Child Psychotherapy

PLAY THERAPY





Play therapy is important for both diagnosis and alleviation of disorder. Play therapy is a form of counseling or psychotherapy that uses play to communicate with and help people, especially children, to prevent or resolve psychosocial challenges. It is useful for depression, ADHD, Impulsiveness, conduct disorders (bullying), aggression, Anxiety, Fearfulness, Low self-esteem, social withdrawal, Reading and writing difficulties. 
Below is the video wherein Applied Behaviour Analysis (ABA) technique is followed for play therapy. 

Applied Behaviour analysis

It describes the seven dimensions of ABA: application; a focus on behavior; the use of analysis; and its technological, conceptually systematic, effective, and general approach.

[edit]Applied

ABA focuses on areas that are of social significance. In doing this, behavior scientists must take into consideration more than just the short-term behavior change, but also look at how behavior changes can affect the consumer, those who are close to the consumer, and how any change will affect the interactions between the two.

[edit]Behavioral

ABA must be behavioral, i.e.: behavior itself must change, not just what the consumer says about the behavior. It is not the goal of the behavior scientists to get their consumers to stop complaining about behavior problems, but rather to change the problem behavior itself. In addition, behavior must be objectively measured. A behavior scientist cannot resort to the measurement of non-behavioral substitutes. (Obviously multidisciplinary work within behavior and psychology may include, for example, analysis of cognition or demographics and exploration of the individual as well, where experimental standards are maintained.)

[edit]Analytic

ABA must be analytic, which means that the behavior analyst can control the behavior that is being changed by changing the control behavior. In the lab, this has been easy as the researcher can start and stop the behavior at will. However, in the applied situation, this is not always as easy, nor ethical, to do. According to Baer, Wolf, and Risley, this difficulty should not stop a science from upholding the strength of its principles.^[21] As such, they referred to two designs that are best used in applied settings to demonstrate control and maintain ethical standards. These are the reversal and multiple baseline designs. The reversal design is one in which the behavior of choice is measured prior to any intervention. Once the pattern appears stable, an intervention is introduced, and behavior is measured. If there is a change in behavior, measurement continues until the new pattern of behavior appears stable. Then, the intervention is removed, or reduced, and the behavior is measured to see if it changes again. If the behavior scientist truly has demonstrated control of the behavior with the intervention, the behavior of interest should change with intervention changes. Here control may be better called "effect" or "influence", of behavior.

[edit]Technological

This means that if any other researcher were to read a description of the study, that researcher would be able to "replicate the application with the same results."^[21] This means that the description must be very detailed and clear. Ambiguous descriptions do not qualify. Cooper et al. describe a good check for the technological characteristic: "have a person trained in applied behavior analysis carefully read the description and then act out the procedure in detail. If the person makes any mistakes, adds any operations, omits any steps, or has to ask any questions to clarify the written description then the description is not sufficiently technological and requires improvement."^[23] This is where the experiment is repeatable.

[edit]Conceptually Systematic

A defining characteristic is in regard to the interventions used; and thus research must be conceptually systematic by only using procedures and interpreting results of these procedures in terms of the principles from which they were derived.^[23]

[edit]Effective

ABA must be effective, which means that the application of these techniques changes the behavior it seeks to change. Specifically, it is not a theoretical importance of the variable, but rather the practical importance (social importance) that is essential.^[21] If the application of behavioral techniques does not produce a large enough effects for practical value, then the application has failed.

[edit]Generality

ABA must be general, which means that it persists over time, in different environments, and spreads to other behaviors not directly treated by the intervention. In addition, continued change in specified behavior after intervention for that behavior has been withdrawn is also an example of generality. It is a goal to identify behavior stimuli with long-lasting and general effect.

[edit]Proposed additional characteristics

In 2005, Heward, et al. added their belief that the following five characteristics should be added:^[24]

• Accountable: Direct and frequent measurement enables analysts to detect their success and failures to make changes in an effort to increase successes while decreasing failures. ABA is a scientific approach in which analysts may guess but then critically test ideas, rather than "guess and guess again."^[25] This constant revision of techniques, commitment to effectiveness and analysis of results leads to an accountable science.
• Public: Applied behavior analysis is completely visible and public. This means that there are no explanations that cannot be observed, but of course these are each imposed. There are no mystical, metaphysical explanations, hidden treatment, or magic.^[24] Thus, ABA produces results whose explanations are available to all of the public.
• Doable: ABA has a pragmatic element in that implementors of interventions can consist of a variety of individuals, from teachers to the participants themselves. This does not mean that ABA requires one simply to learn a few procedures, but with the proper planning, it can effectively be implemented by most everyone willing to invest the effort.^[24]
• Empowering: ABA provides tools to practitioners that allow them to effectively change behavior. By constantly providing visual feedback to the practitioner on the results of the intervention, this feature of ABA allows clinicians to assess their skill level and builds confidence in their technology.^[26]
• Optimistic: According to several leading authors, practitioners skilled in behavior analysis have genuine cause to be optimistic for the following reasons:
  • Individual behavior is largely determined by learning and cumulative effects of the environment, which itself is manipulable
  • Direct and continuous measurements enable practitioners to detect small improvements in performance that might have otherwise been missed
  • As a practitioner uses behavioral techniques with positive outcomes, the more they will become optimistic about future success prospects^[24]
  • The literature provides many examples of success teaching individuals considered previously unteachable.

[edit]Concepts

[edit]Behavior

Main article: Behavior

Behavior is the activity of living organisms. Human behavior is the entire gamut of what people do including thinking and feeling.^[27] Behavior can be determined by applying the Dead Man's test:

If a dead man can do it, it isn't behavior. And if a dead man can't do it, then it is behavior.^[28]

This is obviously only a simple rubric.

