Journal of Marital and Family Therapy 1999,Vol. 25, N0.1,117-123

INFLUENCES ON THE INCLUSION OF CHILDREN IN FAMILYTHERAPY

BRIEF REPORT

Laura Johnson Appalachian State University

Volker Thomas Purdue Univen-ity

This study examined factors that influence family therapists to include children in or exclude them from therapy sessions. We hypothesized that therapist comfort, child problem type (internalizing us. externalizin., family composition (one- us. two-parent families], and presenting problem (child-oriented problem us. adult- oriented problem] aflect therapists’ inclusion of children. A survey of clinical members of AAMFT found that half of the therapists excluded children on the basis of their comfort and that those who felt more comfortable were more likely to include children in sessions. Therapists included children more frequently in cases of an internalizing us. an externalizing child, more with single-parent than two- parent families, and more often when thepresentingproblem focused on a child than on an adult. Implications of thefindings are discussed.

Inclusion of children is an important issue in family therapy, because there is little agreement in the fieid about how and when to involve children in sessions (Stith, Rosen, McCollum, & Herman, 1996). In fact, family therapy has been accused of “not seeing the children at all” (Diller, 1991, p. 23), ignoring their unique role in the family system. There is a paucity of empirical research that investigates the factors associated with inclusion of children in family therapy.

Therapists are continually faced with decisions about whether or not to involve children in sessions, about how many children to include and for how long, and about how to effectively involve them in therapy. Competent therapists often decide to exclude children, focusing on certain dyads and individuals on the basis of their own theoretical orientation and views about therapeutic change. The diversity of family problems and constellations creates many situations in which the physical inclusion of children in therapy sessions is neither necessary nor recommended.

However, some of the basic tenets of family therapy theory suggest that without the presence of all family members, at least in initial sessions, family therapists miss important information and opportunities for intervention (Ackerman, 1970; Baker, 1986; Chasin,

Laura Johnson, PhD, is Assistant Professor in Marriage and Family Therapy/Appalachian

Volker Thomas, PhD, is Assistant Professor in Marriage and Family Therapy at Purdue State University, Boone, NC.

University, West Lafayette, IN.

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1981; Chasin & White, 1989; Diller, 1991; Gil, 1994; Guerney, 1964; Guerney & Guerney, 1987; Guttman. 1975; Kaye & Dichtera, 1986; Lax, 1989; Levant et al., 1985; Minuchin, 1989; Moss-Kdgel, Abramovitz, & Sager, 1989; Nickerson, 1986; Safer, 1965; Savege- Scharff, 1989; Taffel, 1991; Villeneuve, 1979; Villeneuve & LaRoche, 1993; Whitaker, 1967; Zilbach, 1986). When it comes to the inclusion of children in family therapy sessions, the family therapy field faces many unanswered questions. For example, have family therapists inadvertently excluded children in sometimes detrimental ways- perhaps missing important factors such as abuse and neglect or children’s reactions to other important events in the life of the family? What should children hear discussed in therapy sessions? What kind of child problems tend to be handled with the child in the room? Are adult-focused problems appropriate for children to hear, or is it more appropriate to exclude children in such cases? How comfortable do therapists feel about conducting a therapy session with children in the room? How do therapists make decisions about when to include children in sessions and when to exclude them? With the vast number of situations in which family therapists face these decisions, it is surprising that the field has produced few, if any, empirically based guidelines for therapists to follow (Korner, 1988; Korner & Brown, 1990).

The purpose of this study was to shed more light on the criteria family therapists use when they decide whether or not include children in therapy sessions. Specifically, the study examined the following questions: (1) Are family therapists who feel uncomfortable with children more likely to exclude children from sessions than therapists who feel more comfortable with children? (2) Are family therapists more likely to include internalizing (anxious, depressed) children in therapy sessions than externalizing (aggressive, destructive) children? (3) Are family therapists more likely to include children in therapy sessions when they are from single-parent families than when they live in a two-parent family? (4) Are family therapists more likely to include children in therapy sessions when the family presents with a child-oriented problem than when it presents with an adult- oriented problem?

METHOD

Participants The participants in this study were 143 family therapists who responded to a mailing

sent to a list of 402 clinical members of the American Association for Marriage and Family Therapy (AAMFT) chosen randomly from the M F T directory. Although the response rate of 35.6% is considered rather low, the sample matched the population of AAMFT clinical members well with regard to age, sex, ethnic background, highest professional degree, professional experience, and work setting (chi-square analyses did not reveal significant differences).

