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Child-centered play therapy for children with Autism Spectrum Disorder
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Research question: Is Child-Centered Play Therapy delivered by a Psychologist a more evidence based intervention than a multidisciplinary team approach for children over the age of 8 years old with a diagnosis of Autism Spectrum Disorder?
Date: 22/11/2022
Requestor: Star s47F- persona
Endorsed by: Naomi [[s47F- personal privacy](/foi-library/releases/759e22e37354-foi-24-25-0593-decision-document/release-materials/material-001__s47f-personal-privacy/)](/foi-library/releases/759e22e37354-foi-24-25-0593-decision-document/release-materials/material-001__s47f-personal-privacy/)
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- Contents
Child-centered play therapy for children with Autism Spectrum Disorder ……………………………….. 1
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Contents...................................................................................................................................... 1 -
Summary..................................................................................................................................... 2 -
What is Child-Centered Play Therapy? ……………………………………………………………………… 2
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Efficacy of Child-Centered Play Therapy …………………………………………………………………… 3
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Child-centered play therapy for children with autism………………………………………………….. 4
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References ………………………………………………………………………………………………………………… 5
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- Summary
Child-Centered Play Therapy (CCPT) is a type of psychotherapy or counselling used for children with emotional or behavioural issues. CCPT is a non-directive therapy in which the child leads the subject or content of the therapy sessions. Because goals for each session are not set prior to the session, it may be difficult to measure individual outcomes. Despite some quality issues with included studies, there is evidence that CCPT can benefit children with emotional or behavioural concerns. However, there is very limited research concerning children with autism. CCPT has not so far been included in reviews of evidence-based treatments for children with autism. Considering the lack of evidence, it is not possible to determine the comparative efficacy of CCPT and other treatments for children with autism.
- What is Child-Centered Play Therapy?
CCPT is a type of non-directive, developmental and relational psychotherapy for children. It is non-directive in the sense that the child determines what they do during the session (for example, what games or toys they play with) and what they talk about. It is relational in the sense that the therapeutic medium is thought to be the relationship between the child and the therapist. It is developmental in the sense that the child’s behaviours are understood in the context of normal childhood development. This is a modification of Carl Rogers’ adult-oriented non-directive or client-centred therapy. Rogers’ program was first adapted for children by Virginia Axline in the 1940s (Jayne & Ray, 2015; Salter et al, 2016; Hillman, 2018; Ping & Jiar, 2019; Schottelkorb et al, 2020; Hillman, 2018).
Francis et al (2022) note that CCPT is designed to target social, emotional and behavioural development including attachment skills, emotional regulation, emotional recognition, self- control, self-regulation, and social competence. Systematic reviews often track effects of CCPT on problematic behaviours (internalising and externalising), child-parent relationship, stress, confidence and self-concept (Parker et al, 2021a Parker et al, 2021b; Lin & Bratton, 2015; Ray et al, 2015).
There are many kinds of therapy that utilise play and describe themselves as ‘child-centred’. For example, Francis et al identify:
Play Therapy, Theraplay, Play-based interventions, PRT, Joint Attention, Symbolic Play, Engagement & Regulation (JASPER, Advancing Social-communication And Play (ASAP), LEGO Therapy, The Developmental, Individual Difference, Relationship-Based (DIR) Floortime Model, The Paediatric Autism, Communication Therapy (PACT), Stay, Play, & Talk, PLAY Project, Project ImPACT, Early Start Denver Model (ESDM), E- PLAYS, CCPT (Child-centred play therapy), Filial therapy, Animal/Parent/Peer/Sibling assisted play (Francis et al, 2022, pp.6-8).
Therapies which are child-centred and employ a play-based approach might be used by different allied health practitioners including occupational therapists and speech therapists. However, the term ‘Child-Centered Play Therapy’ is a name for a specific kind of
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psychotherapy or counselling. To indicate this, I have capitalised the term and retained the American English spelling.
- Efficacy of Child-Centered Play Therapy
CCPT has built up an evidence-base showing positive outcomes for children with a variety of behavioural and emotional concerns (Cochran et al, 2022). Despite the existing evidence, some clinicians and researchers exclude CCPT from evidence-based approaches to childhood mental health due to the quality of the studies in question (Parker et al, 2021b; Lin & Bratton, 2015).
Two 2015 meta-analyses found evidence of small-medium effect sizes for improvements in certain outcomes. Lin and Bratton (2015) found moderate effects of CCPT on global behaviour problems, internalizing behaviour problems, externalizing behaviour problems, academic performance and moderate to large effect sizes on caregiver–child relationship stress and self- efficacy. Ray et al (2015) looked at CCPT in schools and found small to medium effect sizes for improvement in academic outcomes, reduction in externalising behaviours and total problematic behaviours and small effect sizes for internalising behaviours and self-efficacy.
