the third international theraplay conference 2007 chicago ulrike franke and herbert h.g. wettig...

The Third International Theraplay Conference 2007 Chicago

Ulrike Franke and Herbert H.G. WettigPresenter: Ulrike Franke, Cert. Theraplay Trainer - Supervisor

SLP, Reg. Play Therapist - Supervisor

An analysis of the therapeutic treatment process usingTHERAPLAY®

with two groups of preschool children: oppositional, defiant and shy, withdrawn

Research results of a German controlled longitudinal study April 1998 – January 2006

©2007. Herbert Wettig & Ulrike FrankeTheraplay Institut Oftersheim/Germany

THERAPLAYTherapeutic Treatment Process 1

C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany

THERAPLAY Therapeutic Treatment Process

2

Overview

• Introduction– Central question, hypothesis, learning objectives

• Sample– Kind of sample, sample size, sample characteristic

• Method– Field study, method, kind and time of measurement,

therapeutic process measurement, interrater reliability

• Results– Frequency of incidence and formation of symptoms,

course of therapy, observed therapeutic process,treatment effectiveness, lasting effectiveness



3

Introduction

• Central question

Is THERAPLAY®,a developmentally oriented, interactive, adult directed, short term play therapy, clinically and statistically effective in reducing the symptoms of emotionally and socially behavior disordered preschool children?

• Hypothesis (H1)

It is hypothesized that THERAPLAY®

will significantly reduce the symptoms of oppositional defiance or shyness,with great effect size and without recurrence within the following two years.



4

Learning objectives

• 1. How the course of treatment unfolds with oppositional, defiant preschool childrenusing Theraplay.

• 2. How the course of treatment unfoldswith shy, withdrawn preschool childrenusing Theraplay.

• 3. How the behavior of the treated children comparesto that of the control group of non-symptomatic children at the end of treatment.



5

Sample size and sampling method

• Basic sample is a random sample of 60 out-patients netpresented to the ENT specialist at the Phoniatric Pediatric Audiometric Center Heidelberg, Germany, having a dual diagnosis of language developmental disordersand psychological and behavioral disorders as well.

• Three samples will be compared:

– 30 non-symptomatic children as a control group,matched in sex and age, marked

green– 23 (38% of 60) oppostitional, defiant out-patients,

random sample, marked red– 22 (37% of 60) shy, withdrawn out-patients

random sample, marked blue



6

Sample characteristicsabsolute & percentage

Sample characteristics

non-

symptomatic

oppositonal

defiant

shy

withdrawn

point in time t1 N % N % N %

Sex of the child girls boys

921

3070

617

2674

814

36 64

Status of the child legitimate child illegitimate child adopted child / foster child

29 1 0

97 3 0

21 1 1

91 4 4

18 2 2

82 9 9

Status of the mother unmarried married separated/divorced

129 0

3 97 0

122 0

595 0

022 0

0100

0

Bring up the child parents single

29 1

97 3

21 2

91 9

20 2

91 9

Nursery school / preschool yes

noimmigrated child / bilingual yes

28 2 6

93 720

15 8 3

653514

17 5 2

77 23 10



7

Sample characteristicsmean values

Sample characteristics

non-symptomatic

oppositional

defiant

shy

withdrawn

point in time t1 mean mean mean

Age of the child girls boysAge of the mother (year:month)

4:4 4:736:2

4:9 4:433:7

3:3 4:432:7

Child‘s development C-values visuo-motor visual perception dígit-span memory directly after test memory 20 min. after test cognitive development socio-emotional development

age-standardized6.76.66.45.55.06.16.0



Degree of symptom CASCAP-D oppositional defiant shy

4-point scale1.21.1

4-point scale 3,11,2

4-point scale1,32,5



8

Method

• Target area: Treatment effectiveness/process evaluation • Field study: Measurement in real therapeutic situation• Time of measurement: t1 = diagnosis before treatment

t6 = after treatment terminationt7 = two years after treatment

• Interviewing care-giver: History, socio-demographic data• Psycho-pathological diagnosis: CASCAP-D, 4-point-scale• Video-controlled Observation and Measurement:

- Interaction in play situation: H-MIM in play situation- Interaction in therapeutic situation: Clinical evaluation - Out of all therapeutic sessions of each treated child 7 sessions are selected systematically, divided into 3 sequences each session = 21 - Two clinical rater evaluated by 40 process variables on 6-point-scale