Instruments The Family Therapy Questionnaire-Revised (FTQ-R) included questions designed to

elicit background information on family therapists, as well as on their practices with regard to the inclusion of children in therapy sessions. The FTQ-R was expanded and changed from the Family Therapy Questionnaire (FTQ, Korner & Brown, 1990) to test the hypotheses of this study. For the purpose of this study “children” were defined as those

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under the age of twelve. The ETQ-R measures several distinct concepts, such as inclusion practices and comfort

level, in including children. The inclusion practices scale (60 items) for this sample yielded excellent internal consistency (Cronbach alpha coefficient = .92). The comfort level scale (4 items) had good internal consistency (Cronbach alpha coefficient = ,801.

Vignettes One section of the FTQ-R contained four case vignettes. The vignettes, instead of

simply asking for therapists’ opinions about their inclusion practices, provided a way to gather more direct data regarding these practices. Additionally, the vignettes allowed for the comparison of inclusion practices depending on the child problem type (hypothesis 2: internalizing vs. externalizing), family composition (hypothesis 3: single-parent vs. two- parent), and presenting problem (hypothesis 4: child-oriented vs. adult-oriented). The four case scenarios consisted of different presenting problems and family constellations, whereas the number of children, type of problem, age of parents, age of children, and sex of children were matched in order to lend construct validity to the comparisons. The participants responded to the vignettes in the following order: vignette 1: two-parent family, externalizing child problem; vignette 2: two-parent family, adult problem; vignette 3: two-parent family, internalizing child problem; and vignette 4: single-parent family, externalizing child problem.

Table 1 summarizes the comparisons of the four tested variables.

TABLE 1 Inclusion Comparisons of the Four Tested Variables

I Variable Difference F I 1 Comfort Include > exclude 58.52** 2 Child problem type Internalizing > externalizing 3.0Y

4 Presenting problem Child-oriented > adult-oriented 18.5Y 3 Family composition Single-parent > two-patent 5.10**

*p < .01, **p < ,001

The first hypothesis examined the therapists’ views about the permissibility of excluding children on the basis of comfort level. A frequency distribution of the item, “If a family therapist prefers not to work with children, then it is fine for him or her to exclude them from therapy sessions,” revealed that 71 of 143 respondents (49.7%) either agreed or strongly agreed, and only 35 (24.5%) disagreed or strongly disagreed. A chi-square analysis of this item confirmed that the differences in these percentages were not random (chi-square = 21.3; p < . O l ) in that significantly more therapists agreed than disagreed with this item, thus supporting hypothesis 1.

Another approach to examining hypothesis 1 included an analysis of variance comparing the comfort scores among the four vignettes. Although there was a significant

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main effect (F = 58.52; p < .OOOl), paired comparison t- tests showed that only the comfort score in the adult-oriented problem vignette 2 differed significantly from each of the others (t = -.86 for vignette 1; t= -.86 for vignette 3; t = -34 for vignette 4). Thus, therapists reported significantly less comfort including children in the adult-oriented presenting problem scenario than in the three child-oriented presenting problem scenarios.

The tests for hypotheses 2-4 compared composite inclusion scores for each of the four sets of inclusion items following the vignettes. Repeated measures analysis of variance revealed significant differences between the mean scores of the four vignettes (F = 247.70; p < .OOOl). Pairwise comparisons indicated highly significant differences between mean inclusion scores for all of the targeted vignette comparisons.

Specifically, hypothesis 2 examined the differences for child problem type. Vignettes 1 and 3 (comparing inclusion practices with externalizing and internalizing child problems) were significantly different (t= -3.09; p < .Ol), with all other factors (i.e., sex of child, age, number of parents, presenting problem) controlled for, in that the inclusion scores were significantly higher in the internalizing child problem vignette than in the externalizing child problem vignette. Thus, hypothesis 2 was supported: family therapists are more likely to include internalizing (anxious, depressed) children in therapy sessions than externalizing (aggressive, destructive) children.

Hypothesis 3 tested for differences in family composition. Vignettes 1 and 4 (comparing single-parent and two-parent families) were significantly different (t = -5.099; p < .OOl ) , with all other factors (i.e., sex of child, age, child problem type, presenting problem) controlled for, in that the inclusion scores were significantly higher in the single- parent vignette than in the two-parent vignette. Hypothesis 3 was supported: Family therapists are more likely to include children in therapy sessions when they are from single-parent families than when they live in a two-parent family.

