The Third International Theraplay Conference 2007 Chicago Ulrike Franke and Herbert H.G. Wettig Presenter: Ulrike Franke, Cert. Theraplay Trainer - Supervisor.
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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with two groups of preschool children: oppositional, defiant and shy, withdrawn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
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
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 (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.
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
THERAPLAY Therapeutic Treatment Process
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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 How the course of treatment unfoldswith shy, withdrawn preschool childrenusing Theraplay.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.
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
THERAPLAY Therapeutic Treatment Process
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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
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
THERAPLAY Therapeutic Treatment Process
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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
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
THERAPLAY Therapeutic Treatment Process
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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
age-standardized2.93.12.93.84.22.41.5
age-standardized2.63.02.13.84.32.90.9
Degree of symptom CASCAP-D oppositional defiant shy
4-point scale1.21.1
4-point scale 3,11,2
4-point scale1,32,5
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
THERAPLAY Therapeutic Treatment Process
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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
- 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
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
THERAPLAY Therapeutic Treatment Process
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
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
The course of treatment using Theraplay
If oppositional defiance is decreased therapeutically... then frustration tolerance will increase
non-symptomatic children: oppositional defiance non-symptomatic children: frustration tolerancecallback after 16 weeks time of control callback after 16 weeks time of control
11THERAPLAY Therapeutic Treatment Process
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
The course of treatment using Theraplay
If shyness is decreased therapeutically ...... then courage/risk taking of shy children will increase
non-symptomatic children: shyness non-symptomatic children: courage, risk takingcallback after 16 weeks time of control callback after 16 weeks time of control
12THERAPLAY Therapeutic Treatment Process
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
The course of treatment using Theraplay
If oppositional defiance or shyness decrease ...... then attention will increase
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
16THERAPLAY Therapeutic Treatment Process
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
The course of treatment using Theraplay
If oppositional defiance or shyness decrease ...... then empathy for others will increase
shy withdrawn out-patients: shyness shy withdrawn out-patients: empathy for othersnon-symptomatic children: empathy for others callback after 16 week control time
17THERAPLAY Therapeutic Treatment Process
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
The course of treatment using Theraplay
If oppositional defiance or shyness decrease ...... then trust in others will increase
shy withdrawn out-patients: shyness shy withdrawn out-patients: trust in othersnon-symptomatic children: trust in others callback after 16 week control time
18THERAPLAY Therapeutic Treatment Process
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
The course of treatment using Theraplay
If oppositional defiance or shyness decrease ... then sociability, willingness to make contact will increase
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
19THERAPLAY Therapeutic Treatment Process
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
The course of treatment using Theraplay
If oppositional defiance or shyness decrease ...... then child-therapist relationship will improve
shy withdrawn out-patients: shyness shy withdrawn out-patients: child-therapist relationnon-symptomatic children: child-mother relationship callback after 16 week control time
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
THERAPLAY Therapeutic Treatment Process
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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.
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
THERAPLAY Therapeutic Treatment Process
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Typical negative reaction of the treated childto the offered therapeutic action
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
THERAPLAY Therapeutic Treatment Process
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.
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
THERAPLAY Therapeutic Treatment Process
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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
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
THERAPLAY Therapeutic Treatment Process
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
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 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.
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
THERAPLAY Therapeutic Treatment Process
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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|
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
THERAPLAY Therapeutic Treatment Process
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 ...
C 2007. Herbert H.G. Wettig & Ulrike Franke, Germany
THERAPLAY Therapeutic Treatment Process
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 ...