Behavior is that portion of an organism's interaction with its environment that is characterized by detectable displacement in space through time of some part of the organism and that results in a measurable change in at least one aspect of the environment.^[29] Often, the term behavior is used to reference a larger class of responses that share physical dimensions or function. In this instance, the term response indicates a single instance of that behavior.^[30] If a group of responses have the same function, this group can be classified as a response class. Finally, when discussing a person's collection of behavior, repertoire is used. It can either pertain specifically to a set of response classes that are relevant to a particular situation, or it can refer to every behavior that a person can do.

[edit]Operant conditioning

Main article: Operant conditioning

Operant behavior is that which is selected by its consequences. The conditioning of operant behavior is the result of reinforcement and punishment.^[31] Operant conditioning applies to voluntary responses, which an organism performs deliberately, to produce a desirable outcome. The term operant emphasizes this point: the organism operates in its environment to produce some type of desirable result. For example, operant conditioning is at work when we learn that toiling industriously can bring about a raise or that studying hard for a particular class will result in good grades, in positive reinforcement.

[edit]Respondent conditioning

Main article: Classical conditioning

All organisms respond in predictable ways to certain stimuli. These stimulus–response relations are called reflexes. The response component of the reflex is called respondent behavior. It is defined as behavior which is elicited by antecedent stimuli. Respondent conditioning (also called classical conditioning) is learning in which new stimuli acquire the ability to elicit respondents. This is done through stimulus–stimulus pairing, for example, the stimulus (smell of food) can elicit a person's salivation. By pairing that stimulus (smell) with another stimulus (e.g., a light), the second stimulus can obtain the function of the first stimulus, given that the predictive relationship between the two stimuli is maintained. This is also known as "Pavlov's dog's bell".

[edit]Environment

The environment is the entire constellation of stimuli in which an organism exists.^[32] This includes events both inside and outside of an organism, but only real physical events are included. The environment consists of stimuli. A stimulus is an "energy change that affects an organism through its receptor cells."^[32]

A stimulus can be described:

• Topographically by its physical features.
• Temporally by when they occur in respect to the behavior.
• Functionally by their effect on behavior.

[edit]Reinforcement

Main article: Reinforcement

Reinforcement is the most important principle of behavior^[33] and a key element of most behavior change programs.^[34] It is the process by which behavior is strengthened, if a behavior is followed closely in time by a stimulus and this results in an increase in the future frequency of that behavior. The addition of a stimulus following an event that serves as a reinforcer is termed positive reinforcement. If the removal of an event serves as a reinforcer, this is termed negative reinforcement.^[35] There are multiple schedules of reinforcement that affect the future probability of behavior.

[edit]Punishment

Main article: Punishment (psychology)

Punishment is a process by which a consequence immediately follows a behavior which decreases the future frequency of that behavior. Like reinforcement, a stimulus can be added (positive punishment) or removed (negative punishment). Broadly, there are three types of punishment: presentation of aversive stimuli or shock, response cost or starvation, and time out or detention.^[36] Punishment in practice can often result in unwanted side effects, and has therefore been used only after reinforcement-only procedures have failed to work. Unwanted side effects can include the increase in other unwanted behavior as well as a decrease in desired behaviors. Punishment is also associated in certain cases with increases in the likelihood of aggression by the person.^[37] Some other potential unwanted effects include resentment, escape and avoidance, emotional behavior, and behavioral contrast, with association of the practitioner as antagonist.

[edit]Extinction

Main article: Extinction (psychology)

Extinction is the technical term to describe the procedure of withholding/discontinuing reinforcement of a previously reinforced behavior, resulting in the decrease of that behavior. The behavior is then set to be extinguished (Cooper, et al.). Extinction procedures are often preferred over punishment procedures that are frequently deemed unethical and in many states prohibited. Nonetheless, extinction procedures must be implemented with utmost care by professionals, as they are generally associated with extinction bursts. An extinction burst is the temporary increase in the frequency, intensity, and/or duration of the behavior targeted for extinction. Other characteristics of an extinction burst include a) extinction-produced aggression—the occurrence of an emotional response to an extinction procedure often manifested as aggression; and b) extinction-induced response variability—the occurrence of novel behaviors that did not typically occur prior to the extinction procedure. These novel behaviors are a core component of shaping procedures.

[edit]Discriminated operant and three-term contingency

In addition to a relation being made between behavior and its consequences, operant conditioning also establishes relations between antecedent conditions and behaviors. This differs from the S–R formulations (If-A-then-B), and replaces it with an AB-because-of-C formulation. In other words, the relation between a behavior (B) and its context (A) is because of consequences (C), more specifically, this relationship between AB because of C indicates that the relationship is established by prior consequences that have occurred in similar contexts.^[38] This antecedent–behavior–consequence contingency is termed the three-term contingency. A behavior which occurs more frequently in the presence of an antecedent condition than in its absence is called a discriminated operant O_D. The antecedent stimulus is called a discriminative stimulus S_D. The fact that the discriminated operant occurs only in the presence of the discriminative stimulus is an illustration of stimulus control.^[39] More recently behavior analysts have been focusing on conditions that occur prior to the circumstances for the current behavior of concern that increased the likelihood of the behavior occurring or not occurring. These conditions have been referred to variously as "Setting Event", "Establishing Operations", and "Motivating Operations" by various researchers in their publications.

[edit]Verbal behavior

Main article: Verbal Behavior

B.F. Skinner's classification system of behavior analysis has been applied to treatment of a host of communication disorders.^[40] Skinner's system includes:

• Tact (psychology) – a verbal response evoked by a non-verbal antecedent and maintained by generalized conditioned reinforcement.
• Mand (psychology) – behavior under control of motivating operations maintained by a characterstic reinforcer.
• Intraverbals – verbal behavior for which the relevant antecedent stimulus was other verbal behavior, but which does not share the response topography of that prior verbal stimulus (e.g., responding to another speaker's question).
• Autoclitic – secondary verbal behavior which alters the effect of primary verbal behavior on the listener. Examples involve quantification, grammar, and qualifying statements (e.g., the differential effects of "I think..." vs. "I know...")

