22 nd annual association for play therapy international conference october 4-6, 2005, nashville,...

22nd Annual Association for Play Therapy International Conference

October 4-6, 2005, Nashville, Tennessee, USA

Ulrike Franke & Herbert H.G. Wettig

The Effectiveness of Theraplay®

on Young Children Experiencing Receptive Language Disorders

(Verbal Comprehension Disorder)

® Copyright 2005

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In the US, we tend to reserve the use of the word "suffer" for conditions which are notable for physical pain, so "experience" or "manifest" may be more appropriate verbs for this topic.I'll mark my changes in RED so you'll know what I've done.

Copyright 2005 by Theraplay Institut

The Effectiveness of Theraplay on Receptive Language Disorders

2

Overview• Theraplay®

What is Theraplay? The model for Theraplay. Therapeutic dimensions. Setting. Theoretical background.

• Receptive Language DisordersWhat are receptive language disorders?Level of knowledge. Body of research.

• The Effectiveness of Theraplay on young children with receptive language disordersResearch objective. Methods. Samples. Repeated measurement.Evaluation of the effectiveness of Theraplay on receptive language disordered toddler and preschool children ...... being oppositional defiant... being shy... suffering an autistic-like lack of social mutuality.Statistically significant symptom reduction by Theraplay. Duration of treatment. Number of therapeutic sessions until success.



3

What is Theraplay?



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Historical highlights of Theraplay®

® 1996. The term ‚Theraplay‘ is legally protected by Wz. 39518465. • Halfway through the 1960s: Theraplay was developed by

the Heidelberg-born clinical psychologist Ann M. Jernberg, Ph. D., to support the Head Start Project of Chicago.

• 1967: Jernberg founds The Theraplay Institute in Chicago.• 1979: Ann M. Jernberg‘s first book about Theraplay:

“Theraplay. A New Treatment Using Structured Play forProblem Children and Their Families“ (German: Franke, 1987)

• 1999: Ann M. Jernberg & Phyllis B. Booth‘s book:“Theraplay. Helping Parents and Children Build Better Relationships Through Attachment-Based Play“

• 1998 – 2005: Ulrike Franke & Herbert H. G. Wettig.Scientific research in Germany and Austria evaluatingthe effectiveness of Theraplay on toddler and preschoolers.



5

What is Theraplay®? ® 1996. The term ‚Theraplay‘ is legally protected by the European Patent Office,

Wz. 39518465, and world-wide for The Theraplay Institute, Wilmette, IL, USA.

• Theraplay is a special kind of play therapy.It is a family therapy for hard to treat children creating fun to the children and plucking up their parent‘s courage.

• Theraplay is an interactive play therapy. Theraplay is a play therapy without any toys. Theraplay is based on the pattern of a natural, healthy parent-child interaction.

• Theraplay is a structured play therapy.Structured play and rituals give the child a secure base.

• Theraplay is a directive play therapy.The therapist guides the therapeutic play.



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Theraplay’s orientation

• Theraplay is developmentally oriented.Theraplay as a treatment is oriented to thedevelopmental age of the child, not the chronological one.

• Theraplay is need oriented.The treatment is oriented to the clinical needs of the child.

• Theraplay is affect regulating.Nurturing, touch, interactive care are quieting and soothing.

• Theraplay is a short-term play therapy.Practice-based evidence shows that a disordered childtreated with Theraplay significantly reduces his symptomswithin 19–20 30-minute therapeutic sessions on average.(Children diagnosed with Pervasive Developmental Disorders need 26-27 such sessions in average to achieve the therapeutic aim.)



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The model of Theraplay

• Model for Theraplay ... ... is ”a healthy mother-infant relationship“ (Jernberg, 1979), including Winnicott‘s idea of “a good enough mother“(Winnicott, 1958).

• Basis for the model ... are Jernberg‘s observations of behavior pattern of around 400 observed mother-infant dyads. (Munns, E., cited in Schaefer, 2003. Foundations in Play Therapy)

• The mother is the example for the therapist reacting empathetically to the needs of her child, regulating his or her affect, being attuned to her child, and being touching and playful.

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Therapeutic dimensions of Theraplay

• Jernberg found by observation four important natural dimensions of behavior in mother-child relationships:– structure,– engagement (stimulating the child to become engaged),– challenge, and– nurturing the child.

• These are also the therapeutic dimensions of the interactive short-term play therapy ‘Theraplay‘.



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Structure as a therapeutic dimension of Theraplay

• Structure helps the child to feel secure,- e.g., because the therapist is responsible for guidance,- building limits, that the child can learn to control himself,- mediating well-ordered and easily comprehensible rules.

• Structure helps children experiencing externalized or internalized disturbances,– helps especially hyperactive, over-stimulated children, – helps especially oppositional defiant children, – helps especially children seeking self-efficacy,– helps especially shy, socially withdrawn children,– helps especially socially anxious children, too.



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Engagementstimulation to become engaged

as a therapeutic dimension

• Engaging, playful activitiesestablish a connection between therapist and child.

• The “how to do“ of the stimulation is important, to engage the child in his or her emotional and cognitive functions.

• Children need different kinds of stimulation,to get engaged and involved in a relationship – powerful, active, gentle, soothing ones, etc.



