Debra Price

Purpose of the Study

The purpose of this study was to examine the effectiveness of CCPT with children who were experiencing intrapersonal distress and struggles in interpersonal relationships through a single-case multiple baseline design. Due to the breadth of promising research findings with many presenting concerns, it seems like researching play therapy in way catered to more general presenting concerns would mirror the real-life experience of play therapists and clients while also contributing meaningfully to the literature in demonstrating how CCPT can help reduce a plethora of presenting concerns simultaneously. The researchers sought to determine if CCPT can reduce over-arching symptomology in children within a short time span, between 12 to 16 sessions.

Methods

Participants

The participants were two children recruited through a community counseling clinic located on the campus of a mid-size state university. Participants met eligibility requirements through: a) being between the ages of four to eight years old, b) referred for counseling services, c) experiencing elevated levels of intrapersonal distress and interpersonal relationships as measured by the Youth Outcome Questionnaire, and d) were not receiving other counseling services. The participants are described in more detail with pseudonyms to protect their confidentiality.

Caitlyn was a five-year-old girl who lived with her biological father, step-mother, step-grandmother, and younger step-sibling. Caitlyn was living with her biological mother until she was almost four years old when her mother decided to have her live with her father. Caitlyn had inconsistent contact with her mother since changing living arrangements. Caitlyn had been kicked out of multiple day care programs due to aggressive behavior in the months leading up to her referral for counseling. Her step-mother reported that her physical aggression has increased severely over the past few months prior to starting the study with no prompting event.

Aubrey was a seven-year-old girl who was diagnosed with Attention Deficit Hyper Activity Disorder and was medicated consistently throughout the duration of the study. She was identified by her mother as having tantrums every day, lasting at least one hour, ever since she was just over one-year-old. Her mother reported no event or changes that occurred prior to the onset of her tantrums. Her household consisted of both biological parents and two younger siblings. Aubrey struggled in school, with these effects worsening leading up to her referral for counseling. Aubrey’s largest struggles were around social issues, being described as bossy and controlling of others.

Instruments

Youth Outcome Questionnaire (Y-OQ 2.01). The Y-OQ is a parent report measure for children ages 4 to 17 that assesses behavioral domains of children and adolescents compared to community, inpatient, and outpatient populations. The items are answered on a five point Likert scale. The Y-OQ produces six subscales and has an added therapeutic alliance scale. The two subscales used for the study were intrapersonal distress and interpersonal relationships in addition to the total scale. The intrapersonal distress scale measures the amount of emotional distress, including anxiety and depression, that the child experiences. The internal consistency ratings for the intrapersonal distress scale range from .84-.90 (Burlingame, Mosier, Wells, Atkin, Lambert, Whoolery, Latkowski, 2001). The interpersonal relations subscale measures issues related to the child’s relationship with parents, other adults, and peers. The subscale assesses the child’s attitude towards others, communication style, cooperativeness, aggressiveness, and defiance. The internal consistency ratings for the interpersonal relations scale range from .69-.81 (Burlingame et al., 2001). The total score is the addition of all of the subscales to capture the overall distress in children’s lives. The total score has the highest reliability coefficients ranging from .93-.95 (Burlingame et al., 2001).

Child Behavior Checklist (CBCL). The CBCL was used in this study as a pre and post test measure to provide a context for the results of this research. The CBCL for children ages one and a half to five and 6 to 18 was used to span the age ranges of the participants. The CBCL is a parent report assessment used to measure children’s behaviors compared to other children their age. The CBCL reports strong psychometric properties (Achenbach & Rescorla, 2001).

Parenting Stress Index (PSI).  The PSI is a parent report measure assessing stress within the parent-child system. The PSI measures parents’ level of stress related to parenting an individual child, parents’ level of stress related to parenting in general, and life stress. The PSI was also used as a pre and post measure to provide a context for the relational construct that was measured by the Y-OQ. The psychometric properties of the PSI are strong (Abidin, 2012).

