) mothers having a high educational level and the remaining two mothers having a middle educational level. The mean age of the seven fathers was 43.71 years (range = 39-48, SD = 3.45). All the fathers had a high educational level. For a brief description of the background and reasons for going into therapy, see attachment 1.

Treatment

The BOAM treatment consisted of seven two-weekly 1.5 hour sessions in which the child and parent(s) participated together. During these sessions, the therapist worked on several objectives, which are expected to result in a stronger Gestalt development and support the ordering process within the child. These objectives are self-understanding and regulation of the child, empathy of the parent for the child, self-understanding and regulation of the parents, fulfilling the basic needs of the child by parents in order to prevent stress and the regulation of stressed feelings (ongoing restlessness or acute behavior problems) of the child by the parents. The objectives were reached by providing psycho-education (for example explanation of the ordering process and explanation of behavior), and interventions such as external ordering tools (e.g. a pictogram board) and a stress-regulation scheme.

Design and procedure

After signing up for a free intake, participants were asked to participate in the current study. The study consisted of (1) four online measurements containing several questionnaires (time duration of completing the measurement takes about 1.5 hours) and (2) daily online measurements to monitor the targeted problem behavior of the children (time duration of completing the daily measurements was approximately one minute per day). When parents and their children decided to participate in the study, they signed informed consent. Two measurements were available for the current study: a baseline measurement two weeks prior to the start of the treatment (T0) and a post-treatment measurement two weeks after

completing the BOAM treatment (T1). In addition, the daily measurements (DM) between T0 and T1 were used in the current study. The research has been approved by the Ethical

Committee of Child Development and Educational Studies of the University of Amsterdam. Instruments

Child problem behavior. The Child Behavior Checklist (CBCL; Verhulst & Van der Ende, 2013) was used to measure internalizing and externalizing problem behavior in children over the last six months as reported by parents. This questionnaire consists of 120 items with a 3-point Likert-scale (‘never’, ‘a bit/sometimes, ‘clearly/often’). An example of an item is: ‘Acts too young compared to his/her age’. The total score and the internalizing and

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was high (.96 with p < .001), as well as the test-retest reliability (.95, p < .001). The internal consistency of the problem scales varied with high alphas between .78 and .97. Both content validity and criterion validity have been demonstrated in several studies (Achenbach et al., 2008). The T-scores and cut-off scores for the broadband scales according to the test manual were used in this study.

Executive functioning. To determine the executive functioning of a child and to map potential problems in the executive functioning the Dutch version of the BRIEF Vragenlijst voor Executieve Functies (BRIEF; Huizinga & Smidts, 2013) was completed by the parents. The BRIEF consists of 75 items with a 3-point Likert scale (‘never’, ‘often’, ‘always’) and results in a total score and two index scores: Behavior Regulation (BRI) and Metacognition (MCI). An example of an item is: ‘Gets upset with new situations’. The internal consistency of the BRIEF is excellent, with Cronbach’s alpha’s of at least α =.93 (Huizinga & Smidts, 2013). Test-retest reliability have been proved to be high to excellent, with retest reliability scores for the total score, BRI and MCI .82, .84 and .88 respectively. The inter-rater reliability has been shown to be medium (r = .22) on the index and total scores. Construct validity has been confirmed using a confirmative factor analysis and both the convergent and divergent validity have been demonstrated as expected (Gioia, Isquith, Guy, & Kentworthy, 2002; Huizinga & Smidts, 2013). T-scores and cut-off scores according to the test manual were used in the current study.

Social competence. The Vragenlijst Sociale Vaardigheden van Jongeren (VSVJ; Hulstijn et al., 2006) was used to measure social competence. The VSVJ is designed to measure the relational functioning of a child and disrupting behavior towards others and was originally a self-reporting questionnaire. In this study however it was used as a parent report questionnaire. The VSVJ consists of 31 items with a 5-point Likert scale (‘never’,

‘occasionally’, ‘regularly’, ‘often’, ‘very often’) which results in scores on the prosocial behavior scale (PB scale) and the social inappropriated behavior scale (SIB scale). An example of an item is: ‘My child tries to upset others’. The reliability of the VSVJ is high, with a Cronbach’s alpha of at least α =.79 (Hulstijn et al., 2006) and construct validity was confirmed (Hulstijn, 2005). The PB scale had an expected convergent validity, for the SUB scale there is a lack of evidence (Hulstijn, 2005). Percentile scores and cut-off scores according to the test manual were used in the current study.