For assessment of verbal behavior from Skinner's system see Assessment of Basic Language and Learning Skills.

[edit]Measuring behavior

When measuring behavior, there are both dimensions of behavior and quantifiable measures of behavior. In applied behavior analysis, the quantifiable measures are a derivative of the dimensions. These dimensions are repeatability, temporal extent, and temporal locus.^[41]

[edit]Repeatability

Response classes occur repeatedly throughout time—i.e., how many times the behavior occurs.

• Count is the number of occurrences in behavior.
• Rate/frequency is the number of instances of behavior per unit of time.
• Celeration is the measure of how the rate changes over time.

[edit]Temporal extent

This dimension indicates that each instance of behavior occupies some amount of time—i.e., how long the behavior occurs.

• Duration is the amount of time in which the behavior occurs.

[edit]Temporal locus

Each instance of behavior occurs at a specific point in time—i.e., when the behavior occurs.

• Response latency is the measure of elapsed time between the onset of a stimulus and the initiation of the response.
• Interresponse time is the amount of time that occurs between two consecutive instances of a response class.

[edit]Derivative measures

Derivative measures are unrelated to specific dimensions:

• Percentage is the ratio formed by combining the same dimensional quantities.
• Trials-to-criterion are the number of response opportunities needed to achieve a predetermined level of performance.

[edit]Analyzing behavior change

[edit]Experimental control

In applied behavior analysis, all experiments should include the following:^[42]

• At least one participant
• At least one behavior (dependent variable)
• At least one setting
• A system for measuring the behavior and ongoing visual analysis of data
• At least one treatment or intervention condition
• Manipulations of the independent variable so that its effects on the dependent variable may be quantitatively or qualitatively analyzed
• An intervention that will benefit the participant in some way^[43]

[edit]Functional analysis (psychology)

Main article: Functional analysis (psychology)

[edit]Functional behavior assessment (FBA)

Functional assessment of behavior provides hypotheses about the relationships between specific environmental events and behaviors. Decades of research has established that both desirable and undesirable behaviors are learned through interactions with the social and physical environment. FBA is used to identify the type and source of reinforcement for challenging behaviors as the basis for intervention efforts designed to decrease the occurrence of these behaviors.

[edit]Functions of behavior

The function of a behavior can be thought of as the purpose a behavior serves for a person.

Behavior can serve the following common functions for an individual:

Access to attention

e.g., Child throws toy in order to get mom's attention. (If this behavior results in mom looking at child and giving him lots of attention—even if she's saying "NO"—he will be more likely to engage in the same behavior in the future to get mom's attention.)

Escape/removal of a demand or aversive event

e.g., Mom tells the child "Go clean up" and child runs to the kitchen because s/he does not want to complete the task.

Automatic reinforcement

e.g., Child flaps (or other stereotypic, repetitive movement) because it produces perceptual stimulation/sensory consequences. This also includes pain attenuation via removal of unpleasant stimulation (e.g., toothache, stomach pain, fever)

Access to tangibles (e.g., activities, toys, edibles)

e.g., Child hits mom because s/he wants the toy mom is holding.

We can describe behaviors in various ways such as tantrums, noncompliance, inattention, aggression; however all behavior can be classified as serving one or more of the functions above.

Function is identified in an FBA by identifying the type and source of reinforcement for the behavior of interest. Those reinforcers might be positive or negative social reinforcers provided by someone who interacts with the person, or automatic reinforcers produced directly by the behavior itself.^[44]

• Positive reinforcement – social positive reinforcement (attention), tangible reinforcement, and automatic positive reinforcement.^[44]
• Negative reinforcement – social negative reinforcement (escape), automatic negative reinforcement.^[45]

[edit]Function versus topography

Behaviors may look different but can serve the same function and likewise behavior that looks the same may serve multiple functions. What the behavior looks like often reveals little useful information about the conditions that account for it. However, identifying the conditions that account for a behavior, suggests what conditions need to be altered to change the behavior. Therefore, assessment of function of a behavior can yield useful information with respect to intervention strategies that are likely to be effective.^[45]

[edit]FBA methods

FBA methods can be classified into three types:

• Functional (experimental) analysis
• Descriptive assessment
• Indirect assessment

[edit]Functional (experimental) analysis

A functional analysis is one in which antecedents and consequences are manipulated to indicate their separate effects on the behavior of interest. This type of arrangement is often called synthetic because they are not conducted in a naturally occurring context. However, research is indicating that functional analysis done in a natural environment will yield similar or better results.^[46]

A standard functional analysis normally has four conditions (three test conditions and one control):

• Contingent attention
• Contingent escape
• Alone
• Control condition

While the above four conditions are the most widely used functional analysis experimental conditions, using the basic methodology of functional analysis (and experimental analysis in general) it is possible to arrange any combination of antecedents and consequences for behavior to determine what effect, if any, they have on a behavior.

• Advantages – it has the ability to yield a clear demonstration of the variable(s) that relate to the occurrence of a problem behavior. It serves as the standard of scientific evidence by which other assessment alternatives are evaluated. It represents the method most often used in research on the assessment and treatment of problem behavior.^[47]
• Limitations – assessment process may temporarily strengthen or increase the undesirable behavior to gravely unacceptable levels or result in the behavior acquiring new unpleasant functions. Some behaviors may neither be amenable to functional analyses (e.g., those that, albeit serious, occur infrequently). Functional analyses conducted in contrived settings may not detect the variable that accounts for the occurrence in the natural environment.