Procedures

Institutional Review Board approval was attained for the study. Participants were recruited through the community counseling clinic. As referrals for play therapy were made, the researchers screened participants for inclusion in the study. Informed consent was obtained from parents, and the parents completed the Y-OQ to determine if the child qualified for the study and the CBCL and PSI for contextual data. The parents participated in an interview to gather developmental information on the participants. Children who did not qualify or parents who did not want their children to participate received play therapy services as usual from the counseling clinic. The participants began with a baseline phase where they did not receive CCPT, but the parents completed the Y-OQ three times per week. The baseline phase needed to continue for at least three data points to establish a stable measure for each participant (Kennedy, 2005). Once the first participant achieved a stable baseline phase, the participant began the treatment phase. The second participant continued on in the baseline phase until reaching stability and then began the treatment phase. The treatment phase consisted of weekly 45-minute sessions of CCPT paired with child-centered parent consultation for approximately 12 to 16 sessions, depending on child progress. Occasionally, participants had to miss a week of play therapy due to illness, inclement weather, or scheduled breaks and vacation. Throughout the treatment phase, including missed weeks of play therapy, parents completed the Y-OQ three times per week at evenly spaced intervals. Following the conclusion of the treatment phase, the parents completed the CBCL and PSI again as a post-test measure comparison from the beginning of the study.

CCPT. CCPT was conducted as described in the manual by Ray (2011). The play therapist, first author, made responses consistent with expressing empathic understanding, unconditional positive regard, and congruence to the children and allowed children to be self-directed in their play. Additional skills used were reflections of feeling, therapeutic limit setting, and reflecting the larger meaning. The playroom was set up with toys as described by Landreth (2012), including aggression, mastery, creative expression, and nurturing toys to facilitate maximum expression by the children. The first author conducted the play therapy sessions and had completed over 20 hours of graduate level coursework in play therapy, was a registered play therapist, and had over six years of play therapy experience prior to beginning the study.

Child-Centered Parent Consultation. Child-centered parent consultation was conducted in accordance with guidelines set by Stulmaker and Jayne (in review). The play therapist met with primary caregivers every three to four sessions to gain knowledge on clients’ progress outside of session, address parents’ concerns, and express empathic understanding, unconditional positive regard, and congruence to the parents to strengthen their working relationship and create an environment for change. The sessions varied in length, depending on parent availability, between 20 to 30 minutes each.

Data Analysis

We used visual analysis to examine the level, trend, variability, immediacy of the effect, overlap, and consistency of data across similar phases (Hott, Limberg, Ohrt, & Schmit, 2015; Kennedy, 2005; Kratochwill, Hitchcock, Horner, Levin, Odom, Rindskopf, & Shadish, 2013). Level assesses the means for each phase to determine whether improvement occurred between phases. Trend examines the slope of data points within phases. Variability looks at the amount of difference between the trend line and the individual data points to determine stability of performance in the phases. Immediacy investigates how quickly change in data occurs following a change in phases. Overlap helps determine the effect of the treatment as it examines the amount of data points that overlap between phases. Consistency across participants’ data helps increase credibility of findings through demonstrating replicability.

Furthermore, the Tau-U effect size was calculated for each participant across the phases to quantify the strength of the changes throughout the phases. Tau-U is a more conservative effect size that controls for the baseline trend and considers overlap of data (Parker, Vannest, Davis, & Sauber, 2011). Tau-U seems to be more appropriate than other types of single-case effect size calculations as it can handle smaller data sets and discriminates at the upper and lower limits of measurement (Vannest & Ninci, 2015). Interpretation recommendations for Tau-U effects are as follows; .20 and under is small, .20 to .60 is moderate, .60 to .80 is large, and greater than .80 is a very large change within the phase.