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Challenge as a therapeutic dimension

• Challenging activities help the child, – to develop

his or her sense of self, self-reliance, self-esteem,– to feel competent and self-sufficient,– to go into risks appropriate for his or her age.

• Challenging activities are especially useful with shy, bashful, socially withdrawn, non-flexible, anxious children, who may think of themselves as not being capable.



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Nurturing as a therapeutic dimension

• Quieting, calming, soothing, nurturing activities– give the child

the warm feeling of a secure, certain, safe surrounding, in which a caregiver offers comfort and stability,

– fulfills unsatisfied needs of the early childhood,– helps the child to relax,– relieves emotional grief and physical pain, – builds an internal image on his or her own mind,

of being lovable, endearing, and being worthy of others.• Nurturing is especially essential for

hyperactive, oppositional defiant, and aggressive children.



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Attitudes and activities of the therapist(some examples)

• Sensitive empathizing with the needs of the child,• sensitively building a relationship with the child,• playful interpersonal activities (without toys),• directive guidance of the interaction with the child,• silently ignoring aggressive activities of the child,• intervening paradoxically in case of resistance by the child,• gently reinforcing the self-confidence of the child, • solicitously taking care of small injuries of the child,• lovingly imitating sounds of an autistic child,• playfully stimulating activities of a shy, withdrawn child,• emotionally addressing the right hemisphere of the brain.



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Therapeutic Setting(The picture of the boy is approved by his parents)

• TheTherapist(hidden by the small picture)is guiding the therapy,structures, interacts,plays with the child,and is nurturing him;

• The Co-Therapist gives the child a warm feeling of being safe,

• acts for and togetherwith the little child,

• speaks for the non-comprehending child,

• protects the therapistfrom injuries by aggressive children.

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Changes on this slide are noted in GREEN.



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Example of a child manifesting receptive language disorder

Thomas at the beginning of the therapy. Clip from the 2nd therapeutic session

(30 min. duration of the session plus preparation and evaluation afterwards)

• Start of Video 1



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Example of a child manifesting receptive language disorder

Thomas halfway through the therapy. Clip from the 9th therapeutic session

(30 min. duration of the session plus preparation and evaluation afterwards)

• Start of Video 2



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Neurobiology as a background to understand the effectiveness of Theraplay

• The neural network of the infant‘s brain – develops particularly fast during the first 18-24 month after birth

due to interpersonal interaction with his or her empathetic caregiver. – The kind of positive or negative emotional interaction

between the caregiver and the brain of the child forms neural pathways that determine who the child will be and how he or she will behave in later life.

– That is the root position of intellectual development of the child. Daniel J. Siegel, 1999, School of Medicine, UCLA Los Angeles und Children‘s Mental Health Alliance, N.Y.

• Affect regulation – origins in the self of the child. Allan N. Schore, 1994

• Affect dys-regulation – origins in disorder of the socio-emotional self of the child. – Negative experiences in the early childhood have

a long-term effect on emotional affect dys-regulation of the child. Allan N. Schore, 2003



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Attachment theory as a background to understand the effectiveness of Theraplay

• Neuronal self-organization of the child‘s developing brain is based on the relationship of the context with the caregiver‘s brain.

• Affect regulation is a main principleof organizing the human development and motivation.

• Learning to regulate affect is connected to the development of attachment with others.

• Attachment theory shows that empathetic turn-takingand engaged interaction between caregiver and child will...– build a secure attachment between caregiver and child,– form the child‘s internal working model of himself and his world

positively,– and determine the regulation of the child‘s emotions and activities.(e.g., Bowlby, 1988, 1995; Brisch, 2003; Stern, 1974, 1986, 1995)

• Secure or non-secure attachment between the child and his or her caregiver significantly influences the later life of the child.

(e.g., Goldberg, 2000; Hughes, 1998; Rutter, 1994; Waters, Weinfield, & Hamilton, 2000; Ziegenhain & Jacobsen, 1999. Cross-cultural: van Ijzendorn & Sagi, 1999)



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Touch as a therapeutic element of Theraplay

• The positive effect of loving, nurturing, soothing touch is evidence-based by scientific research.(e.g., Field: Touch, 2001; Montagu, 1988)

• Touching the child by his or her caregiver produces an increased release of endorphins in the child‘s brain.

• The raised endorphin level increases the pleasure of both brains and the interpersonal interaction between them.

• Research, for example, has shown, that premature children who are touched repeatedly in a loving, nurturing, soothing way will grow faster in body weight and overall maturation than children who are not touched in this way.(Field: Touch, 2001)



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Play as a therapeutic element of Theraplay

• Play smoothes the way for a relationship with the child.• Play improves the child‘s attention and concentration,

- motivates the child‘s cooperation,- loosens up the child‘s efforts and stressors,- takes away the oppressiveness of a severe situation,- possibly lessens the child‘s depressing reality.

• Play lets the child‘s neuronal system blossom out,- optimizes the neuronal organization of his brain,- breaks the cascade of negative social influences which would otherwise possibly shape the child‘s brain



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Therapeutic perspectives of Theraplay

• The perspective into the child‘s disorder.The view of the child‘s symptoms to be treated.

• The perspective into the child‘s development.The view of the level of the child‘s current development.