• Interrater-reliability: r=.45 up to r=.90, p=.01 up to p<.0001



9

Resultson the therapeutic treatment process using Theraplay

• oppostional defiant out-patientscompared withthe non-symptomatic control children

• If oppositional defiance decreases

• then healthy behavior increases - frustration tolerance

- attention and self-confidence- emotional mood, good feeling in the therapeutic situation

- empathy for and trust in others- socialbility/willing to contact- child-therapist relationship (non-symptomatic: child-mother relation)

• shy withdrawn out-patientscompared withthe non-symptomatic control children

• Ifshyness decreases

• then healthy behavior increases- courage and risk taking- attention and self-confidence- emotional mood, good feeling in the therapeutic situation- empathy for and trust in others- sociability/willing to contact- child-therapist relationship (non-symptomatic: child-mother-relation)

10THERAPLAY Therapeutic Treatment Process


The course of treatment using Theraplay

If oppositional defiance is decreased therapeutically... then frustration tolerance will increase

1

2

3

4

5

6

1_1 1_2 1_3 2_1 2_2 2_3 3_1 3_2 3_3 4_1 4_2 4_3 5_1 5_2 5_3 6_1 6_2 6_3 7_1 7_2 7_3Seven systematically selected sessions with 3 sequences each child

Cha

nge

of s

ympt

oms

durin

g th

e co

urse

of t

reat

men

t

oppositional defiant out-patients: oppositional defiance oppositional defiant out-patients: frustration tolerance

non-symptomatic children: oppositional defiance non-symptomatic children: frustration tolerancecallback after 16 weeks time of control callback after 16 weeks time of control




If shyness is decreased therapeutically ...... then courage/risk taking of shy children will increase

1

2

3

4

5

6

1_1 1_2 1_3 2_1 2_2 2_3 3_1 3_2 3_3 4_1 4_2 4_3 5_1 5_2 5_3 6_1 6_2 6_3 7_1 7_2 7_3

Seven systematically selected sessions with 3 sequences each child

Cha

nge

of s

ympt

oms

durin

g th

e co

urse

of t

reat

men

t

shy withdrawn out-patients: shyness shy withdrawn out-patients: courage, risk taking

non-symptomatic children: shyness non-symptomatic children: courage, risk takingcallback after 16 weeks time of control callback after 16 weeks time of control




If oppositional defiance or shyness decrease ...... then attention will increase

1

2

3

4

5

6

1_1 1_2 1_3 2_1 2_2 2_3 3_1 3_2 3_3 4_1 4_2 4_3 5_1 5_2 5_3 6_1 6_2 6_3 7_1 7_2 7_3


Cha

nge

of s

ympt

oms

durin

g th

e co

urse

of t

reat

men

t

oppositional defiant out-patients: oppositional defiance oppositonal defiant out-patients: attention

shy withdrawn out-patients: shyness shy withdrawn out-patients: attention

non-symptomatic children: attention callback after 16 week control time




If oppositional defiance or shyness decrease ...... then self-confidence will increase

1

2

3

4

5

6

1_1 1_2 1_3 2_1 2_2 2_3 3_1 3_2 3_3 4_1 4_2 4_3 5_1 5_2 5_3 6_1 6_2 6_3 7_1 7_2 7_3


Cha

nge

of s

ympt

oms

durin

g th

e co

urse

of t

reat

men

t

oppositional defiant out-patients: oppositional defiance oppositional defiant out-patients: self-confidenceshy withdrawn out-patients: shyness shy withdrawn out-patients: self-confidencenon-symptomatic children: self-confidence callback after 16 week control time




If oppositional defiance or shyness decrease ... then emotional mood in therapeutic situation will improve

1

2

3

4

5

6


Cha

nge

of s

ympt

oms

durin

g th

e co

urse

of t

reat

men

t

oppositional defiant out-patients: oppositional defiance oppositional defiant out-patients: emotional mood in...

shy withdrawn out-patients: shyness shy withdrawn out-patients: emotional mood in...non-symptomatic children: emotional mood in interaction callback after 16 week control time




If oppositional defiance or shyness decrease ... thengood feeling in the therapeutical situation will increase

1

2

3

4

5

6

1_1 1_2 1_3 2_1 2_2 2_3 3_1 3_2 3_3 4_1 4_2 4_3 5_1 5_2 5_3 6_1 6_2 6_3 7_1 7_2 7_3