Results

Participant 1: Caitlyn

Caitlyn received 16 sessions of CCPT and four parent consultation sessions. The level for interpersonal relationships and total scores showed a marked improvement between phases for Caitlyn. However, the level for intrapersonal distress did not show much improvement. The slopes for all subscales showed an upward trend in the baseline phases and then a downward trend in the treatment phases. The ranges and standard deviations for all of the baseline phases were smaller than the ranges and standard deviations for the treatment phases, indicating stability through the baseline phase but more variability in the treatment phase. When examining immediacy, it seems like Caitlyn did respond immediately to CCPT in all three subscales; however, the effects were not maintained until further into the treatment phase. Overlap was calculated by the percentage of all nonoverlapping data (PND), indicating the most improvement in interpersonal relationships. Her Tau-U effect sizes fell into the large range for all scales, indicating substantial improvement from baseline to intervention phases. Overall, it appears as if the effects of CCPT for Caitlyn seemed most pronounced towards the end of the treatment phase, resulting in the variability throughout her treatment. She seemed to be entering into a consistent measure of improvement by the end.

Participant 2: Aubrey

Aubrey received 12 sessions of CCPT and three parent consultation sessions. The level for all subscales showed a marked improvement between phases for Aubrey. The slopes for intrapersonal distressed showed an upward trend in the baseline phase and then a downward trend in the treatment phase. However, the other two subscales showed mixed results with already trending downward baseline and intervention phases with one baseline phase indicating more of a decreasing trend. The ranges and standard deviations for all of the baseline phases were smaller than the ranges and standard deviations for the treatment phases, indicating stability through the baseline phase but more variability in the treatment phase. Although the differences in ranges and standard deviations were not as large for Aubrey as with Caitlyn’s scores. When examining immediacy, it seems like Aubrey responded subtly to CCPT in all three subscales essentially continued steady progress throughout the treatment phase. Overlap was calculated by the percentage of all nonoverlapping data (PND), indicating high levels of improvement across subscales and specifically with interpersonal relationships and total scores. Her Tau-U effect sizes fell into the moderate to large range for all scales, indicating substantial improvement from baseline to intervention phases. Overall, it appears as if the effects of CCPT for Aubrey seemed to consistently increase as the treatment phase progressed.

Overall

To review means, standard deviations, and effect size calculations, see Table 1. Additionally, graphs for Caitlyn and Aubrey’s data can be found in Figure 1. Caitlyn and Aubrey both seemed to benefit from the CCPT intervention as evidenced by the data. When reviewing consistency of data patterns across similar phases, it appears as if they ended up in similar trajectories by the end of the treatment phase. Caitlyn seemed to show more dramatic effects towards the end of treatment while Aubrey seemed to consistently respond to CCPT. It appears as if CCPT was effective to reduce intrapersonal distress, interpersonal relationships, and total scores with both participants.


To view their scores in figure 1, click here.

Table 1: Means, Standard Deviations, R2, PND, and Tau-U Scores for All Participants Across All Phases

 

          Caitlyn                                    Aubrey

 

Scale and Phase                                  M           SD         R2                M              SD        R2

 

Intrapersonal Distress

            Baseline                                  21.25     3.30      .664              24.11              1.83       .349

            CCPT                                      20.08     7.97      -.484             17.89              4.42       -.472

            PND                                        30.43%                                    80.43%

Tau-U                                      -.62*                                        -.88

            Tau-U Overall                        -.4983

 

Interpersonal Relationships

            Baseline                                  20.00     3.92      .462              15.00               1.22      -.745

            CCPT                                      12.48     8.13      -.575             7.78               3.89      -.694

            PND                                        65.21%                                    95.65%

Tau-U                                      -.90*                                        -.40*

            Tau-U Overall                         -.81

 

Total

            Baseline                                  89.75      20.30     .744            96.44                4.07      -.640

            CCPT                                      75.15      30.50     -.574           68.43                6.30      -.667

            PND                                        56.52%                                    100%

Tau-U                                      -.75*                                        -.53*

            Tau-U Overall                         -.69

 

Note: * = corrected for trend in baseline. Decreased scores indicate improvement.