• The perspective into the child‘s resources.The view of the child‘s capability to develop aptitudes.

• The perspective into the child‘s relationships.The view of the child‘s interactive behavior and his or her change in the therapeutic relationship.

• The perspective into the child‘s motivation.The view of the child‘s willingness to cooperate,to get involved in therapeutic play, and with that, to change his behavior patterns.



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Symptomsin which Theraplay is particularly effective

(examples)

• Symptoms of external behavior or conduct disorders– e.g., hyperactive, impulsive, inattentive children,– non-cooperative, oppositional defiant, aggressive ones.

• Symptoms of internal disorders in interactive behavior– e.g., shy, bashful, socially withdrawn children,– suffering a lack of confidence in themselves and others.

• Symptoms of affective attachment disorders– traumatized, hospitalized, foster and adoptive children.

• Symptoms of pervasive and developmental disorders– e.g., autistic-like lack of social mutuality in interaction,– e.g., developmental delay, receptive language disorder.



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What is a receptive language disorder?

Another term for receptive language disorder is ‘Verbal comprehension disorder‘



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Verbal comprehensionLiterature: Amorosa & Noterdaeme (2003). Rezeptive Sprachstörungen. Manual

• Verbal comprehension in the broader sense ...... is the ability to include former experiences and the situation in which words are spoken, aside from the word‘s contents, and to react in accordance with the word‘s meaning. (This definition is similar to the ordinary term “to understand“.)

• Verbal comprehension in the narrow sense ...... is the ability to understand the sense and meaning of remarks based on a word‘s meaning and on the use of the grammatical rules, i.e. to understand decontextualized language



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Description of receptive language disorderICD-10 International Classification of Diseases, Chapter V Mental Disorders (F80.2)DSM-IV Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (315.31)

• Receptive language disorder is a specific developmental language disorder.

• The child‘s language comprehension is below the level of the child‘s developmental age.

• Research criteria on basis of ICD-10: The child‘s language comprehension measured by a standardized test score which is below the limits of ...- 2 standard deviation from the child‘s chronological age- 1 standard deviation from the child‘s non-verbal IQ.



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The problem of inconspicuousness of the receptive language disorder

1) Literature: Amorosa & Noterdaeme (2003). Rezeptive Sprachstörungen. Manual 2) Lit.: Knoelker, Mattejat & Schulte-Markwort (2000). Kinder- und Jugendpsychiatriee

• Receptive language disorder is a developmental disorder1.• Developmental disorders of speech and language

are narrowly tied to the biological maturation of the brain2.• The common pattern of speech and language development

of receptive language disordered children is deviant from the early stages of development on1.

• Nevertheless receptive language disorderis often failed to be noticed by parents and physicians1.

• Most parents recognize their child‘s receptive language disorder much too late.It is suspected that parents are accustomed to communicating with their children using facial expressions and gestures, and that their children learned to say “Yes, yes...“ to give the impression that they understood their parents’ words. Often the children have just interpreted the gestures of their parents.



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Significance of language comprehension(Some statements)

• Language comprehension is closely connected with the child‘s whole development.(K. Sarimski, 1984, 29, zit. in Mathieu, 1995, 37)

• The development of language comprehensionis embedded in the development of the mind and cognition.(K. Sarimski, 1984, 29, zit. in Mathieu, 1995, 37)

• With lacking or impaired language comprehension it is impossible for the child to have important experiences and because of that to make good (developmental) progress. (S. Mathieu, 1995. Vergleichende Untersuchung. In: VHN 64, 36-52)

• The estimated rate of prevalence is around 3 % of children.(Knoelker, Mattejat & Schulte-Markwort (2000). Kinder- und Jugendpsychiatrie)



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Consequences of receptive language disorder 1) Literature: Amorosa & Noterdaeme (2003). Rezeptive Sprachstörungen. Manual

2) Lit.: Knoelker, Mattejat & Schulte-Markwort (2000). Kinder- und Jugendpsychiatrie

• Receptive language disorder interferes not only with the child‘s total language development, but also with the cognitive and emotional development1.

• Receptive language disorder results in negative effectsboth on social interaction with caregivers and others,and in the child‘s academic development as well1.

• Children with receptive language disorder are at high risk, to develop emotional, social and behavior disorders later2.

• In nearly all casesthe expressive language is distinctly impaired, as well2.



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Missing approachesto treat receptive language disorders

Literature: Amorosa & Noterdaeme (2003). Rezeptive Sprachstörungen. Manual

• Specific therapeutic approaches are missed to a large extent. At least in the German speaking area of Western Europe there are no specific approaches to treating young children‘s verbal comprehension disorder.

• Logopaedia is found in practice to be a lengthy treatment. Speech-language intervention is not effective until the receptive language disordered child starts to be cooperative, attentive and able to concentrate.

• There is very little literature.In scientific literature there are very few recommendations for the therapeutic needs of such children.



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Very little research has been done with verbal comprehension disorder

Lit.: B. Zollinger, 1995. Störungen des Sprachverständnisses. Edition SZH, 109-122

• Literature about development of verbal comprehension.In fact, there is a great number of authors describing how and when children start to speak their first words and sentences.However, there is only a very small body of publications aboutthe basics of children‘s development of verbal comprehension.