Daily measure of individual problem behaviors. Parents selected three to eight items

from the completed questionnaires which they experienced as most typically describing the problem of their child, most of the questions concerning problem behavior (second

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dimension) and few questions concerning the ordering (first dimension). These items were rewritten and incorporated as daily measurable 10-point Likert scale questions. Some questions were recoded for the analyses, so that a higher score represents a higher degree of problem behavior. The daily measurements before the onset of the treatment form the baseline phase (phase A) of this study. From the day the treatment has started, de daily measurements form the treatment phase (phase B).

Analyses

Due to alterations in the questionnaires send to parents at T0 and T1, not every measure was administered to all participants. The first three participants in the current study did not fill in the VSVJ and the BRIEF questionnaires. Furthermore, the parents of the third case thought the daily measurements would consume too much time, so they decided not to participate in this part of the study. For an overview of the questionnaires per participant, see attachment 2, Table 5. One parent was a study drop-out: the non-biological mother of case 104 and 105 gave birth during the BOAM treatment and she was not able to complete the measurements (but she did complete treatment). The T1 results of case nine were not (yet) available, because this family received more treatment sessions and their T1 measurement was postponed. However, their daily measurements were available and used for the current study. For an overview of the daily measurements per participant, see attachment 3, Table 6.

The data of the subscale scores and average daily measurements were checked on both normality and outliers. The normality assumptions of the paired t-test were assessed by Shapiro’s Wilk test, which revealed three violations of this assumption. Additionally, inspections of boxplots revealed one subscale with outliers amongst the normal distributed scales. For this scale (VSVJ SIB), the percentile scores were converted back to the raw scores, which resulted in the disappearance of the outliers. For the three normality violating scales, a Wilcoxon signed-rank test was executed. The results on the CBCL Internalizing scale

however have to be interpreted with caution due to the violation of the symmetry assumption of the Wilcoxon signed rank test.

To evaluate the statistical and clinical significance of the intervention effects on an individual level, the Mixed Models analysis method of Maric, De Haan, Hogendoorn, Wolters and Huizenga (2015) was used, analyzing the mean scores on the daily measurements per parent. In addition, the results of the questionnaires of T0 and T1 of the individual parents were analyzed using the Reliable Change Index (RCI; Jacobsen & Traux, 1991), determining whether the changes in reported (problem) behavior were statistically significant with -1.96 < RCI > 1.96 being statistically significant (Jacobsen, Roberts, Berns, & McGlinchey, 1999).

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The RCI was calculated for CBCL (Total, Internalizing and Externalizing), VSVJ (PB and SIB) and the BRIEF (Total, MCI and BRI). All test-retest reliabilities of these scales as well as the standard deviations corresponding to the age of the participants were obtained from the test manuals (Achenbach & Rescorla, 2000; Huizinga & Smidts, 2013; Hulsteijn et al., 2006; Verhulst & Van der Ende, 2013). Additionally, to determine the clinical relevance of the improvement, the scores on the questionnaires were compared to the cut-off scores which indicate clinical, subclinical or non-clinical (problem) behavior (Ferguson, Robertson, & Splaine, 2002) according to the test manuals.

For assessing treatment effectiveness on a group level, difference scores were

calculated for the CBCL (Total, Internalizing and Externalizing t-scores), VSVJ (PB and SIB scores), the BRIEF (Total, MC and BI scores), and the daily measures mean scores of the goals were calculated per participant (combining scores of both parents if applicable) to be able to compare results between participants, because of varying numbers of goals per parent. The scores on T0 and T1 for the children that were completed by two parents were averaged to create one parent score for each child. Additionally, a paired t-test or Wilcoxon signed-rank test was executed to determine significant changes. In addition Cohen’s d’s were calculated for all subscales, in order to assess the effect size of the BOAM-treatment on problem behavior and executive functioning. Alphas were set at a 95% confidence level for all analyses.