[edit]Descriptive FBA

As with functional analysis, descriptive functional behavior assessment utilizes direct observation of behavior; unlike functional analysis, however, observations are made under naturally occurring conditions. Therefore, descriptive assessments involve observation of the problem behavior in relation to events that are not arranged in a systematic manner.^[48]

There are three variations of descriptive assessment:

• ABC (antecedent–behavior–consequence) continuous recording – observer records occurrences of targeted behavior and selected environmental events in the natural routine.
• ABC narrative recording – data are collected only when behaviors of interest are observed, and the recording encompasses any events that immediately precede and follow the target behavior.
• Scatterplots – a procedure for recording the extent to which a target behavior occurs more often at particular times than others.^[49][50]

[edit]Indirect FBA

This method uses structured interviews, checklists, rating scales, or questionnaires to obtain information from persons who are familiar with the person exhibiting the behavior to identify possible conditions or events in the natural environment that correlate with the problem behavior. They are called "indirect" because they do not involve direct observation of the behavior, but rather solicit information based on others' recollections of the behavior.^[48]

• Advantages – some can provide a useful source of information in guiding subsequent, more objective assessments, and contribute to the development of hypotheses about variables that might occasion or maintain the behaviors of concern.
• Limitations – informants may not have accurate and unbiased recall of behavior and the conditions under which it occurred.

[edit]Conducting a FBA

Provided the strengths and limitations of the different FBA procedures, FBA can best be viewed as a four-step process:^[51]

1. The gathering of information via indirect and descriptive assessment.
2. Interpretation of information from indirect and descriptive assessment and formulation of a hypothesis about the purpose of problem behavior.
3. Testing of a hypothesis using a functional analysis.
4. Developing intervention options based on the function of problem behavior.

[edit]Technologies discovered through ABA research

[edit]Task analysis

Task analysis is a process in which a task is analyzed into its component parts so that those parts can be taught through the use of chaining: forward chaining, backward chaining and total task presentation. Task analysis has been used in organizational behavior management, a behavior analytic approach to changing organizations.^[52] Behavioral scripts often emerge from a task analysis.^[53][54] Bergan conducted a task analysis of the behavioral consultation relationship^[55] and Thomas Kratochwill developed a training program based on teaching Bergan's skills.^[56] A similar approach was used for the development of microskills training for counselors.^[57][58][59] Ivey would later call this "behaviorist" phase a very productive one^[60] and the skills-based approach came to dominate counselor training during 1970–90.^[61] Task analysis was also used in determining the skills needed to access a career.^[62] In education, Englemann (1968) used task analysis as part of the methods to design the Direct Instruction curriculum.^[63]

[edit]Chaining

Main article: Chaining

The skill to be learned is broken down into small units for easy learning. For example, a person learning to brush teeth independently may start with learning to unscrew the toothpaste cap. Once they have learned this, the next step may be squeezing the tube, etc.^[64][65]

For problem behavior, chains can also be analyzed and the chain can be disrupted to prevent the problem behavior.^[66] Some behavior therapies, such as dialectical behavior therapy, make extensive use of behavior chain analysis.^[67]

[edit]Prompting

A prompt is a cue or assistance to encourage the desired response from an individual.^[68] Prompts are often categorized into a prompt hierarchy from most intrusive to least intrusive. There is some controversy about what is considered most intrusive: physically intrusive versus hardest prompt to fade (i.e., verbal).^[69] In a faultless learning approach, prompts are given in a most-to-least sequence and faded systematically to ensure the individual experiences a high level of success.^[70] There may be instances in which a least-to-most prompt method is preferred. Prompts are faded systematically and as quickly as possible to avoid prompt dependency. The goal of teaching using prompts would be to fade prompts towards independence, so that no prompts are needed for the individual to perform the desired behavior.^[71][72]

Types of prompts:

• Vocal prompts: Utilizing a vocalization to indicate the desired response.
• Visual prompts: A visual cue or picture.
• Gestural prompts: Utilizing a physical gesture to indicate the desired response.
• Positional prompt: The target item is placed closer to the individual.
• Modeling: Modeling the desired response for the student. This type of prompt is best suited for individuals who learn through imitation and can attend to a model.
• Physical prompts: Physically manipulating the individual to produce the desired response. There are many degrees of physical prompts. The most intrusive being hand-over-hand, and the least intrusive being a slight tap to initiate movement.^[70]

This is not an exhaustive list of all possible prompts. When using prompts to systematically teach a skill, not all prompts need to be used in the hierarchy; prompts are chosen based on which ones are most effective for a particular individual.

[edit]Fading

The overall goal is for an individual to eventually not need prompts. As an individual gains mastery of a skill at a particular prompt level, the prompt is faded to a less intrusive prompt. This ensures that the individual does not become overly dependent on a particular prompt when learning a new behavior or skill.

[edit]Thinning a reinforcement schedule

Thinning is often confused with fading. Fading refers to a prompt being removed, where thinning refers to the spacing of a reinforcement schedule getting larger.^[73] Some support exists that a 30% decrease in reinforcement can be an efficient way to thin.^[74] Schedule thinning is often an important and neglected issue in contingency management and token economy systems, especially when developed by unqualified practitioners (see professional practice of behavior analysis).^[75]

[edit]Generalization

Generalization is the expansion of a student's performance ability beyond the initial conditions set for acquisition of a skill.^[76] Generalization can occur across people, places, and materials used for teaching. For example, once a skill is learned in one setting, with a particular instructor, and with specific materials, the skill is taught in more general settings with more variation from the initial acquisition phase. For example, if a student has successfully mastered learning colors at the table, the teacher may take the student around the house or his school and then generalize the skill in these more natural environments with other materials. Behavior analysts have spent considerable amount of time studying factors that lead to generalization.^[77]

[edit]Shaping

Main article: Shaping (psychology)