• There is nearly no research on verbal comprehension.Nearly no research reports are published about the results of controlled studies to evaluate the effectivenessof treatments to improve receptive language disorder.

• The reason why studies are missed?Receptive language disorder is not observable. Only the child‘s reaction to requests can be observed to compare children with and without verbal comprehension deficits.



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Researchevaluating the effectiveness of Theraplay

on toddler and preschool childrendiagnosed with receptive language disorder

(Verbal comprehension disorder)



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Research approach and objective

• Two field studieswith repeated measurement in treatment settings.

• 1998-2005 A controlled Longitudinal Study (CLS) with a follow-up 2 years after termination of the treatment

• 2000-2004 A nation-wide Multi-Center Study (MCS)

in 9 quite different treatment facilities

• Objective of the studies: Evaluation of the effectiveness of Theraplayon toddler and preschool children with dual diagnoses of developmental speech-language disorders and different kinds of behavior disorders,e.g. external, internal, pervasive ones.



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Method of the Controlled Longitudinal Study

• Controlled Longitudinal Study (CLS)1998 – 2003 N = 60 toddler and preschool children (gross sample N = 68)

with dual diagnoses of developmental language disorder and clinically symptomatic behavior disorder, whose treatment with Theraplay was terminated in 2003.

N = 30 clinically non-symptomatic, ”normal“ control children of the same age and sex (equally matched sample)

• 2000 – 2005 N = 40 follow-up two years after individual discharge from therapy.Advantages: – Repeated measurement (waiting time begin - 2 years after therapy) – High internal validity of the results in this patient cohort.

• Disadvantages: – Generalization to other groups of patients is impossible, because...– of being carried out in only one region, the wider area of Heidelberg,– of being carried out in only one facility (Phoniatric Paedaudiologic Center),– of being carried out by only one Theraplay therapist.

• Therefore, in 2000 a nation-wide Multi-Center-Study (MCS) was started.

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Method of the Multi-Center Study

• A nation-wide Multi-Center Study (MCS)2000 – 2004 N = 319 clinically symptomatic toddler and preschoolers whose treatment with Theraplay terminated in 2004 .

• Nation-wide in Germany and Austria• by 14 therapists of different professions• carried out in 9 different therapeutic facilities as ...

– an out-patient department of an early intervention facility,– a kindergarten, department of a center for handicapped children,– a ward, department of a child and adolescent psychiatric unit,– a kindergarten of a child welfare unit in an area of social deprivation,– an out-patient department of a phoniatric paed-audiologic unit,– a speech therapy unit in an early intervention facility, – a private practice of children‘s psychological psychotherapist,– a private practice of children‘s speech-language therapists, etc.



35

Research instrumentsThe only instruments described here are those which were needed for this part of

the study. In addition to these, other observation sheets, diagnostic tests, and questionnaires were used.

• Data referring to the child and his or her family or caregiverQuestionnaire gathering data regarding the child‘s history and the socio-demographic data of his amily/caregiver.

• Diagnosis, formation, and change of the child‘s symptoms Repeated clinical evaluation of the child‘s symptoms using CASCAP-D, the German version of the Clinical Assessment Scale for Child and Adolescent Psychopathology (Doepfner et al., 1999)

Comment: At the beginning of this research in 1998 CASCAP-D was part of the basic documentation in child and adolescent psychiatry and children‘s hospitals.

• Data about the duration of the treatment with TheraplayQuestionnaire: completed by the therapist on basis of patient‘s record.



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Points in time of measurement

• Points in time of the Controlled Longitudinal Study (CLS) – t1 = at the beginning of the therapy using Theraplay– t6 = after the end of the therapy using Theraplay– t7 = 2 years after end of the therapy using Theraplay

CASCAP-D was not used at the beginning of the waiting time (time t0).Results measured at points during the process of therapy t2 – t5 are not reported.

• Normal, clinically non-symptomatic Control Group (CG-N)– t1 = at the beginning of a 16-week waiting time– t6 = after the end of the 16-week waiting time

• Points in time of the Multi-Center study (MCS) – t1 = at the beginning of the therapy using Theraplay– t6 = after the end of the therapy using Theraplay.

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37

Sub-samples of children demonstrating receptive language disorder

CLS Controlled Longitudinal Study 1998-2005• N= 52 children in total* with receptive language disorder

of these N= 19 oppositional defiant childrenN= 19 shy children N= 14 children with an autistic-like lack of social mutuality

• N= 30 clinically non-symptomatic toddler and preschoolers of the same age and sex (matched control sample)

MCS Multi-Center Study since 2000 (9 different facilities)

• N=193 children in total* with receptive language disorder of these N=109 oppositional defiant children Kinder

N= 99 shy childrenN= 45 children with an autistic-like lack of social mutuality

*All sub-samples are toddler and preschool children with dual diagnoses of both receptive language disorder and behavior disorders.