Results Individual treatment effectiveness

Mixed Models analysis

The results of the individual treatment efficacy regarding the daily measurements using the Mixed Models analysis are displayed in Table 2. The Mixed Models analysis of Maric et al. (2015) resulted in four test estimates per parent: the Intercept effect (b0), Phase

effect (b1), Time in phase effect (b2) and the Time in phase × Phase effect (b3), the latter three

being the estimates of interest. The phase effect represents the end of the treatment phase compared to the end of the baseline phase, and this estimate is preferably significant meaning parents reported significant less problem behavior at the end of treatment. The time in phase effect represents the slope of change during the baseline phase, which is preferably non-significant as this would mean that the reported problem behavior was stable during baseline. The last, and most important, estimate is the Time × Time in phase effect, which represents the slope of change during the treatment phase as compared to the baseline phase. A

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Table 2.

Treatment Efficacy Results Using Mixed Models

a. Results Concerning the Mean of the Daily Measurements from Mother 101

Estimate SE p 95% Confidence Interval Lower bound Upper bound

Intercept (b0) 3.943 .909 .000 2.080 5.806

Phase (b1) -2.945 1.054 .014 -5.193 -.697

Time_in_phase (b2) .062 .169 .717 -.282 .407

Time_in_phase * phase (b3) -.046 .170 .788 -.394 .303

b. Results Concerning the Mean of the Daily Measurements from Father 101

Intercept (b0) 4.697 .577 .000 3.530 5.864

Phase (b1) -3.536 .661 .000 -4.900 -2.170

Time_in_phase (b2) 0.039 .118 .741 -.199 .277

Time_in_phase * phase (b3) -0.008 .119 .943 -.248 .231

c. Results Concerning the Mean of the Daily Measurements from Mother 102

Intercept (b0) 3.136 .563 .000 1.989 4.283

Phase (b1) -1.946 .614 .004 -3.205 -.687

Time_in_phase (b2) -.116 .117 .329 -.353 .122

Time_in_phase * phase (b3) .130 .117 .267 -.108 .367

d. Results Concerning the Mean of the Daily Measurements from Father 102

Intercept (b0) 2.341 .478 .000 1.373 3.310

Phase (b1) -.438 .511 .397 -1.475 .599

Time_in_phase (b2) .003 .100 .979 -.200 .200

e. Results Concerning the Mean of the Daily Measurements from Mother 104

Intercept (b0) 2.674 1.099 .019 .464 4.883

Phase (b1) -1.322 1.191 .274 -3.731 1.088

Time_in_phase (b2) -.157 .186 .403 -.530 .216

f. Results Concerning the Mean of the Daily Measurements from Mother 105

Intercept (b0) .208 .982 .833 -1.766 2.184

Phase (b1) -.284 1.069 .792 -2.451 1.884

Time_in_phase (b2) .331 .166 .052* -.003 .664

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g. Results Concerning the Mean of the Daily Measurements from Mother 106

Estimate SE P 95% Confidence Interval Lower bound Upper bound Intercept (b0) 3.515 1.068 .002 1.379 5.650

Phase (b1) -.232 1.103 .834 -2.441 1.976

Time_in_phase (b2) .514 .353 .149 -.189 1.218

Time_in_phase * phase (b3) -.507 .353 .155 -1.210 .197

h. Results Concerning the Mean of the Daily Measurements from Mother 107

Intercept (b0) 2.110 .630 .002 .840 3.379

Phase (b1) .216 .639 .757 -1.191 1.623

Time_in_phase (b2) .120 .069 .088* -.018 .258

Time_in_phase * phase (b3) -.122 .069 .084* -.261 .017

i. Results Concerning the Mean of the Daily Measurements from Mother 108

Intercept (b0) 1.180 .308 .001 .547 1.812

Phase (b1) -.277 .430 .525 -1.163 .608

Time_in_phase (b2) .020 .009 .038 .001 .039

Time_in_phase * phase (b3) -.010 .012 .425 -.035 .0152

j. Results Concerning the Mean of the Daily Measurements from Father 108

Intercept (b0) 3.363 .155 .000 3.048 3.677

Phase (b1) -.744 .215 .001 -1.181 -.308

Time_in_phase (b2) .002 .004 .622 -.007 .011

k. Results Concerning the Mean of the Daily Measurements from Mother 109

Intercept (b0) 4.517 .603 .000 3.288 5.747

Phase (b1) .893 .680 .201 -.509 2.295

Time_in_phase (b2) .132 .066 .053* -.002 .266

Time_in_phase * phase (b3) -.135 .066 .049 -.270 -.001

Note. P-values in bold indicate significant estimates.

