1. The Third International Theraplay Conference 2007 Chicago Ulrike Franke and Herbert H.G. Wettig Presenter: Ulrike Franke, Cert. Theraplay Trainer - Supervisor SLP, Reg. Play Therapist - Supervisor An analysis of the therapeutic treatment process using THERAPLAY® with two groups of preschool children: oppositional, defiant and shy, withdrawn Research results of a German controlled longitudinal study April 1998 – January 2006 ©2007.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 Franke Theraplay Institut Oftersheim/Germany THERAPLAY Therapeutic Treatment Process 1

2. 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. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 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 (H 1 ) 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. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 4 Learning objectives 1. How the course of treatment unfolds with oppositional, defiant preschool children using Theraplay. 2.How the course of treatment unfolds with shy, withdrawn preschool children using Theraplay. 3.How the behavior of the treated children compares to that of the control group of non-symptomatic children at the end of treatment.

5. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 5 Sample size and sampling method Basic sample is a random sample of 60 out-patients net presented to the ENT specialist at the Phoniatric Pediatric Audiometric Center Heidelberg, Germany, having a dual diagnosis of language developmental disorders and psychological and behavioral disorders as well. Three samples will be compared: –30non-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. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 6 Sample characteristics absolute & percentage Sample characteristics  non- symptomatic  oppositonal defiant shy withdrawn point in time t 1 N%N%N% Sex of the child girls boys 9 21 30 70 6 17 26 74 8 14 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 1 29 0 3 97 0 1 22 0 5 95 0 0 22 0 0 100 0 Bring up the child parents single 29 1 97 3 21 2 91 9 20 2 91 9 Nursery school / preschool yes no immigrated child / bilingual yes 28 2 6 93 7 20 15 8 3 65 35 14 17 5 2 77 23 10

7. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 7 Sample characteristics mean values Sample characteristics  non- symptomatic  oppositional defiant shy withdrawn point in time t 1 mean Age of the child girls boys Age of the mother (year:month) 4:4 4:7 36:2 4:9 4:4 33:7 3:3 4:4 32:7 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-standardized 6.7 6.6 6.4 5.5 5.0 6.1 6.0 age-standardized 2.9 3.1 2.9 3.8 4.2 2.4 1.5 age-standardized 2.6 3.0 2.1 3.8 4.3 2.9 0.9 Degree of symptom CASCAP-D oppositional defiant shy 4-point scale 1.2 1.1 4-point scale 3,1 1,2 4-point scale 1,3 2,5

8. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 8 Method Target area: Treatment effectiveness/process evaluation Field study: Measurement in real therapeutic situation Time of measurement: t 1 = diagnosis before treatment t 6 = after treatment termination t 7 = 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. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 9 Results on the therapeutic treatment process using Theraplay oppostional defiant out-patients compared with the 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-patients compared with the non-symptomatic control children If shyness 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 )

10. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 10 The course of treatment using Theraplay If oppositional defiance is decreased therapeutically... then frustration tolerance will increase

11. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 11 The course of treatment using Theraplay If shyness is decreased therapeutically...... then courage/risk taking of shy children will increase

12. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 12 The course of treatment using Theraplay If oppositional defiance or shyness decrease...... then attention will increase

13. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 13 The course of treatment using Theraplay If oppositional defiance or shyness decrease...... then self-confidence will increase

14. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 14 The course of treatment using Theraplay If oppositional defiance or shyness decrease... then emotional mood in therapeutic situation will improve

15. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 15 The course of treatment using Theraplay If oppositional defiance or shyness decrease... then good feeling in the therapeutical situation will increase

16. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 16 The course of treatment using Theraplay If oppositional defiance or shyness decrease...... then empathy for others will increase

17. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 17 The course of treatment using Theraplay If oppositional defiance or shyness decrease...... then trust in others will increase

18. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 18 The course of treatment using Theraplay If oppositional defiance or shyness decrease... then sociability, willingness to make contact will increase

19. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 19 The course of treatment using Theraplay If oppositional defiance or shyness decrease...... then child-therapist relationship will improve

20. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 20 Results in detail Typical 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 always is a phase when the disordered child shows a negative reaction to the offered therapeutic action. The results of the German longitudinal study confirm Jernberg‘s hypothesis. Most often at the beginning of the fifth of seven sessions systematically selected out of all sessions of each child the patients showed negative reactions to offered actions.

21. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 21 Typical negative reaction of the treated child to the offered therapeutic action

22. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 22 Results in detail Typical 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 2 nd, 3 rd, 4 th, 5 th or 6 th 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. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 23 Increasing symptoms during therapeutic sessions of oppositional defiant out-patients

24. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 24 Increasing symptoms during therapeutic sessions of shy withdrawn out-patients

25. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 25 Additional Results Effectiveness and lasting effect of the Theraplay treatment The effectiveness of the Theraplay treatment was measured 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 change of 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 t 6 ) - to diagnosis two years after treatment termination (time point t 7 =lasting effect) Method: Clinical Assessment Scale for Child and Adolescent Psychopathology German version: CASCAP-D, measuring on a 4-point scale from M=1 to M=4.

26. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 26 Additional Results Effectiveness and lasting effect of Theraplay Method: CASCAP-D 4-point scale: from 1.0=non-symptomatic to 4.0=high Diagnosed degree of the symptom mean per time point t-Test signifi- cance effect size M1M1 M6M6 M7M7 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... 1.1 2.0 3.1 4.0 3.0 2.0 - 1.3 1.4 1.5 1.4 1.2 - 1.2 - - - - - p<.0001 p<.0001 p<.0001 p<.0001 p<.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... 1.2 2.5 3.0 4.0 3.0 2.0 - 1.1 1.4 1.5 1.3 1.2 - 1.2 - - - - - p<.0001 p<.0001 p<.0001 p<.0001 p<.0001 - d=|2.46| d=|2.26| d>|1.00| d>|1.00| d>|1.00|

27. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 27 Additional Results Effectiveness and lasting effect of the treatment of oppositional defiant out-patients using Theraplay

28. C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany THERAPLAY Therapeutic Treatment Process 28 Additional Results Effectiveness and lasting effect of the treatment of shy withdrawn out-patients using Theraplay