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Age and sex of the children with receptive language disorders

Mean of age (M). Sex in %

CLS: Age in years: month

• M = 4;03 N= 52 in total language disordered toddler, preschooler

Boys Girls 4;04 years 4;03 years

N = 38 N = 14• M = 4;06 N= 30 matched clinically

non-symptomatic toddler, preschooler Control sample N

MCS: Age in years: month• M = 4;02 N=193 in total

language disordered toddler, preschooler Boys Girls

4;02 years 4;02 years N = 133 N = 60

CLS: Sex in % Boys Girls Ratio 2,7:1• 73% 27% N= 52 in total

language disordered toddler, preschooler N = 38 Boys N = 14 Girls

• 70% 30% N= 30 clinically non-symptomatic toddler, preschooler

Cóntrol sample N

MCS: Sex in %Boys Girls Ratio 2,2:1

• 69% 31% N=193 in total language

disordered toddler, preschooler N = 133 Boys N = 60 Girls

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Marital status of household and upbringing of the children with receptive language disorder

CLS: N=52 receptivelanguage disordered children

• Social status of the mothers90% married mothers10% unmarried mothers (unmarried living together, been separated, single mothers)

• Social status of the children85% legitimate children11% illegitimate natural Kinder 4% adopted and foster children

• Upbringing of the child88% by both parents12% by one parent

• 69% in kindergarten

MCS: N=193 receptivelanguage disordered children

• Social status of the mothers69% married mothers31% unmarried mothers(unmarried living together, beenseparated, widowed, single mothers)

• Social status of the children79% legitimate children15% illegitimate natural children 6% adopted and foster children

• Upbringing of the child80% by both parents20% by one parent

• 77% in kindergarten

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I would suggest eliminating the part about the legitimate vs. illegitimate status of the children from all the slides, as that is not necessarily a dichotomy that is identified in the US. There is almost no social stigma attached to this any more, and unless there is a statistically significant difference in these populations, I wouldn't include it.However, the single-parent vs. two-parent data (including married parents, unmarried but living together, divorced or widowed parents, one vs. two parent foster or adoptive homes, etc) may be indicative of something more important, and should be included.



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Initial Degree of receptive language disorder (point in time t1 at the beginning of therapy)Evaluation of the symptoms using CASCAP-D, Doepfner et al., 1999:

*4=severe..., 3=moderate..., 2=mild symptoms; 1=clinically non-symptomatic

Sub-samples of toddler and preschool childrenwith receptive language disorder N

mean*

Mt1

sd

st1

N= 52 Toddler and preschool children, Controlled Longitudinal Study (CLS)

= Initial degree of symptom’s severity on average 52 3.12 0.81

N=193 Toddler and preschool children, Multi-Center Study (MCS)

4 = initially severe degree of symptoms 73 4.00 0.00

3 = initially moderate degree of symptoms 68 3.00 0.00

2 = initially mild degree of symptoms 52 2.00 0.00

= initial degree of symptom’s severity on average 193 3.11 0.78

N= 30 Clinically non-symptomatic toddler and preschoolers Control Group N (CGN)

= initial degree of symptom’s severity on average 30 1.00 0.00



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The effectiveness of Theraplay on receptive language disorders

MCS: N = 193 receptive language disordered of 291 behavior disordered children CLS: N = 52 receptive language disordered of 60 behavior disordered children .CGN: N = 30 clinically non-symptomatic children ( = Control group N) .

Degree of markedness and change of the symptoms of children suffering from receptive language disorder,

and the lasting effect two years after Theraplay4.0

2.4

3.0

2.02.0

1.5

1.0

2.02.3

2.1

3.13.1

1

2

3

4

Beginning of therapy (t1) End of therapy (t6) 2 years after therapy (t7)

De

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MCS: 4 = initially severe degree of symptom MCS: 3 = initially moderate degree of symptom

MCS: 2 = initially mild degree of symptom CGN: 1 = clinically non-symptomatic control NMCS: degree of symptoms in average CLS: degree of symptoms in average



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Initial mean degree (Mt1), change (Mt1 Mt6)and statistical significance (p) of the change

of receptive language disorders with Theraplay (Evaluation of the degree of symptoms using CASCAP-D, Doepfner et al., 1999)

Sub-samples of toddler and preschool childrenwith receptive language disorder

Change of symptoms

N Mt1 Mt6st6

significance

prob.

N= 52 Toddler and preschool children, Controlled Longitudinal Study (CLS)

= degree of symptom’s severity on average 52 3.12 1.55 0.9 p<.0001

N=193 Toddler and preschool children, Multi-Center Study (MCS)

Scale: 4 = severe degree of symptoms 73 4.00 2.42 0.9 p<.0001

3 = moderate degree of symptoms 68 3.00 1.97 0.7 p<.0001

2 = mild degree of symptoms 52 2.00 1.46 0.5 p<.0001

= degree of symptom’s severity on average 193 2.11 2.01 0.8 p<.0001

N= 30 Clinically non-symptomatic toddler and preschooler, Control Group N (CGN)

= degree of symptom’s severity on average 30 1.00............ 0.0 -



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The effectiveness of Theraplayon receptive language disordered

toddler and preschool childrenwith oppositional defiant behavior



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What isoppositional defiant behavior?

Example case in point: Bastian

• The child provokes arguments.• Frequently saying NO, irrespective of being useful - or not. • Frequently ignoring rules or instructions of adults.• Frequently fighting with adults and with other children.• Exceptionally frequent and severe tantrums.• Frequently shifting own failings onto other children.• Frequently feeling bothered by others.• Frequently being mad at and filled with wrath against others.• Frequently being spiteful and vindictive toward others.• The child punches, kicks, or bites adults and other children.