These results are supported by a 2021 meta-analysis looking at CCPT for problematic behaviour. Parker et al (2021b) showed small to medium effect size for reduction in externalising behaviour, medium effect size for reduction in overall problematic behaviour and small effect size for reduction in aggressive behaviour. In contrast, Kuhn et al (2022) reviewed child-focused interventions used to treat externalising behaviour and found most studies did not report a positive effect. However, the authors grouped together seven studies covering play therapy, non-directive or child-centred therapy and included only one study from 2002 identifying use of CCPT.
Two systematic reviews explored CCPT in a trauma context. Humble et al (2019) reviewed only seven studies of CCPT for young people with a history of trauma and found considerable variation in results and measures. The authors do note some consistency in significant outcomes for internalising problems, self-concept, and self-competence. Parker et al (2021a) reviewed 32 studies and found the proportion of studies showing significant results varied with outcome:
• externalising behaviour – 9 of 15 studies reported significant results • internalising behaviour – 4 of 11 studies reported significant results • total problem behaviours – 9 of 13 studies reported significant results • parental empathy – all of 8 studies reported significant results • total stress – 4 of 10 studies reported significant results • parent stress – 4 of 8 studies reported significant results • child stress – 3 of 6 studies reported significant results.
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The authors did not report on effect sizes of reviewed studies. The authors note the need for increased rigour and consistency in studies including intervention in more realistic settings, larger sample sizes, use of consistent outcome measures, longer study timeframes and better statistical analyses.
- Child-Centered Play Therapy for children with autism
While Francis et al (2022) note that CCPT is not designed for people with autism, CCPT researchers and practitioners suggest the therapy may be well-suited for use with children with autism. CCPT intends to create an environment in which the child feels safe, understood and feels they are able to express themselves in whatever way they prefer. This environment is thought to create the conditions for greater receptiveness to the effect of the therapeutic relationship and greater opportunity to practice self-regulation skills. Researchers contrast this with behavioural approaches, which they say set up an expectation that the child’s behaviour is a problem and needs to be fixed (Schottelkorb et al, 2020). In addition, CCPT may affect some areas typically targeted in treatment for children with autism such as anxiety, difficulty with joint attention, imitation response, theory of mind and symbolic and functional play skills (Schottelkorb et al, 2020; Hillman, 2018). Hillman suggests:
Within the CCPT framework, joint attention is explored as the child shares his or her interest areas with the therapist. These circumstances create a safe platform where the child can be free from inhibitions. Over time, as the child feels more secure, this platform typically broadens, allowing the child to engage in a wider range of activities and increased interactions with the therapist. The repertoire of social behaviors emerging in the therapy room can then be generalized to other supportive environments, such as the home (Hillman, 2018, p.79).
Despite its wide-spread use, there is only a small literature examining the use of CCPT for children with autism. Schottelkorb et al (2020) identify only two studies. Salter et al (2016) identify four studies, all single case studies. A systematic review of play-based interventions for young people with autism (Francis et al, 2022), found only one paper using CCPT that met their inclusion criteria. Based on a database search and bibliographical search of existing studies, there appear to be a total of seven primary studies considering the effectiveness of CCPT for children with autism and one systematic review specifically focussed on CCPT for children with autism. Of the seven primary studies, four were case studies, two were multiple participant single case design studies and one was a randomly controlled trial. Of the two single case design studies, one included three participants (Salter et al, 2016) and the other included five participants (Ware Balch et al, 2015). The RCT included 23 participants (Schottelkorb et al, 2020). The total number of subjects considered in the evidence base is 35.
Hillman et al (2018) found some support for the use of CCPT for children with autism, specifically around reducing problematic behaviours, however the evidence is not strong. The review only included a combined total of 10 participants. Treatment duration was around 10 weeks for each of the studies, session duration varied from 30 to 60 minutes and frequency varied from weekly to twice weekly. The participants of all four studies were also undertaking
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other therapies, including applied behaviour analysis, speech therapy and social skills training. It is therefore difficult to separate the effect of CCPT from other therapies.