Note. P-values with an * indicate a significant trend

.

significant effect means that the slope of change during the treatment was significantly different compared to the baseline phase.

Both parents of case 101 reported statistically significant less problematic behavior of their child at the end of the treatment phase, compared to the end of the baseline phase (b2 =

-2.945 and -3.536, p = .014, p < .001 mother and father respectively). This means both parents noticed improvements in their son’s self-esteem, concentration and self-harming behavior. Both parents did not report a significant difference in slope between de phases.

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The mother of case 102 reported statistically significant less problematic behavior of her child at the end of the BOAM treatment compared to the end of the baseline phase (b2 = -1.946, p =

.004), meaning she has noticed a decrease in misbehavior, compulsive behavior and a sense of injustice in her daughter. The father of case 102 did not report a difference in the end of both phases regarding this behavior. Both parents did not report a significant difference in slope between the phases.

The mother of case 104 did not report a significant change in problem behavior, comparing the end of both phases, and also a non-significant effect was found for comparing the slopes between the phases. This mother is also the mother of case 105, participants being twin brothers. The mother also did not report a change in the problem behavior at the end of both phases for case 105. However, for the rate of change in the baseline phase, a significant trend was found (b2 = .331, p = .052), which means an increase in problem behavior during

the baseline phase was reported. Furthermore, a significant trend was found for the difference in slope between the phases (b3 = -.318, p = .062). This means it seems this mother saw a

bigger change and improvements during de treatment phase compared to the baseline phase. For case 106, the mother reported no significant change in problem behavior

comparing the end of the intervention phase with the baseline phase and also a non-significant effect was found for comparing the slopes between the phases.

The mother of case 107 did not report a significant decrease in problem behavior comparing the ends of both phases. A significant trend was found for the change during the baseline phase (b2 = .120, p = .088), meaning the mother reported an increase in problem

behavior during the baseline phase. Another significant trend was found for the change in slope between the phases (b3 = -.122, p = .084), meaning this mother reported a larger rate of

change and improvement in problem behavior of her child during the treatment phase compared to the baseline phase.

The parents of case 108 show mixed results. The mother reported no significant differences between the ends of both phases. The father reported a significant decrease in problem behavior, comparing the end of the treatment phase with the baseline phase (b1 =

-.744, p =.001). This means this father saw a significant decrease in the anxious, nervous and disrupting behavior of his daughter over time. However, the mother reported a significant increase in this problem behavior during the baseline (b2 = .020, p = .038), and no significant

change comparing the change during treatment with the baseline.

The mother of case 109 reported no significant change in problem behavior at the end of the treatment phase compared to the baseline phase. There was a significant trend for the

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rate of change in the baseline phase (b2 = .132, p = .053), meaning that the problem behavior

increased during the baseline phase. This mother reported a significant decrease in the difference of the slopes between the two phases (b3 = -.135, p = .049), meaning it seems she

saw a bigger change and improvement in her son’s self-consciousness, pro-social behavior and initiative during the treatment phase compared to the baseline phase.

Reliable Change Index

The results of the calculation of the RCI are displayed in Table 3. For case 101 both mother and father reported clinical significant improvements on the CBCL Total (RCI = 8.35 resp. 11.30), Internalizing (RCI = 6.23 resp. 9.34) and Externalizing scales (RCI = 6.85 resp. 7.26). This means that both parents saw a decrease in total, internalizing and externalizing problem behavior in their son after the BOAM treatment, compared to the start of the

treatment. Additionally, parents first scored their son as having clinical problem behavior, but reported his behavior as being non-clinical after the treatment according to the test manual.

The father of case 102 reported a clinically significant increase of problem behavior after the BOAM treatment on the CBCL Total (RCI = 2.62) and Externalizing scales (RCI = -6.00). Furthermore, the scores on these scales changed from the non-clinical range to the clinical range.