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Is this a child's name ? (I'm not familiar with it!)



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The effectiveness of Theraplayon relevant symptoms in social interaction

of oppositional defiant, receptive language disordered children

The effectiveness of Theraplay on symptomssuch as...

• the child‘s oppositional defiant behavior• the child‘s non-cooperative behavior• the child‘s attention deficit, and• the child‘s receptive language disorder.

Comparingthe treated receptive language disordered toddler and preschool childrenwith matched clinically non-symptomatic, ‘normal‘ control children (CG-N).



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Sub-samplesof children with both oppositional defiant

and receptive language disorders

• MCS: N=109 oppositional defiant, language disordered children Mean: children with receptive language disorder

• N= 54 oppositional defiant, language disordered children with severe marked symptoms

• N= 38 oppositional defiant, language disordered children with moderate marked symptoms

• N= 26 oppositional defiant, language disordered children with mild marked symptoms

• CLS: N= 19 oppositional defiant, language disordered children Mean: children with receptive language disorder

• CGN: N= 30 clinically non-symptomatic, ‘normal‘ control sample matched in age and sex



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The effectiveness of Theraplayon oppositional defiant interactive behavior

of oppositional defiant, receptive language disordered childrenMCS: N = 109 receptive language disordered, oppositional defiant childrenCLS: N = 19 receptive language disordered, oppositional defiant children CGN: N = 30 clinically non-symptomatic children of same age and sex ()


and the lasting effect two years after Theraplay4,0

1,6

3,0

1,3

2,0

1,21,11,4

3,2

1

2

3

4


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The effectiveness of Theraplayon non-cooperative behavior



and the lasting effect two years after Theraplay

3,0

1,71,5

1,11,5

3,1

1

2

3

4


Deg

ree o

f ch

ang

e

CGN: 1 = clinically non-symptomatic control N MCS: degree of symptoms in average

CLS: degree of symptoms in average



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The effectiveness of Theraplayon attention deficit

of oppositional defiant, receptive language disordered childrenMCS: N = 109 receptive language disordered, oppositional defiant children CLS: N = 19 receptive language disordered, oppositional defiant children CGN: N = 30 clinically non-symptomatic children of same age and sex ()



1,3

3,1

2,0

2,9

2,01,7

1

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4


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The effectiveness of Theraplayon receptive language disorder




1,0

3,0

2,01,7

2,9

2,1

1

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4


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Statistical significance of the symptom reduction after Theraplay

on oppositional defiant, receptive language disordered childrenM=Mean using CASCAP-D, =change of symptom, sd=standard deviation

4-grade scale: 4= severe..., 3=moderate..., 2=mild marked; 1=clinically non-symptomatic

symptoms

CLS: N=19 oppositional defiant,

receptive language disorderedtoddler and preschool children

MCS: N=109 oppositional defiant,


Mt1 Mt6 sdt6

Significanceprob.

Mt1 Mt6 sdt6

Significanceprob.

oppositionaldefiant behavior

3.2 1.4 0.5 p<.0001 3.2 1.4 0.8 p<.0001

non-cooperativebehavior

3.1 1.7 0.9 p<.0001 3.0 1.5 1.0 p<.0001

attention deficit 2.9 1.9 1.0 p<.0025 3.1 2.0 0.7 p<.0001

receptive langu-age disordered

2.9 2.1 0.8 p<.0010 3.0 2,0 0.8 p<.0001



52

Duration of the Theraplay treatment of oppositional defiant, receptive language disordered children

Number of therapeutic 30-minute sessionsMean number of sessions required to achieve the therapeutic aim

Average number of therapeutic Theraplay sessions on initially oppositional defiant, receptive language disordered children

18,2

20,3

0 5 10 15 20 25 30

N=109, M=20.3, sd=11.2 range 10 - 60 sessions

N=19, M=18.2, sd=6.9, range 9 - 36 sessions

Average number of therapeutic 30-minute Theraplay sessions

CLS: Number of sessions MCS: Number of sessions



53

Improvement of the child‘s verbal comprehension

• Research instrument: Pizzamiglio verbal comprehension-test (see B. Zollinger, CH)

• Repeated testing of the child‘s verbal comprehension– at the beginning of the waiting time (t0)– at the beginning of the Theraplay therapy (t1)– at the end of the Theraplay therapy (t6)– two years after the end of the Theraplay therapy (t7) (only investigated in the controlled longitudinal study CLS)



54

Improvement of the child‘s verbal comprehensionof oppositional defiant, receptive language disordered children

Research instrument: Pizzamiglio verbal comprehension test (see B. Zollinger)Mean

Improvement of the verbal comprehension of oppositional defiant, receptive language disordered

children from beginning of the waiting time untill two years after Theraplay treatment

22, 3

19, 2

23, 5

25, 3

18

20

22

24

26

Beginning waitingtime (t0) Beginning of therapy (t1) End of therapy (t6) 2 years after therapy (t7)

De

gre

e o

f c

ha

ng

e

Repeatedly measured only in the controlled longitudinal studyN=19 oppositional defiant, receptive language disordered children

Statistical significance of symptom's change from t1 - t6: prob=.0198



55


toddler and preschool childrendemonstrating shy interactive behavior



56

Shy behaviorin situations of social interaction

Outlining the term ‘shy‘ based on CASCAP-D (Doepfner et al., 1999)

• Obviously the child feels very insecure and unwell in many situations.