Shaping involves gradually modifying the existing behavior into the desired behavior. If the student engages with a dog by hitting it, then he or she could have their behavior shaped by reinforcing interactions in which he or she touches the dog more gently. Over many interactions, successful shaping would replace the hitting behavior with patting or other gentler behavior. Shaping is based on a behavior analyst's thorough knowledge of operant conditioning principles andextinction. Recent efforts to teach shaping have used simulated computer tasks.^[78]

[edit]Video modeling

Main article: Video modeling

One teaching technique found to be effective with some students, particularly children, is the use of video modeling (the use of taped sequences as exemplars of behavior). It can be used by therapists to assist in the acquisition of both verbal and motor responses, in some cases for long chains of behavior.^[79][80]

[edit]Interventions based on an FBA

Critical to behavior analytic interventions is the concept of a systematic behavioral case formulation with a functional behavioral assessment or analysis at the core.^[81][82] This approach should apply a behavior analytic theory of change (see Behavioral change theories). This formulation should include a thorough functional assessment, a skills assessment, a sequential analysis (behavior chain analysis), an ecological assessment, a look at existing evidenced-based behavioral models for the problem behavior (such as Fordyce's model of chronic pain)^[83] and then a treatment plan based on how environmental factors influence behavior. Some argue that behavior analytic case formulation can be improved with an assessment of rules and rule-governed behavior.^[84][85][86] Some of the interventions that result from this type of conceptualization involve training specific communication skills to replace the problem behaviors as well as specific setting, antecedent, behavior, and consequence strategies.^[87]

[edit]Efficacy in autism

ABA-based techniques are often used to treat autism, so much so that ABA itself is often mistakenly considered to be synonymous with therapy for autism.^[3] ABA for autism may be limited by diagnostic severity and IQ.^[88][89] The most influential and widely cited review of the literature regarding efficacy of treatments for Autism is the National Research Council's book Educating Children with Autism (2001) which clearly concluded that ABA was the best research supported and most effective treatment for the main characteristics of Autism. Some critics claimed that the NRC's report was an inside job by behavior analysts but there were no board certified behavior analysts on the panel (which did include physicians, speech pathologists, educators, psychologists, and others). Recent reviews of the efficacy of ABA-based techniques in autism include:

• A 2007 clinical report of the American Academy of Pediatrics concluded that the benefit of ABA-based interventions in autism spectrum disorders (ASDs) "has been well documented" and that "children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior."^[90]
• Researchers from the MIND Institute published an evidence-based review of comprehensive treatment approaches in 2008. On the basis of "the strength of the findings from the four best-designed, controlled studies," they were of the opinion that one ABA-based approach (the Lovaas technique created by Ole Ivar Lovaas) is "well-established" for improving intellectual performance of young children with ASD.^[91]
• A 2009 review of psycho-educational interventions for children with autism whose mean age was six years or less at intake found that five high-quality ("Level 1" or "Level 2") studies assessed ABA-based treatments. On the basis of these and other studies, the author concluded that ABA is "well-established" and is "demonstrated effective in enhancing global functioning in pre-school children with autism when treatment is intensive and carried out by trained therapists."^[92]
• A 2009 paper included a descriptive analysis, an effect size analysis, and a meta-analysis of 13 reports published from 1987–2007 of early intensive behavioral intervention (EIBI, a form of ABA-based treatment with origins in the Lovaas technique) for autism. It determined that EIBI's effect sizes were "generally positive" for IQ, adaptive behavior, expressive language, and receptive language. The paper did note limitations of its findings including the lack of published comparisons between EIBI and other "empirically validated treatment programs."^[93]
• In a 2009 systematic review of 11 studies published from 1987–2007, the researchers wrote "there is strong evidence that EIBI is effective for some, but not all, children with autism spectrum disorders, and there is wide variability in response to treatment." Furthermore, any improvements are likely to be greatest in the first year of intervention.^[94]
• A 2009 meta-analysis of nine studies published from 1987–2007 concluded that EIBI has a "large" effect on full-scale intelligence and a "moderate" effect on adaptive behavior in autistic children.^[95]
• In 2011, investigators from Vanderbilt University under contract with the Agency for Healthcare Research and Quality performed a comprehensive review of the scientific literature on ABA-based and other therapies for autism spectrum disorders; the ABA-based therapies included the UCLA/Lovaas method and the Early Start Denver Model (the latter developed by Sally Rogers and Geraldine Dawson).^[96] They concluded that "both approaches were associated with ... improvements in cognitive performance, language skills, and adaptive behavior skills."^[96]:ES-9 However, they also concluded that "the strength of evidence ... is low," "many children continue to display prominent areas of impairment," "subgroups may account for a majority of the change," there is "little evidence of practical effectiveness or feasibility beyond research studies," and the published studies "used small samples, different treatment approaches and duration, and different outcome measurements."^[96]:ES-10

A 2009 systematic review and meta-analysis by Spreckley and Boyd of four 2000–2007 studies (involving a total of 76 children) came to different conclusions than the aforementioned reviews.^[97] Spreckley and Boyd reported that applied behavior intervention (ABI), another name for EIBI, did not significantly improve outcomes compared with standard care of preschool children with ASD in the areas of cognitive outcome, expressive language, receptive language, and adaptive behavior.^[97] In a letter to the editor, however, authors of the four studies meta-analyzed claimed that Spreckley and Boyd had misinterpreted one study comparing two forms of ABI with each other as a comparison of ABI with standard care, which erroneously decreased the observed efficacy of ABI.^[98] Furthermore, the four studies' authors raised the possibility that Spreckley and Boyd had excluded some other studies unnecessarily, and that including such studies could have led to a more favorable evaluation of ABI.^[98] Spreckley, Boyd, and the four studies' authors did agree that large multi-site randomized trials are needed to improve the understanding of ABA's efficacy in autism.^[98]

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Play has been recognized as important since the time of Plato (429-347 B.C.) who reportedly observed, “you can discover more about a person in an hour of play than in a year of conversation.” In the eighteenth century Rousseau (1762/1930), in his book ‘Emile’ wrote about the importance of observing play as a vehicle to learn about and understand children. Friedrich Fröbel, in his book The Education of Man (1903), emphasized the importance of symbolism in play. He observed, “play is the highest development in childhood, for it alone is the free expression of what is in the child’s soul…. children’s play is not mere sport. It is full of meaning and import.” (Fröbel, 1903, p. 22) The first documented case, describing the therapeutic use of play, was in 1909 when Sigmund Freud published his work with “Little Hans.” Little Hans was a five-year-old child who was suffering from a simple phobia. Freud saw him once briefly and recommended that his father take note of Hans’ play to provide insights that might assist the child. The case of “Little Hans” was the first case in which a child’s difficulty was related to emotional factors.

