Terapia de aceptación y compromiso en un niño con celos y rumia disfuncionales

Full reference: Alonso-Sanz, A., Barbero-Rubio, A., Ruiz, F. J., & Gil-Luciano, B. (2022). Acceptance and commitment therapy in a child with jealousy and dysfunctional rumination: A case study. Revista de Psicoterapia, 33(122), 21-45.

Study type: Single-case A-B design with follow-up measurements.

Background and objectives

Acceptance and Commitment Therapy (ACT) is establishing itself as a promising intervention for childhood psychological problems. However, empirical evidence on its efficacy in childhood populations remains limited. This article contributes to this evidence base by presenting a case study of a 9-year-old boy (J) who exhibited aggressive behaviors and dysfunctional rumination, particularly toward his younger brother. The objective was to examine the efficacy of an ACT intervention grounded in the three main strategies derived from the conceptualization of psychological flexibility from Relational Frame Theory (RFT).

The work was conducted in the private practice context of the therapists with the consent of J's mother and father. The case is particularly relevant because it illustrates how ACT addresses both behavioral problems and dysfunctional thought processes (rumination) in childhood in an integrated manner, with special emphasis on altering rumination responses.

Method

Participants

The participant was J, a 9-year-old boy living with his parents and his younger 6-year-old brother. At the time of intervention, he was in the appropriate grade level (5th grade). His parents sought a consultation requesting an assessment of J regarding the difficulties he demonstrated in managing anger across different situations within the family context. Behavioral problems included aggressive behaviors toward his brother, especially in play contexts or daily routines such as breakfast or school commutes. J exhibited strong aggressive conduct, and his parents were also concerned about him getting "stuck on things" (rumination), mainly in situations where he felt he had not been considered or had felt rejected in some way.

Design

A single-case A-B design with follow-up measurements was used. The complete work with the family consisted of eight sessions: five intervention sessions (three with J and two with his parents), preceded by two evaluation sessions and followed by one follow-up session at 2 months. Both evaluation and intervention sessions were conducted weekly, with approximately one-hour duration (except the first parental intervention session, which lasted one and a half hours) and were conducted by two therapists (the first two authors of this work).

Intervention

The intervention consisted of two main components:

Intervention with Parents (2 sessions + 1 follow-up):

First session: Analyze descriptive records of problematic situations; explore more useful ways of acting; identify the inflexible pattern in conflicts with J; and specify intervention objectives.
Second session: Continue exploring problematic situations; expand contact with values related to parenting; train the skill of responding with greater observational distance.
Follow-up: Analyze records; expand values related to parenting.

Intervention with J (3 sessions):

Interventions were based on the definition of psychological flexibility from Törneke et al. (2016) and Luciano et al. (2022) and the main strategies to increase this repertoire. Intervention with J focused on strengthening his flexible pattern through different exercises and metaphors, with special emphasis on altering his rumination response.

Session 1: Create a motivational context of meaning for therapeutic work; discriminate the inflexible pattern and its costs; establish flexible action.
- Exercises: Volcano metaphor; Dumbledore; When I was Volcano Chief
Session 2: Explore flexible actions throughout the week; discriminate what can be controlled and what cannot; experiment with thinking from a didactic and hierarchical perspective; train the skill of establishing observational distance with thoughts and emotions and integrating them as part of oneself to permit contact with what is relevant.
- Exercises: Pinkel's Laboratory (Control and Lack of Control of Events); Dumbledore's Pensieve; Magic Time-turner
Session 3: Explore flexible actions conducted throughout the week; train the skill of establishing observational distance with thoughts and emotions and integrating them as part of oneself to permit contact with what is relevant; derive rules that specify natural appetitive consequences of cooperating as a team and strengthen follow-through through multiple examples.
- Exercises: Villa-Arriba and Villa-Abajo metaphor; Indiana Jones Missions

Outcome measures

Several records were established that parents completed at the end of each day to establish a baseline and track changes in J's behavior:

Descriptive conflict record: Parents noted the time of day a conflict with his brother occurred, the context, what J's reaction had been, and what followed that reaction.
Frequency record of anger episodes: Since parents could not memorize all of J's anger episodes, they were given a daily record to note the frequency of such episodes. They only recorded episodes in which the discussion had been elevated (with yelling, hitting, etc.) and had a minimum duration of two minutes.
Intensity record of anger episodes: Concurrently, parents rated the overall intensity of the day's anger episodes on a scale from 0 (not at all intense) to 10 (very intense).
Complaint level: To measure rumination behavior, a daily complaint level record was used. This was conceptualized as interactions in which J repeatedly complained about something, whether related to an event with his brother (most frequent) or any other situation.

Data analysis

The intervention results were analyzed visually with the aid of the non-parametric effect size calculation Tau-U (Parker et al., 2011). This statistic is a non-overlap effect size between baseline and intervention data. Since it does not require the fulfillment of parametric assumptions, it is a widely used indicator in this type of studies. Tau-U values range between -1 and 1 and can be interpreted as the percentage of data that improves across phases.

Results

Visual Analysis

Figures 2 and 3 present the evolution of the frequency and intensity of J's anger episodes. According to Figure 1, a change in trend was observed in the frequency of anger episodes beginning in the second session. This trend stabilized in post-treatment and was maintained at follow-up. The average of problematic daily anger episodes in the baseline was 2, while at follow-up it was 0.5.