The strongest evidence is from Schottelkorb et al (2020). This RCT was published in 2020 but submitted for publication in 2018 and so did not consider the findings of Hillman et al (2018) in their discussion. Schottelkorb et al investigated the effect of intensive CCPT (four 30-minute sessions per week for 12 weeks) on core autism symptoms and externalising behaviours. They compared the treatment group to a waitlist control and therefore no comparison of therapeutic approaches is possible. Of the 23 participants, 11 were receiving speech therapy at the time of intervention and 16 were receiving occupational therapy. The authors found improvement in social responsiveness and reduction in externalising behaviours. However, limitations include small sample size, lack of follow up and reliance on only parent reported outcomes. In addition, due to the intensity of the therapy, the results may not say much about less intensive therapy.
While there are theoretical and experimental reasons suggesting CCPT is potentially effective for children with autism, this is based on minimal evidence and is likely to be revised with further published research. The status of CCPT is not assessed by either Steinbrenner et al (2020) or Whitehouse et al (2020), two systematic reviews of evidence-based treatments for children with autism.
- References
Cochran, N. H., Nordling, W. J., & Cochran, J. L. (2022). Child-centered play therapy: A practical guide to therapeutic relationships with children. Routledge.
Francis, G., Deniz, E., Torgerson, C., & Toseeb, U. (2022). Play-based interventions for mental health: A systematic review and meta-analysis focused on children and adolescents with autism spectrum disorder and developmental language disorder. Autism & Developmental Language Impairments, 7, 239694152110731. https://doi.org/10.1177/23969415211073118
Hillman, H. (2018). Child-centered play therapy as an intervention for children with autism: A literature review. International Journal of Play Therapy, 27(4), 198–204. https://doi.org/10.1037/pla0000083
Jayne, K. M., & Ray, D. C. (2015). Therapist-provided conditions in child-centered play therapy. The Journal of Humanistic Counseling, 54(2), 86–103. https://doi.org/10.1002/johc.12005
Kuhn, M., Gonzalez, E., Weil, L., Izguttinov, A., & Walker, S. (2022). Effectiveness of Child- Focused Interventions for Externalizing Behavior: a Rapid Evidence Review. Research on child and adolescent psychopathology, 50(8), 987–1009. https://doi.org/10.1007/s10802-022-00904-6
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Lin, Y.-W. and Bratton, S.C. (2015), A Meta-Analytic Review of Child-Centered Play Therapy Approaches. Journal of Counseling & Development, 93: 45-58. https://doi.org/10.1002/j.1556-6676.2015.00180.x
Parker, M. M., Hergenrather, K., Smelser, Q., & Kelly, C. T. (2021a). Exploring child-centered play therapy and trauma: A systematic review of literature. International Journal of Play Therapy, 30(1), 2–13. https://doi.org/10.1037/pla0000136
Parker, M. M., Hunnicutt Hollenbaugh, K. M., & Kelly, C. T. (2021b). Exploring the impact of child-centered play therapy for children exhibiting behavioral problems: A meta- analysis. International Journal of Play Therapy, 30(4), 259–271. https://doi.org/10.1037/pla0000128
Ray, D. C., Armstrong, S. A., Balkin, R. S., & Jayne, K. M. (2015). Child-centered play therapy in the schools: Review and meta-analysis. Psychology in the Schools, 52(2), 107–123. https://doi.org/10.1002/pits.21798
Salter, K., Beamish, W., & Davies, M. (2016). The effects of child-centered play therapy (CCPT) on the social and emotional growth of young Australian children with autism. International Journal of Play Therapy, 25(2), 78–90. https://doi.org/10.1037/pla0000012
Schottelkorb, A. A., Swan, K. L., & Ogawa, Y. (2020). Intensive child‐centered play therapy for children on the autism spectrum: A pilot study. Journal of Counseling and Development: JCD, 98(1), 63–73. https://doi.org/10.1002/jcad.12300
Steinbrenner, J. R., Hume, K., Odom, S. L., Morin, K. L., Nowell, S. W., Tomaszewski, B., Szendrey, S., McIntyre, N. S., Yücesoy-Özkan, S., & Savage, M. N. (2020). Evidence- based practices for children, youth, and young adults with Autism. The University of North Carolina at Chapel Hill, Frank Porter Graham Child Development Institute, National Clearinghouse on Autism Evidence and Practice Review Team.
Ting, J. H. P., & Yeo, K. J. (2019). Play and Autism Spectrum Disorder: a perspective on theory and education approaches. Labuan E-Journal of Muamalat and Society, (1), 35– 47. https://doi.org/10.51200/ljms.vi1.2543
Whitehouse, A., Varcin, K., Waddington, H., Sulek, R., Bent, C., Ashburner, J., Eapen, V., Goodall, E., Hudry, K., Roberts, J., Silove, N., Trembath, D. (2020). Interventions for children on the autism spectrum: A synthesis of research evidence. Autism CRC, Brisbane.
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