One significant improvement was found for case 104 as reported by his mother. The score on the CBCL Total scale has decreased clinically significant (RCI = 2.14). However, this did not lead to a clinical improvement, with both scores on T0 and T1 falling in the clinical range. The same mother reported several significant results for case 105. The scores on the CBCL Total (RCI = 2.89) and Internalizing scale (RCI = 3.04) and the VSVJ PB scale (RCI = -3.03) improved clinically significant. Additionally, the scores on the CBCL Total scale changed from a clinical to a sub-clinical score and the VSVJ PB score changed from a clinical to a non-clinical score.

For case 106 three significant improvements were reported by his mother. The scores CBCL Total (RCI = 2.62) and Externalizing (RCI = 2.38) scale and the VSVJ SIB score (RCI = 2.64) improved clinically significant. Additionally, according to the test manual, the score on the VSVJ SIB scale changed from a clinical to a non-clinical score.

The mother of case 108 reported no clinical or significant improvements. In fact, she reported two clinical significant deteriorations on the CBCL Total scale (RCI = -2.25) and VSVJ PB scale (RCI = 4.80). Additionally, these scales changed from a sub-clinical to a clinical score and from a non-clinical to a clinical score respectively. The rest of the parents did not report any significant changes on de subscale scores.

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Table 3.

Results of the Reliable Change Index (RCI) for all Individual Parents

Note. aA non-clinical score according to the test manual

b

A subclinical score according to the test manual

c

A clinical score according to the test manual An RCI with an * indicates a significant change

An RCI in bold with an * indicates clinical significant improvement

T0 sum T1 sum Sdif RCI (Sdif) T0 sum T1 sum Sdif RCI (Sdif)

Case 101 Mother Case 101 Father

CBCL Total 53c 5a 5.75 8.35* CBCL Total 79c 14a 5.75 11.30*

CBCL Int 15c 1a 2.25 6.23* CBCL Int 24c 3a 2.25 9.34*

CBCL Ext 19c 2a 2.48 6.85* CBCL Ext 25c 7a 2.48 7.26*

Case 102 mother Case 102 father

CBCL Total 44b 47b 5.33 -0.56 CBCL Total 22a 36a 5.33 -2.62* CBCL Int 6a 7a 2.29 -0.44 CBCL Int 2a 4a 2.29 -0.87 CBCL Ext 22c 24c 2.00 -1.00 CBCL Ext 10a 22c 2.00 -6.00*

CBCL Total 11a 13a 4.26 -0.33 CBCL Total 11a 9a 4.26 0.33 CBCL Int 4a 1a 1.59 1.33 CBCL Int 4a 3a 1.59 0.44 CBCL Ext 3a 3a 1.78 0.00 CBCL Ext 2a 0a 1.78 0.79

Case 104 mother Case 105 mother

CBCL Total 85c 65c 9.35 2.14* CBCL Total 84c 57b 9.35 2.89*

CBCL Int 29c 24c 3.61 1.38 CBCL Int 33c 22c 3.61 3.04*

CBCL Ext 24c 17a 6.19 1.13 CBCL Ext 23b 18a 6.19 0.81 BRIEF Total 157b 154b 15.59 0.19 BRIEF Total 177c 162b 15.59 0.96 BRIEF BR 64b 68c 6.40 -0.63 BRIEF BR 72c 69c 6.40 0.47 BRIEF MC 88b 80b 8.55 0.94 BRIEF MC 100b 88b 8.55 1.40 VSVJ PB 49c 51a 4.94 -0.40 VSVJ PB 39c 54a 4.94 -3.03*

VSVJ SIB 42a 44a 6.07 -0.33 VSVJ SIB 52c 43a 6.07 1.48

Case 106 mother Case 107 mother

CBCL Total 77c 61c 6.03 2.62* CBCL Total 39a 43b 5.75 -0.70 CBCL Int 16c 15c 2.25 0.44 CBCL Int 4a 4a 2.25 0.00 CBCL Ext 27c 21c 2.52 2.38* CBCL Ext 19c 21c 2.48 -1.21 BRIEF Total 152b 132a 15.59 1.28 BRIEF Total 153b 140b 15.59 0.83 BRIEF BR 64b 52b 6.40 1.87 BRIEF BR 63c 60b 6.40 0.47 BRIEF MC 84a 77a 8.55 0.82 BRIEF MC 85b 77a 8.55 0.94 VSVJ PB 56a 53a 4.95 0.61 VSVJ PB 45c 43c 4.49 0.40 VSVJ SIB 54c 38a 6.07 2.64* VSVJ SIB 45a 42a 6.07 0.49