• The child speaks – if at all – generally weakly, faltering, turning red, in short: is shy.

• The child avoids eye contact in social interaction.• The child avoids almost any contact with peers.• In most situations the child is unable to

maintain his or her rights in the presence of peer demands. • Shyness is not a clinically classified disorder,

but is frequently the beginning of later learning disorders.



57

The effectiveness of Theraplayon relevant symptoms in social interaction

of shy, receptive language disordered toddler- and preschool children


• the child‘s oppositional defiant behavior• the child‘s non-cooperative behavior• the child‘s attention deficit, and• the child‘s receptive language disorder.




58

Sub-samplesof shy, receptive language disordered children

• MCS: N= 99 shy, language disordered children Mean: children with receptive language disorder

• N= 33 shy, language disordered children with severe marked symptoms

• N= 34 shy, language disordered children with moderate marked symptoms

• N= 32 shy, language disordered children with mild marked symptoms

• CLS: N= 19 shy, language disordered children Mean: children with receptive language disorder

• CGN: N= 30 clinically non-symptomatic, ‚normal‘ control sample matched in age and sex

Preferred Customer

Does this line refer to mild, moderate, and severe symptoms of shyness or of receptive language disorder?



59

The effectiveness of Theraplayon the interactive behavior

of shy, receptive language disordered children MCS: N = 109 receptive language disordered, shy children CLS: N = 19 receptive language disordered, shy children

CGN: N = 30 clinically non-symptomatic control children of same age and sex ()



1,51,2

2,0

1,11,2 1,3

2,5

1,1

3,03,0

1,11

2

3

4


Deg

ree

of

chan

ge

MCS: 4 = initially severe degree of symptom MCS: 3 = initially moderate degree of symptomMCS: 2 = initially mild degree of symptom CGN: 1 = clinically non-symptomatic control NMCS: degree of symptoms in average CLS: degree of symptoms in average



60






2,0

1,1

2,3

1,3 1,11,4

1

2

3

4


De

gre

e o

f c

ha

ng

e





61

The effectiveness of Theraplayon inattentive behavior





1,2

2,8

1,91,61,7

2,9

1

2

3

4


Deg

ree o

f ch

an

ge





62

The effectiveness of Theraplayon receptive language disorders





3,1

1,9

2,32,1

1,0

3,0

1

2

3

4


De

gre

e o

f c

ha

ng

e





63


with shy, receptive language disordered childrenM=Mean using CASCAP-D, =change of symptom, s=standard deviation


symptoms

CLS: N=19 oppositional defiant,


MCS: N=109 oppositional defiant,


Mt1 Mt6 sdt6

Significance

prob.Mt1 Mt6 sdt6

Significance

prob.

shy 2,5 1.1 0.3 p=.0025 3.0 1.3 0.6 p<.0001

non-cooperative 2.0 1.4 0.6 p=.0051 2.3 1.3 0.6 p<.0001

inattentive 2.4 1.9 0.7 p=.0099 2.8 1.8 0.7 p<.0001

receptive languagedisordered

3.0 2.2 0.9 p=.0013 3.1 1.9 0.7 p<.0001



64

Duration of Theraplay treatmentof initially shy, receptive language disordered children

Number of therapeutic 30-minute sessionsMean number of sessions required to achieve the therapeutic aim

Average number of therapeutic sessions on initially shy, receptive language disordered children

17,0

18,8

0 5 10 15 20 25 30

N = 99, M = 18.8, sd = 10.1 range 6 - 55

N = 19, M = 17.0, sd = 4.5 range 11 - 31

Average number of therapeutic 30-minute sessionsCLS: Number of sessions MCS: Number of sessions



65

Improvement of the child‘s verbal comprehension

• Research instrument: Pizzamiglio verbal comprehension-test (see B. Zollinger, CH)

• Repeated testing of the child‘s verbal comprehension– at the beginning of the waiting time (t0)– at the beginning of the Theraplay therapy (t1)– at the end of the Theraplay therapy (t6)– two years after the end of the Theraplay therapy (t7) (only investigated in the controlled longitudinal study CLS)



66

Improvement of the child‘s verbal comprehensionof shy, receptive language disordered children

Research instrument: Pizzamiglio verbal comprehension test (see B. Zollinger)Mean

Improvement of the verbal comprehension of shy, receptive language disordered children

from the beginning of the waiting timeuntill two years after Theraplay treatment

13,5

16,2

22,7

27,1

12

16

20

24

28

Beginn der Wartezeit (t0) Beginning of therapy (t1) End of therapy (t6) 2 years after therapy (t7)

Deg

ree

of

chan

ge

Repeatedly measured only in the Controlled Longitudinal Study (CLS)

N = 19 shy, receptive language disordered toddler and preschool children

Statistic significance of the symptom's change from t1 - t6: prob<.05



67


toddler and preschool childrenwith

an autistic-like lack of social mutuality



68

Autistic-like lack of social mutuality in situations of social interaction

Outlining the term ‘autistic-like lack of social mutuality‘ based on CASCAP-D (Doepfner et al., 1999)

• Lack of social mutualityis found particularly often in autistic children.