Cha

nge

of s

ympt

oms

durin

g th

e co

urse

of t

reat

men

t

oppositional defiant out-patients: oppositional defiance oppositional defiant out-patients: good-feeling in ...

shy withdrawn out-patients: shyness shy withdrawn out-patients: good-feeling in ...non-symptomatic children: good-feeling in interaction callback after 16 week control time




If oppositional defiance or shyness decrease ...... then empathy for others will increase

1

2

3

4

5

6


Cha

nge

of s

ympt

oms

durin

g th

e co

urse

of t

reat

men

t

oppositional defiant out-patients: oppositional defiance oppositional defiant out-patients: empathy for others

shy withdrawn out-patients: shyness shy withdrawn out-patients: empathy for othersnon-symptomatic children: empathy for others callback after 16 week control time




If oppositional defiance or shyness decrease ...... then trust in others will increase

1

2

3

4

5

6


Cha

nge

of s

ympt

oms

durin

g th

e co

urse

of t

reat

men

t

oppositional defiant out-patients: oppositional defiance oppositional defiant out-patients: trust in others

shy withdrawn out-patients: shyness shy withdrawn out-patients: trust in othersnon-symptomatic children: trust in others callback after 16 week control time




If oppositional defiance or shyness decrease ... then sociability, willingness to make contact will increase

1

2

3

4

5

6

1_1 1_2 1_3 2_1 2_2 2_3 3_1 3_2 3_3 4_1 4_2 4_3 5_1 5_2 5_3 6_1 6_2 6_3 7_1 7_2 7_3


Cha

nge

of s

ympt

oms

durin

g th

e co

urse

of t

reat

men

t

oppositional defiant out-patients: oppositional defiance oppositional defiant out-patients: sociability, willing to ...

shy withdrawn out-patients: shyness shy withdrawn out-patients: sociability, willing to contactnon-symptomatic children: sociability, willing to contact callback after 16 week control time




If oppositional defiance or shyness decrease ...... then child-therapist relationship will improve

1

2

3

4

5

6

1_1 1_2 1_3 2_1 2_2 2_3 3_1 3_2 3_3 4_1 4_2 4_3 5_1 5_2 5_3 6_1 6_2 6_3 7_1 7_2 7_3


Cha

nge

of s

ympt

oms

durin

g th

e co

urse

of t

reat

men

t

oppositional defiant out-patients: oppositional defiance oppositional defiant patients: child-therapist relation

shy withdrawn out-patients: shyness shy withdrawn out-patients: child-therapist relationnon-symptomatic children: child-mother relationship callback after 16 week control time



20

Results in detailTypical negative reaction of the child

• Ann M. Jernberg (1979) wrote about different phases during a therapeutic treatment process using Theraplay.

• Her experience-based hypothesis was that there alwaysis a phase when the disordered child shows a negative reaction to the offered therapeutic action.

• The results of the German longitudinal study confirmJernberg‘s hypothesis.

• Most often at the beginning of the fifth of seven sessionssystematically selected out of all sessions of each childthe patients showed negative reactions to offered actions.



21

Typical negative reaction of the treated childto the offered therapeutic action

3,5

4

4,5

5

. sequ. 4_2 sequ. 4_3 sequ. 5_1 sequ. 5_2 sequ. 5_3 .

Selected sequences around the beginning of the 5th session (sequence 5_1)

Ch

ang

e o

f sym

pto

ms

du

rin

g th

e se

ssio

ns

oppositional defiant: emotional mood oppositional defiant: good-feeling

oppositional defiant: frustration tolerance oppositional defiant: self-conficence

oppositional defiant: attention oppositional defiant: empathy



22

Results in detailTypical therapeutic session process using Theraplay

• There was often from the beginning to the end of a therapeutic session an increasing positive change in behavior such as in the 2nd, 3rd, 4th, 5th or 6th of the seven sessions sytematically selected in intervals out of the total number of sessions each patient needed to achieve the therapeutic goal.

• But during the time between two sessions (usually a week) the achieved level of the behavior often relapsed somewhat.

• In that case in the next session the therapist had to start again on a lower level to change the behavior therapeutically.

• See the sequences 2_1 to 2_3, 3_1 to 3_3 etc. up to 6_1 to 6_3 of symptoms of oppositional defiant or shy withdrawn patients.