CBCL Total 46b 58c 5.33 -2.25* CBCL Total 65c 65c 5.33 0.00 CBCL Int 24c 29c 2.29 -2.18 CBCL Int 29c 30c 2.29 -0.44 CBCL Ext 4a 3a 2.00 0,50 CBCL Ext 3a 3a 2.00 0.00 BRIEF Total 116a 126b 15.59 -0.64 BRIEF Total 146b 139b 15.59 0.45 BRIEF BR 44a 46b 6.40 -0.31 BRIEF BR 55b 56b 6.40 -0.16 BRIEF MC 68a 74a 8.55 -0.70 BRIEF MC 85b 78a 8.55 0.82 VSVJ PB 60a 40c 4.17 4.80* VSVJ PB 45c 49c 4.17 -0.96 VSVJ SIB 21a 22a 5.39 -0.19 VSVJ SIB 27a 25a 5.39 0.37

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Treatment effectiveness for the group

Child problem behavior

Treatment effectiveness results for the group are displayed in Table 4. Parents scored lower T-scores for child problem behavior after the BOAM treatment (M = 63.75, SD = 58.88) compared to the CBCL T-scores before treatment (M = 63.75, SD = 9.82). A paired t-test revealed that this decrease is not statistically significant, t(7) = -1.415, p = .200. However, calculation of Cohen’s d revealed an effect size of -0.50, which is considered a medium effect. Similar results were obtained for internalizing, z = -1.439, p = .150, d = -.51, and externalizing problems, z = -1.334, p = .182, d = -0.47.

Social competence

Nonsignificant results were found for prosocial behavior, t(4) = .326 , p =.760 , d = -.14, and socially inappropriate behavior , t(4) = -1.636, p = .177, d = -0.73. Note however, that the effect size for socially inappropriate behavior being decreased after treatment was almost large, despite the non-significant result.

Executive functions

Parents reported lower T-scores on the BRIEF Total scale for their children after the BOAM treatment compared to before the treatment. This decrease was trend significant, t(4) = -2.240, p = .089, d = -1.00. On the BRIEF MC index parents reported a statistically significant decrease in T-scores for executive function problems concerning metacognition after the BOAM, t(4) = -4.468, p = .011, d = -2.00. A non-significant change in the median scores on the BRIEF BI index was found, z =-.677, p = .498, d = -0.30.

Daily measurements

Lastly, parents reported lower scores on questions concerning their child’s problem behavior during the treatment phase compared to the baseline phase, which was a statistically significant decrease with a large effect size, t(7) = -2.444, p = .045, d = -0.86.

Summary of results

Summarizing the individual results, eight out of nine participants demonstrated improvement on at least one measure (Mixed Model, RCI, change from (sub) clinical to normal score). However, only four out of eleven Mixed Models proved to be significant, 13 out of 66 RCI’s were significant, and only 14 out of 66 scores changed from (sub) clinical level to normal level. Summarizing the group results, two significant effects of the BOAM treatment were found on the group level for the problem behavior measured with the daily measurements and problems regarding metacognition, an area within the executive functions.

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Table 4.

Results of the Group Analyzes and Effect Sizes of the BOAM Treatment

Note. * in bold = significant improvement

Note. * = trend significant improvement

A significant trend was found for the general executive functions. For the rest of the (sub) scales, no significant effects were found, but medium to large effect sizes were found for seven out of nine scales.

Discussion

The present study examined the effectiveness of the BOAM method on a range of outcomes measures for nine children as reported by their parents. Main results can be summarized as follows: on the group level, some promising results were found, with several medium to large effect sizes for the BOAM treatment effect, however, only significant (trend) effects were found for metacognition, daily measured problem behavior and the general executive functioning. On the individual level, mixed results were found for the participants, with just below half of the parents reporting significant improvements on a broad range of behavioral issues. In addition, some parents reported no change at all and a few parents even reported deteriorations in problem behavior.