• Frequently such children are unable to maintain eye contact and to use facial expression, gestures and body language in situations of social interaction.

• Such children are nearly unable to establish an appropriate mutual contact with othersin situations of social interaction.

• Such children have nearly no contact with peers.



69

The effectiveness of Theraplayon operationally defined symptoms

of receptive language disordered childrenwith an autistic-like lack of social mutuality


• the child’s autistic-like lack of social mutuality• the child’s playing disorder• the child‘s non-cooperative behavior• the child‘s attention deficit, and• the child‘s receptive language disorder.




70

Sub-samplesof receptive language disordered childrenwith an autistic-like lack of social mutuality

• MCS: N=45 language disordered children lacking social mutuality Mean: children with receptive language disorder

• N=12 language disordered children lacking social mutuality with severe marked symptoms

• N=19 language disordered children lacking social mutuality with moderate marked symptoms

• N=14 language disordered children lacking social mutuality with mild marked symptoms

• CLS: N=14 language disordered children lacking social mutuality Mean: children with receptive language disorder

• CGN: N=30 clinically non-symptomatic, ‘normal‘ control sample matched in age and sex



71

The effectiveness of Theraplayon an autistic-like lack of social mutuality

of receptive language disordered children lacking social mutualityMCS: N = 45 receptive language disordered children lacking social mutualityCLS: N = 14 receptive language disordered children lacking social mutuality CGN: N = 30 clinically non-symptomatic children matched in age and sex ()



2,5

2,12,0

1,31,0

3,1

2,0

3,0

1,9

1

2

3

4


De

gre

e o

f c

ha

ng

e





72

The effectiveness of Theraplayon playing disorder




3,1

1,0

2,9

1,81,91,9

1

2

3

4


De

gre

e o

f c

ha

ng

e





73





3,5

1,1

2,8

1,71,81,8

1

2

3

4


Deg

ree o

f ch

an

ge





74

The effectiveness of Theraplayon attention deficit




1,3

3,1

2,62,9

2,0

3,5

1

2

3

4


Deg

ree o

f ch

an

ge





75

The effectiveness of Theraplayon receptive language disorder




3,5

2,4

2,92,6

1,0

3,8

1

2

3

4


De

gre

e o

f c

ha

ng

e





76


on receptive language disordered children lacking social mutualityM=Mean using CASCAP-D, =change of symptom, s=standard deviation


symptoms

CLS: N=14 receptive language disorderedtoddler and preschool children

with an autistic-likelack of social mutuality

MCS: N=45 receptive language disorderedtoddler and preschool children

with an autistic-likelack of social mutuality

Mt1 Mt6 sdt6

Significance

prob.Mt1 Mt6 sdt6

Significance

prob.

an autistic-like lackof social mutuality 3.1 2.1 1.0 p=.0013 3.0 1.9 0.9 p<.0001

playing disorder 3.1 1.9 0.9 p<.0001 2.9 1.8 0.9 p<.0001

non-cooperativeness 3.5 1.8 0.7 p<.0001 2.8 1.7 0.7 p<.0001

attention deficit 3.5 2.6 1.1 p=.0104 3.1 2.0 0.9 p<.0001

receptive language disorder

3.8 2.9 0.7 p=.0002 3.5 2.4 0.9 p<.0001

Preferred Customer

In the third line of the title section, shouldn't this one say "children with an autistic-like lack of social mutuality", rather than "shy"?



77

Duration of Theraplay treatment of receptive language disordered children

diagnosed with an autistic-like lack of social mutuality Number of therapeutic 30-minute sessions

Mean number of sessions required to achieve the therapeutic aim

Average number of therapeutic sessions on receptive language disordered children

with initially an autistic-like lack of social mutuality

27.3

25.6

0 5 10 15 20 25 30

N = 45, M = 25.6, sd = 12.6 range 10 - 60

N = 14, M = 27.3, sd = 9.0 range 17 - 43

Average number of therapeutic 30-minute sessionsCLS: Number of sessions MCS: Number of sessions



78

Theraplay InstitutUlrike Franke und Herbert Wettig KG

Obere Burghalde 42, D-71229 Leonberg www.theraplay-institut.org

Questions about Theraplay treatmentUlrike Franke, RPT-S, CTT-T, SLP

Mozartstr. 1, D-68723 Oftersheim (Germany)Phone ++49-6202-54051 Fax ++49-6202-54958

[email protected] [email protected] www.theraplay-institut.de

Questions about Theraplay research

Herbert H.G. Wettig, DiplompsychologeObere Burghalde 42, D-71229 Leonberg (Germany)

Phone ++49-7152-27062 Fax [email protected] [email protected]

www.theraplay-institut.de

Theraplay is legally protected by Wz. 39518465 and The Theraplay Institute, Wilmette IL

mailto:[email protected]






http://www.theraplay.de/



http://www.theraplay-institut.de/
















22 nd annual association for play therapy international conference october 4-6, 2005, nashville,...

Documents

effectiveness of theraplay

theraplay institute

term theraplay

overview theraplay

model of theraplay model

therapeutic play

interactive play therapy

structured play therapy