The intensity of anger episodes followed a pattern similar to frequency. Beginning in the second session, episodes started decreasing significantly in intensity. The average intensity of episodes in the baseline was 7.4, while at follow-up it was 1.5. In conclusion, anger episodes became less frequent and intense following introduction of the intervention.

The intensity of J's complaints also showed a similar evolution. Beginning in the second session, complaint intensity began to decrease until reaching a low level. Specifically, the average intensity of complaints in baseline was 7.6 and decreased to 1.25 at follow-up.

Statistical Analysis

Statistical analysis coincided with visual analysis. The baselines of the three dependent variables showed no statistically significant trend (anger episodes: Tau-U = 0.300, p = .462; anger intensity: Tau-U = 0, p = 1; complaint intensity: Tau-U = 0.300, p = .462). However, after intervention introduction, statistically significant decreasing trends were found (anger episodes: Tau-U = 0.360, p = .037; anger intensity: Tau-U = -0.582, p < .001; complaint intensity: Tau-U = -0.680, p < .001). All effect sizes of the intervention were statistically significant (anger episodes: Tau-U = -0.678, p = .023; anger intensity: Tau-U = -0.667, p = .025; complaint intensity: Tau-U = -0.678, p = .023).

Results were maintained at the two-month follow-up. Specifically, analyses revealed statistically significant Tau-U values when comparing baseline data with follow-up data (anger episodes: Tau-U = -0.900, p = .028; anger intensity: Tau-U = -1, p = .014; complaint intensity: Tau-U = -1, p = .014).

Parental Report

Parents' comments confirmed the trend in the records: "We started to have the feeling that it is no longer a continuous war." Regarding rumination, parents reported throughout the sessions that J made much less mention of aspects he disliked about his brother or school, and when he did, he no longer spent as much time dwelling on them, with increased time now devoted to schoolwork, family conversations, and leisure activities. Additionally, they commented that times when all were together at home were "much more bearable."

At follow-up, parents reported detecting relevant changes in J's repertoire, expressing it as follows: "He is more focused and acts as the older brother, he has assumed more responsibility." Although he still did not show much affection toward his brother, they have gained a certain complicity and have even started playing together when at home. Additionally, they reported that his class teacher noticed a change in behavior and commented that his attitude in class is more friendly and he no longer "tries to be right all the time in group activities."

Discussion and conclusions

The present study aimed to examine the efficacy of an ACT intervention in a 9-year-old boy presenting with aggressive behaviors and dysfunctional rumination. The intervention was grounded in the three main ACT strategies derived from the conceptualization of psychological flexibility from RFT.

Specifically, the intervention had two main foci. On one hand, work with J's parents focused on their own ability to respond to those thoughts and emotions with discriminative and inflexible function from a hierarchical perspective with the "I" objective, while facilitating the derivation of rules that pointed to actions aimed at strengthening the flexibility repertoire in J. On the other hand, direct work with J centered on strengthening his flexible pattern through different exercises and metaphors, with special emphasis on altering his rumination response.

The intervention's effect was evaluated using an A-B single-case design with three measures recorded by parents: frequency and intensity of anger episodes. The intervention proved highly efficacious, both in reducing the frequency and intensity of anger episodes and in reducing complaint intensity, which was taken as an indicator of childhood rumination.

Specifically, taking into account visual analysis and parental reports, results showed clinically significant changes in all three measures. Statistical analysis confirmed that the intervention had statistically significant effects on all variables.

Furthermore, this study is consonant with promising findings found in previous similar ACT studies in childhood populations. This study adds to the commitment to anchor interventions to the definition of psychological flexibility in children from RFT, so that the movements made throughout the intervention could be clarified in terms of the relational processes involved (Luciano et al., in press; Ruiz et al., 2012; Ruiz y Perete, 2015; Salazar et al., 2020; Törneke et al., 2016).

This study must be interpreted considering certain limitations. First, it is a case study, so more replicas are necessary to confirm ACT efficacy for this type of difficulties. In this regard, it should be noted that the intervention design does not allow isolating the effect of intervention with parents J from direct intervention with J, and only a combined effect of the various components can be discussed. Second, measures based on parental reports have widespread limitations in the literature, so it would have been more appropriate to have independent evaluators in future studies. However, it should be noted that this study was conducted in a private practice context. While there is difficulty in data collection through independent observers, it also has the advantage of analyzing intervention efficacy in a natural context. In conclusion, future studies could take into account these prior considerations and, on one hand, compare the efficacy of combined intervention with parents and child, intervention exclusively with the child, and intervention exclusively with the parents; and, on the other, add other types of measures, for example in the sessions themselves, that would allow for more complete analysis of changes.

In conclusion, this study sheds further light on the efficacy of ACT-based interventions in the childhood field and, more specifically, of interventions aimed at reducing rumination as a predominant reaction and precursor to other more problematic inflexible reactions such as aggressive behaviors.

Significance and contribution

This study contributes to the field of childhood psychological treatment by demonstrating the efficacy of an intervention grounded in psychological flexibility for simultaneously reducing aggressive behaviors and dysfunctional rumination patterns. The research illustrates how strategies based on Relational Frame Theory (RFT)—including discrimination of inflexible patterns, work with values and committed actions, and developing observational distance from problematic private events—can generate clinically significant changes in childhood clinical practice. The integrated approach combining direct intervention with the child and parental support underscores the importance of considering the complete relational context in treating childhood emotional and behavioral difficulties.