Although some promising results were found, a minority of the results proved to be significant. Since the difference in the rate of change between phases is the variable of most interest in single case studies (Borckardt et al., 2008), the lack of finding significant

interaction effects for the individual treatment effects may be somewhat disappointing. This may be attributed to the fact that the present study lacks follow-up measurements. Follow-up measurements increase the likelihood of drawing valid inferences in single case studies (Graham, Karmarkar, & Ottenbacher, 2012; Kratochwill & Levin, 2014) and larger effect sizes and significant results can be found in follow-ups. Indeed, a meta-analysis including 33 studies on the effects of short term psychodynamic psychotherapy, concluded that effect sizes increases towards the follow-up (Abbass, Hancock, Henderson and Kisely, 2006).

(Sub)scale N t/z-score p Effect Size

CBCL Total 9 t = -1.415 .200 -0.50

CBCL Internalizing 9 z = -1.439 .150 -0.51 CBCL Externalizing 9 z = -1.334 .182 -0.47 VSVJ Prosocial behavior 5 t = -0.326 .760 -0.14 VSVJ Social inappropriate behavior 5 t = -1.636 .177 -0.73

BRIEF Total 5 t = -2.240 .089* -1.00

BRIEF Metacognition 5 t = -4.468 .011* -2.00 BRIEF Behavior inhibition 5 z = -0.677 .498 -0.30 Daily measurements 8 t = -2.444 .045* -0.86

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Furthermore, Shedler (2012) stated that larger effect sizes found during the follow-up compared to the post test implies that psychodynamic therapy triggers psychological processes that cause continuing change after the therapy, which may also be the case in the BOAM treatment. That is, parents go through a process during the BOAM therapy, and may evolve from ‘unaware incompetent’ to ‘aware incompetent’ to ‘aware competent’ to ‘unaware competent’ (Truijens, 2015). Parents become aware of this process during therapy, in which they learn that the problem (behavior) of their child is intertwined with their parental

behavior. Parents have to make an effort to change parental behavior, which takes time, energy and ordering capacity of the parent. This process does not necessarily translate into immediate change in behavior, and therefore change in the child’s behavior.

Significant results were found for executive functions regarding metacognition scale and the daily measurements, a trend significance was found for general executive functioning. The daily measurements measured the most problematic behavior of a child, which was the center of attention in the BOAM therapy. Parents are given insight on a metacognitive level on this problem behavior and have practical interventions presented to them to target these specific problem behaviors. The (trend) significant results for executive functioning is a confirmation of the hypothesized role of executive functioning in child problem behavior and one of the possible common underlying causes of the symptoms of a variety of disorders. During the BOAM therapy, parents become aware of the physical ordering stage and support their child’s physical ordering. According to the theory, executive functions can develop when this ordering need is fulfilled. Because the EF are a factor in multiple disorders, and the EF were developed during the BOAM treatment, this may have further attributed to the significant decline in problem behavior in the daily measurements.

Only three (trend) significant results on group level were found. An explanation for the lack of significant results could be the small sample size in the current study. Small sample sizes are associated with smaller statistical power (Button et al., 2013) and outcomes of statistical power analysis depend on four variables: N, alpha, power and ES (Cohen, 1992). Therefore, with a large N more statistical power will be generated and likelihood of rejecting H0 increases (Cohen, 1992), meaning the probability of finding significant effects increases.

Given the small sample size of the current study, and the majority of the ES found being medium to large despite the lack of significant results, the first results on effectiveness of the BOAM therapy are promising. Replicating the group analysis with a larger sample size is recommended, because a larger sample size will create more power to translate the medium to large effect sizes in significant results.

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Limitations of the study need to be noted. First, as discussed above, a follow-up and a larger sample size are necessary. Second, currently a (standard) treatment protocol is lacking. The lack of a treatment protocol stems from the belief within the BOAM method that subjects and problems come up naturally and the therapist intertwines the BOAM interventions and psycho-education during the sessions (Truijens, 2015). This means that not every family received the treatment in the same order, and not every family accomplishes the same steps in the fixed amount of therapy sessions. In both RCI’s and single case studies, explicit treatment protocols are important regarding the treatment integrity (Carriere, Mitchell, & Senior, 2015; Fryling, Wallace, & Yassine, 2012) and the treatment adherence (Tate & Perdices, 2015). Sanetti and Kratochwill (2009) pointed out several aspects of treatment integrity that may affect intervention outcomes: the content of the intervention, the quality and quantity of the intervention steps transferred, and the process, which concerns how well the intervention was delivered. The authors argue that studies assessing the treatment integrity adequately, have demonstrated a direct relationship between higher treatment integrity and better outcomes. Additionally, not all treatment components may be equally effective in generating positive treatment effects. In order to distinguish critical and supplementary components of a therapy, treatment integrity plays an important role. Although deviations in treatments may lead to a higher contextual relevance (Sanetti & Kratochwill, 2009), it is recommended to develop a treatment protocol for the BOAM method to increase the treatment integrity and thus the treatment effectiveness, as well as for research regarding critical treatment components.