Hermine Hug-Hellmuth (1921) formalized the play therapy process by providing children with play materials to express themselves and emphasize the use of the play to analyze the child. In 1919, Melanie Klein (1955) began toimplement the technique of using play as a means of analyzing children under the age of six. She believed that child’s play was essentially the same as free association used with adults, and that as such, it was provide access to thechild’s unconscious. Anna Freud (1946, 1965) utilized play as a means to facilitate positive attachment to the therapist and gain access to the child’s inner life.

In the 1930s David Levy (1938) developed a technique he called release therapy. His technique emphasized a structured approach. A child, who had experienced a specific stressful situation, would be allowed to engage in free play. Subsequently, the therapist would introduce play materials related to the stress-evoking situation allowing the child to reenact the traumatic event and release the associated emotions.

In 1955, Gove Hambidge expanded on Levy’s work emphasizing a “Structured Play Therapy” model, which was more direct in introducing situations. The format of the approach was to establish rapport, recreate the stress-evoking situation, play out the situation and then free play to recover.

Jesse Taft (1933) and Frederick Allen (1934) developed an approach they entitled relationship therapy. The primary emphasis is placed on the emotional relationship between the therapist and the child. The focus is placed on the child’s freedom and strength to choose.

Carl Rogers (1942) expanded the work of the relationship therapist and developed non-directive therapy, later called client-centered therapy (Rogers, 1951). Virginia Axline (1950) expanded on her mentor's concepts. In her article entitled ‘Entering the child’s world via play experiences’ Axline summarized her concept of play therapy stating, “A play experience is therapeutic because it provides a secure relationship between the child and the adult, so that the child has the freedom and room to state himself in his own terms, exactly as he is at that moment in his own way and in his own time” (Progressive Education, 27, p. 68).

In 1953 Clark Moustakas wrote his first book Children in Play Therapy. In 1956 he compiled Publication of The Self, the result of the dialogues between Abraham Maslow, Carl Rogers, Clark Moustakas and others, forging the Humanistic Psychology movement.

Filial therapy, developed by Bernard and Louise Guerney, was a new innovation in play therapy during the 1960s. The filial approach emphasizes a structured training program for parents in which they learn how to employ child-centered play sessions in the home. In the 1960s, with the advent of school counselors, school-based play therapy began a major shift from the private sector. Counselor-educators such as Alexander (1964); Landreth (1969, 1972); Muro (1968); Myrick and Holdin (1971); Nelson (1966); and Waterland (1970) began to contribute significantly, especially in terms of using play therapy as both an educational and preventive tool in dealing with children’s issues.

1973 Clark Moustakas continues his journey into play therapy and publishes his novel "The child's discovery of himself". Clark Moustakas' work as being concerned with the kind of relationship needed to make therapy a growth experience. His stages start with the child's feelings being generally negative and as they are expressed, they become less intense, the end results tend to be the emergence of more positive feelings and more balanced relationships. Today, his daughter Kerry Moustakas continues his legacy as an author and president of The Michigan School of Professional Psychology. 2004 Clark and Kerry Moustakas publish Loneliness, Creativity and Love: Awakening Meanings in Life.

[edit]Growth of Organizations

In 1982, the Association for Play Therapy (APT) was established marking not only the desire to promote the advancement of play therapy, but to acknowledge the extensive growth of play therapy. Currently, the APT has almost 5,000 members in twenty-six countries (2006). Play therapy training is provided, according to a survey conducted by the Center for Play Therapy at the University of North Texas (2000), by 102 universities and colleges throughout the United States.

In 1985, the work of two key Canadians in the field of child psychology and play therapy, Mark Barnes and Cynthia Taylor, resulted in the establishment of Certification Standards through the non-profit Canadian child psychotherapy and play therapy association. A fledgling group of practising Canadian child psychotherapists and play therapists worked on developing an organization to meet professional needs. It gradually expanded and eventually a Board of Directors was formed; objects and by-laws were designed, revised, re-revised and finally approved by the Government of Canada. The Canadian association was eventually recognized as a non-profit organization in 1986.

During 1995/1996, a whole new horizon opened up for the profession of play therapy as a result of the Canadian Play Therapy Institute's pioneering efforts on an International basis. Play Therapy International was founded from the Canadian Play Therapy Institute and there now existed a mutually supportive recognition between Play Therapy International/The International Board of Examiners of Certified Play Therapists, The Canadian Play Therapy Institute, as well as a number of other professional bodies throughout the world.

In the UK, The United Kingdom Society for Play and Creative Arts Therapies Limited (known in short as PTUK) was originally set up in October 2000 as Play Therapy UK with the encouragement of Play Therapy International. Meanwhile the British Association of Play Therapists was distinguished from its American counterpart in 1996 and was granted charity status within the UK in 2006 by the UK Charities Commission.

By 2010 Play Therapy International has partnered sister organisations in Ireland, Canada, Australasia, France, Spain, Wales, Malaysia, Romania, Russia, United Kingdom, Slovenia, Germany, New Zealand, Hong Kong, Korea and Ethiopia.