Hypothesis 4 explores the differences in presenting problems. Vignettes 2 and 3 (comparing child-oriented and adult-oriented presenting problems) were significantly different (t = -18.55; p < .OOl), with all other factors (i.e., sex of child, age, child problem type, family composition) controlled for, in that the inclusion scores in the child-oriented problem vignette were significantly higher than in the adult-oriented problem vignette. Hypothesis 4 was also supported: family therapists are more likely to include children in therapy sessions when the family presents with a child-oriented problem than when they present with an adult-oriented problem.

In summary, the results of this study supported the four hypotheses about the inclusion of children in family therapy sessions.

DISCUSSION

The following discussion must be interpreted in the context of a relatively low survey response rate of 35.6%, which somewhat questions the study’s validity. However, we think that cautious interpretation is warranted because the response rate may reflect the low interest of the field in the issue of including children in family therapy sessions.

As the results of this study indicate, many family therapists base their decision about the inclusion of children in therapy sessions on personal comfort level and preference. Almost half (49.7%) of the surveyed therapists felt comfortable with the exclusion of children because of personal preference. This finding raises questions regarding the

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reasons that so many family therapists do not feel comfortable including children in their work. Is their discomfort related to lack of training, to their theoretical orientation, to simple preference, or to other factors? If those therapists who are uncomfortable with children, confined their caseloads to situations where children were not involved, then this finding might be unimportant. However, it is more likely that those therapists do see cases in which children are directly or indirectly involved. Whatever the reasons, more research is needed to answer these questions.

The differences in therapists’ responses to the four vignettes suggest that comfort level is not only affecting overall inclusion but is differentially impacting inclusion decisions. Therapists in this study had significantly higher inclusion scores for internalizing than for externalizing child problems. Therapist comfort level in session may be the reason for this difference. Externalizing, aggressive children can be very challenging in family sessions. It is often easier to ask the parents to leave these children with a baby-sitter than to struggle through a session with such a child. Quiet, internalizing children do not present such obvious and immediate challenges and may therefore be more welcomed in the family therapy setting.

Family composition is another important factor in family therapists’ decision whether to include children in therapy sessions. We found that therapists include children more frequently when they work with single-parent families than when they see two-parent families. Because systems therapists are trained to work with multiple family members, this difference may relate to comfort level in that many family therapists are less comfortable working with an individual than with more than one person in the room (Weiss, 1979).

K. Helmeke (personal communication, 1995) suggests that this finding may also relate to a tendency for therapists to create a two-parent system with a single parent, joining with the single parent to form a surrogate two-parent system in which a new hierarchy is established. The therapeutic challenge in such cases requires the therapist’s flexibility to move in and out of the therapeutic system in support of the single parent without violating appropriate therapeutic boundaries (Minuchin, 1974).

The higher inclusion rate for single-parent families may also be explained by the lower income levels and decreased access to child care of such families. If so, then children may be included in sessions even when the therapist deems it to be less than ideal for the situation because there is no adequate alternative. This would require the therapist to be flexible enough to be effective in less-than-optimal circumstances. This tendency to include children more often when two parents are not available merits further inquiry. Qualitative research that seeks to understand the reasons for this difference would provide important information.

The finding that family therapists include children more frequently when the presenting problem is child-oriented than when it is adult-oriented seems obvious and plausible. Yet it may be more complicated than it appears at first glance. What guidelines do therapist apply in such cases? In a follow-up study on this question we found that therapists’ beliefs about the appropriateness of including children in sessions dealing with adult oriented problems does have some impact on these inclusion decisions. The greater the belief that inclusion in such cases is inappropriate, the less inclusive therapists were when the presenting problem was adult-oriented. However, the divided feelings about the appropriateness of such inclusion (30.8% considered inclusion of children inappropriate; 42% considered inclusion of children appropriate) indicates that more research needs to

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be done, investigating which types of adult problems and which marital and family problems therapists think merit the inclusion of children. The research of Stith, Rosen, McCollum, Coleman, and Herman (1996) highlights the need to develop clearer guidelines on this issue, because children in their study reported wanting very much to be involved in sessions even when the problem was not about them.

As the results of this study indicate, the inclusion of children in family therapy sessions is an issue we d o not know much about. This conclusion is ironic for a field that purports to provide all-inclusive and innovative mental health services. Further investigation, using multiple research methods, is warranted regarding such issues as therapist comfort level with children in sessions, the criteria therapists use to make inclusion decisions, and how the family therapy field is meeting the needs of children. It is highly important for the field of family therapy to be a leader in the acknowledgment and study of childhood problems. Family therapists need to be able to better apply general systems theory to the excellent base of research in areas of childhood concerns, finding ways to integrate these knowledge bases in a way that supports families.

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