A third limitation is the study’s sample. On the one hand the problems of the

participants were very heterogeneous, while on the other hand parental educational level and ethnicity was very homogeneous (highly educated, Caucasian parents). The heterogeneity of problem behaviors makes it difficult to draw firm conclusions regarding the effectiveness of treatment as it might be that the treatment works better for one type of problem behavior than the other. Further, the lack of heterogeneity in parental demographics complicates the

generalization to the broader population (Kratochwill & Levin, 2014; Nikles & Mitchell, 2015), in this case whether the BOAM method is an effective method in helping a broad range of children and their parents with a broad range of developmental problems. It is desirable to investigate whether there are problem areas which benefit especially from the BOAM-method (although this might be in contrast with the philosophy of the method) and it is important to assess the effectiveness of the BOAM method for the broad population (including lower educated families and parents or children with mild intellectual disabilities).

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To summarize, this pilot study was the first study to analyze the treatment results of this new treatment method in two ways: (1) by analyzing nine N-of-1 trials and (2) examining group effectiveness. For some of the children the BOAM-method proved to be effective on different levels: problem behavior, social skills, or executive functioning problems. For other children, the evidence of effectiveness was not observed. The BOAM therapy is a promising therapy irrespective of specific disorder, DSM classification or comorbidity, which could be a new approach on child problem behavior in the mental health care. Further development of the method could contribute to the expansion of methods available in the mental health care. However, it is important to include long term follow-ups to assess whether the psychological processes are triggered during the BOAM treatment and whether changes occur after the BOAM treatment.

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Attachment 1.

Single cases individually described

Case 1. Case 1 concerns a nineteen years old male and his parents. During the intake Case 1’s parents reported mood problems and self-injurious behavior. He was still living at home and both parents experienced problems with case 1 within the home situation. Six sessions took place with case 1 and the therapist, and one session with case 1, his parents and the therapist. Case 2. Case 2 concerns a seven year old girl and her parents. During the intake the parents reported their daughter was having a hard time with transitions between situations, being easily upset, being jealous at her sister and not obeying the rules. Six sessions took place with case 1, her parents and the therapist, one session was with the parents and therapist, and an extra session with the parents was added to the therapy (focusing on the partner relation and communication between the parents).

Case 3. Case 3 concerns a seven years old boy. His parents reported problems with performance anxiety. The school performance of this boy lagged behind considering is intelligence. His parents reported mostly school related problems, but also reported inflexibility and temper tantrums at home. Seven sessions took place with case 3 and his parents.

Case 4 and 5. Case 4 and 5 concerns two four year old boy twins. Parents reported ASD symptoms and labeled these problems as highly giftedness. The boys were easily distracted, insecure, and showed performance anxiety. The mothers were quite sure the problems could be attributed to highly giftedness, but school reported a lack of executive functions and social competence which caused an impasse between parents and school. Two therapy sessions were held at home because one of the mothers gave birth to a third child and four sessions took place at the treatment center. The parents and twins had six BOAM-therapy sessions. The time of the seventh session was used for the therapist to write a rapport for the future school of the kids.

Case 6. Case 6 concerns an eight year old boy with PDD-NOS and Dysthymia. During the intake there was an untenable situation at school. This boy showed a lot of externalizing behavior, had temper tantrums and was difficult to control. The parents of this boy are divorced, and only the mother attended the therapy sessions (although there was contact between the boy and the father, and the therapist made phone calls to the father to involve him in therapy). This boy attended six sessions with his mother and one session was at school with case 6, his mother and teacher.