[edit]Models of play therapy

An individual engaging in sandplay therapy.

Equipment used for sandplay therapy.

Play therapy can be divided into two basic types: nondirective and directive. Nondirective play therapy is a non-intrusive method in which children are encouraged to work toward their own solutions to problems through play. It is typically classified as a psychodynamic therapy. In contrast, directive play therapy is a method that includes more structure and guidance by the therapist as children work through emotional and behavioral difficulties through play. It often contains a behavioral component and the process includes more prompting by the therapist. Directive play therapy is more likely to be classified as a type of cognitive behavioral therapy.^[1] Both types of play therapy have received at least some empirical support.^[2] On average, play therapy treatment groups when compared to control groups improve by .8 standard deviations.^[2]

[edit]Nondirective play therapy

Nondirective play therapy, also called client-centered and unstructured play therapy, is guided by the notion that if given the chance to speak and play freely under optimal therapeutic conditions, troubled children and young people will be able to resolve their own problems and work toward their own solutions. In other words, nondirective play therapy is regarded as non-intrusive.^[3] The hallmark of nondirective play therapy is that it has few boundary conditions and thus can be used at any age.^[4] This therapy originates from Carl Rogers's non-directive psychotherapy and in his characterization of the optimal therapeutic conditions. Virginia Axline adapted Carl Rogers's theories to child therapy in 1946 and is widely considered the founder of this therapy.^[5] Different techniques have since been established that fall under the realm of nondirective play therapy, including traditional sandplay therapy, family therapy, and play therapy with the use of toys. Each of these forms is covered briefly below.

Traditional sandplay therapy and its development are attributed to Margaret Lowenfeld, who established this technique in 1929. As in traditional nondirective play therapy, the notion is that allowing an individual to freely play with the sand and accompanying objects inside the sandtray will facilitate the healing process and be therapeutic to the unconscious. When constructing the sandtray, little instruction is provided and little to no "talk" therapy on the part of the therapist is given. This protocol emphasizes the importance of the non-verbal free play in this therapy. Upon its completion, the patient may talk about his or her creation, and the therapist, without the use of directives and without touching the sandtray, may provide guidance. After a number of sessions, the therapist may provide interpretations.^[6] This is also often used during family therapy. The limitations presented by the boundaries of the sandtray can serve as physical and symbolic limitations to families in which boundary distinctions are an issue. Also observance by the therapist of a family working together on a sandtray may show evidence of unhealthy alliances, depending on who works with who, which objects are selected to be incorporated into the sandtray, and who chooses which objects. A therapist may assess these choices and intervene in an effort to guide the formation of healthier relationships.^[7] Parents may sometimes conduct this nondirective play therapy with their children while a therapist observes. Research shows that therapy conducted by a parent produces a larger treatment effect than play therapy conducted by a therapist.^[2]

Using toys in nondirective play therapy with children is another common method therapists employ, a method which was derived from the creative toys used in Freud's theoretical orientations.^[8]The idea behind this method is that children will be better able to express their feelings toward themselves and their environment through play with toys than through verbalization of their feelings. Through these actions, then, children may be able to experience catharsis, gain more or better insight into their consciousness, thoughts, and emotions, and test their own reality.^[9]Popular toys used during therapy are animals, dolls, hand puppets, crayons, and cars. Therapists have deemed toys such as these more likely to encourage dramatic play or creative associations, both of which are important in expression.^[8]

[edit]Efficacy of nondirective play therapy

Play therapy has been considered to be an established and popular mode of therapy for children for over sixty years.^[10] Critics of play therapy have questioned the effectiveness of the technique for use with children and have suggested using other interventions with greater empirical support such as cognitive behavioral therapy.^[1] They also argue that therapists focus more on the institution of play rather than the empirical literature when conducting therapy ^[11] Classically, Lebo argued against the efficacy of play therapy in 1953, and Phillips reiterated his argument again in 1985. Both claimed that play therapy lacks in several areas of hard research. Many studies included small sample sizes, which limits the generalizeability, and many studies also only compared the effects of play therapy to a control group. Without a comparison to other therapies, it is difficult to determine if play therapy really is the most effective treatment.^[12][13] Recent play therapy researchers have worked to conduct more experimental studies with larger sample sizes, specific definitions and measures of treatment, and more direct comparisons.^[11]

Research is lacking on the overall effectiveness of using toys in nondirective play therapy. Dell Lebo found that out of a sample of over 4,000 children, those who played with recommended toys vs. non-recommended or no toys during nondirective play therapy were not more likely to verbally express themselves to the therapist. Examples of recommended toys would be dolls or crayons, while example of non-recommended toys would be marbles or a checker game.^[8]There is also ongoing controversy in choosing toys for use in nondirective play therapy, with choices being largely made through intuition rather than through research.^[9] However, other research shows that following specific criteria when choosing toys in nondirective play therapy can make treatment more efficacious. Criteria for a desirable treatment toy include a toy that facilitates contact with the child, encourages catharsis, and lead to play that can be easily interpreted by a therapist.^[9]

Several meta analyses have shown promising results toward the efficacy of nondirective play therapy. Meta analysis by authors LeBlanc and Ritchie, 2001, found an effect size of 0.66 for nondirective play therapy.^[3] This finding is comparable to the effect size of 0.71 found for psychotherapy used with children,^[14] indicating that both nondirective play and non-play therapies are almost equally effective in treating children with emotional difficulties. Meta analysis by authors Ray, Bratton, Rhine and Jones, 2001, found an even larger effect size for nondirective play therapy, with children performing at 0.93 standard deviations better than non-treatment groups.^[1] These results are stronger than previous meta-analytic results, which reported effect sizes of 0.71,^[14] 0.71,^[15] and 0.66.^[3] Meta analysis by authors Bratton, Ray, Rhine, and Jones, 2005, also found a large effect size of 0.92 for children being treated with nondirective play therapy.^[2] Results from all meta-analyses indicate that nondirective play therapy has been shown to be just as effective as psychotherapy used with children and even generates higher effect sizes in some studies.^[1][2]