23

Increasing symptoms during therapeutic sessionsof oppositional defiant out-patients

3,0

3,5

4,0

4,5

5,0

As an example: Sessions 3, 4, 5 and 6 of seven out of all sessions of the patients

Ch

ang

e o

f sy

mp

tom

s d

uri

ng

th

e se

ssio

n

attention self-confidencegood-feeling in the therapeutic situation trust in othersfrustration tolerance



24

Increasing symptoms during therapeutic sessionsof shy withdrawn out-patients

3,0

3,5

4,0

4,5

5,0

As an example: Sessions 3, 4, 5 and 6 of seven out of all sessions of the patients

Ch

an

ge

of s

ymp

tom

du

rin

g a

ses

sio

n

attention self-confidence

good-feeling in the therapeutic situation trust in others

courage, risk taking



25

Additional Results

Effectiveness and lasting effect of the Theraplay treatment

• The effectiveness of the Theraplay treatment wasmeasured by two field studies with comparable samples(1) N= 60 out-patients of a controlled longitudinal study (CLS)(2) N=333 out-patients of a replicating multi-center study (MCS)(3) N= 30 non-symptomatic children, matched control group (NCG)

• Out-patients of the MCS were clinically divided into 3 groups(MCS-H) out-patients suffering from a high level of symptoms of the disorder(MCS-M) out-patients suffering from a medium level of symptoms of the disorder(MCS-L) out-patients suffering from a low level of symptoms of the disorder

• The effectiveness of the treatment was measured by the effect size and the clinically and statistically significant changeof a symptom between every two different time points during the process- from diagnosis of a symptom before start of the treatment (time point t1)- to diagnosis after treatment termination (time point t6)- to diagnosis two years after treatment termination (time point t7=lasting effect)

• Method: Clinical Assessment Scale for Child and Adolescent PsychopathologyGerman version: CASCAP-D, measuring on a 4-point scale from M=1 to M=4.



26

Additional Results

Effectiveness and lasting effect of TheraplayMethod: CASCAP-D4-point scale:from 1.0=non-symptomatic to 4.0=high

Diagnosed degreeof the symptom

mean per time point

t-Testsignifi-cance

effectsize

M1 M6 M7 p(1-6) d(1-6)

Oppostional defiant out-patients- NCG: non-symptomatic control- CLS longitudinal study average- MCS multi-center study average--- MCS-H: high level of ...--- MCS-M: medium level of ...--- MCS-L: low level of ...

1.12.03.14.03.02.0

-1.31.41.51.41.2

-1.2----

-p<.0001p<.0001p<.0001p<.0001p<.0001

-d=|0.78|d=|2.55|d>|1.00| d>|1.00| d>|1.00|

Shy withdrawn out-patients- NCG: non-symptomatic control- CLS longitudinal study average- MCS multi-center study average--- MCS-H: high level of ...--- MCS-M: medium level of ...--- MCS-L: low level of ...

1.22.53.04.03.02.0

-1.11.41.51.31.2

-1.2----

-p<.0001p<.0001p<.0001p<.0001p<.0001

-d=|2.46| d=|2.26|d>|1.00|d>|1.00|d>|1.00|



27

Additional Results

Effectiveness and lasting effect of the treatmentof oppositional defiant out-patients using Theraplay

1,1

2

1,31,2

3,1

4

2

1,41,5

3

1,4

1,21

2

3

4

Start of treatment treatment termination 2 years after termination

Mar

ked

deg

ree

of c

han

ge

of t

he

sym

pto

m

NCG: 30 non-symptomatic children CLS: 23 oppositional defiant out-patients

MCS: 186 oppositional defiant out-patients MCS-H: 73 oppositional with a high level of ...

MCS-M: 63 oppositional with a medium level of ... MCS-L: 50 oppositional with a low level of ...



28

Additional Results

Effectiveness and lasting effect of the treatmentof shy withdrawn out-patients using Theraplay

1,2

2,5

1,11,2

3

4

2

1,41,5

3

1,31,2

1

2

3

4

Start of treatment treatment termination 2 years after termination

Mar

ked

deg

ree

of c

han

ge

of t

he

sym

pto

m

NCG: 30 non-symptomatic children CLS: 22 shy withdrawn out-patients

MCS: 167 shy withdrawn out-patients MCS-H: shy patients with a high level of ...

MCS-M: shy patients with a medium level of ... MCS-L: shy patients with a low level of ...

the third international theraplay conference 2007 chicago ulrike franke and herbert h.g. wettig...

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