There are several predictors that may also influence the effectiveness of play therapy with children. Number of sessions is a significant predictor in post-test outcomes, with more sessions being indicative of higher effect sizes.^[1]Although positive effects can be seen with the average 16 sessions,^[5] there is a peak effect when a child can complete 35-40 sessions.^[3] An exception to this finding is children undergoing play therapy in critical-incident settings, such as hospitals and domestic violence shelters. Results from studies that looked at these children indicated a large positive effect size after only 7 sessions, which provides the implication that children in crisis may respond more readily to treatment ^[2] Parental involvement is also a significant predictor of positive play therapy results. This involvement generally entails participation in each session with the therapist and the child.^[16] Parental involvement in play therapy sessions has also been shown to diminish stress in the parent-child relationship when kids are exhibiting both internal and external behavior problems.^[17] Despite these predictors which have been shown to increase effect sizes, play therapy has been shown to be equally effective across age, gender, and individual vs. group settings.^[1][2]

[edit]Directive play therapy

Directive play therapy is guided by the notion that using directives to guide the child through play will cause a faster change than is generated by nondirective play therapy. The therapist plays a much bigger role in directive play therapy. Therapists may use several techniques to engage the child, such as engaging in play with the child themselves or suggesting new topics instead of letting the child direct the conversation himself.^[18] Stories read by directive therapists are more likely to have an underlying purpose, and therapists are more likely to create interpretations of stories that children tell. In directive therapy games are generally chosen for the child, and children are given themes and character profiles when engaging in doll or puppet activities.^[19] This therapy still leaves room for free expression by the child, but it is more structured than nondirective play therapy. There are also different established techniques that are used in directive play therapy, including directed sandtray therapy and cognitive behavioral play therapy.^[18]

Directed sandtray therapy is more commonly used with trauma victims and involves the "talk" therapy to a much greater extent. Because trauma is often debilitating, directed sandplay therapy works to create change in the present, without the lengthy healing process often required in traditional sandplay therapy.^[6] This is why the role of the therapist is important in this approach. Therapists may ask clients questions about their sandtray, suggest them to change the sandtray, ask them to elaborate on why they chose particular objects to put in the tray, and on rare occasions, change the sandtray themselves. Use of directives by the therapist is very common. While traditional sandplay therapy is thought to work best in helping clients access troubling memories, directed sandtray therapy is used to help people manage their memories and the impact it has had on their lives.^[6]

Roger Phillips, in the early 1980s, was one of the first to suggest that combining aspects of cognitive behavioral therapy with play interventions would be a good theory to investigate.^[12] Cognitive behavioral play therapy was then developed to be used with very young children between two and six years of age. It incorporates aspects of Beck's cognitive therapy with play therapy because children may not have the developed cognitive abilities necessary for participation in straight cognitive therapy.^[20] In this therapy, specific toys such as dolls and stuffed animals may be used to model particular cognitive strategies, such as effective coping mechanisms and problem-solving skills. Little emphasis is placed on the children's verbalizations in these interactions but rather on their actions and their play.^[19] Creating stories with the dolls and stuffed animals is a common method used by cognitive behavioral play therapists in order to change children's maladaptive thinking.

[edit]Efficacy of directive play therapy

The efficacy of directive play therapy has been less established than that of nondirective play therapy, yet the numbers still indicate that this mode of play therapy is also effective. In 2001 meta analysis by authors Ray, Bratton, Rhine, and Jones, direct play therapy was found to have an effect size of .73 compared to the .93 effect size that nondirective play therapy was found to have.^[1] Similarly in 2005 meta analysis by authors Bratton, Ray, Rhine, and Jones, directive therapy had an effect size of 0.71, while nondirective play therapy had an effect size of 0.92.^[2] Although the effect sizes of directive therapy are statistically significantly lower than those of nondirective play therapy, they are still comparable to the effect sizes for psychotherapy used with children, demonstrated by Casey,^[14] Weisz,^[15] and LeBlanc.^[3] A potential reason for the difference in the effect size may be due to the amount of studies that have been done on nondirective vs. directive play therapy. Approximately 73 studies in each meta analysis examined nondirective play therapy, while there were only 12 studies that looked at directive play therapy. Once more research is done on directive play therapy, there is potential that effect sizes between nondirective and directive play therapy will be more comparable.^[1][2]

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Classification of psychiatric Disorders

Child psychotherapy refers to psychotherapeautic procedure for children  experiencing difficulties with their emotions or behavior.  Although there are different types of psychotherapy, each relies on communications as the basic tool for bringing about change in a person's feelings and behaviors.  Psychotherapy may involve an individual child, a group of children, a family, or multiple families.  In children and adolescents, playing, drawing, building, and pretending, as well as talking, are important ways of sharing feelings and resolving problems.

As part of the initial assessment, a qualified mental health professional or child and adolescent psychiatrist will determine the need for psychotherapy.  This decision will be based on such things as the child's current problems, history, level of development, ability to cooperate with treatment, and what interventions are most likely to help with the presenting concerns.  Psychotherapy is often used in combination with other treatments (medication, behavior management, or work with the school).  The relationship that develops between the therapist and the patient is very important.  The child or adolescent must feel comfortable, safe and understood.  This type of trusting environment makes it much easier for the child to express his/her thoughts and feelings and to use the therapy in a helpful way.

Psychotherapy helps children and adolescents in a variety of ways.  They receive emotional support, resolve conflicts with people, understand feelings and problems, and try out new solutions to old problems.  Goals for therapy may be specific (change in behavior, improved relations with friends or family), or more general (less anxiety, better self-esteem).  The length of psychotherapy depends on the complexity and severity of problems.