It is important that the worksheet is completed and the questions below are answered.
Assignment
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COUN 6626: Research Methodology and Program Evaluation
Week 4 Scholarly Article Content Analysis
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Case Conceptualization:
Orion is a 4-year-old African American child. He comes into counseling referred by his primary pediatrician. Orion has been diagnosed with an autism spectrum disorder. He has difficulty with communication, has deficits in empathizing with others’ intentions, and struggles with single-mindedness. Orion’s parents and preschool teacher have noticed a pervasive pattern of emotional dysregulation which includes frequent episodes of hysterical crying. Orion’s parents are concerned that he is not going to be promoted to kindergarten next year if he does not improve his ability to relate positively with others and improve his ability to regulate his emotions.
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Article:
Haas, S. C., & Ray, D. C. (2020, July 6). Child-Centered Play Therapy With Children Affected by
Adverse Childhood Experiences: A Single-Case Design. International Journal of Play Therapy.
Advance online publication.
http://dx.doi.org/10.1037/pla0000135
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1. Is the article above a peer-reviewed, scholarly source?
Tip: Peer review is part of the editorial process an article goes through before it is published in a peer-reviewed journal. Once an article is submitted to a peer-reviewed journal, the journal editors send that article to “peers” or scholars in the field to evaluate the article. To determine if a journal is peer reviewed (also sometimes called refereed journals), try one or both of these steps:
· Look up the journal in the UlrichsWeb.com (available on the A-Z Database List) and determine whether it is identified as peer reviewed. Ulrich’s is a directory. It is a searchable list of periodicals (magazines, journals, newspapers, etc.). It provides information about each periodical such as publisher, scope, and whether the journal uses peer review.
· Examine the journal’s website and review the submission and editorial process for evidence of peer review.
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2. What is the (a) problem the researchers were investigating/purpose of the research and (b) research question the researchers were trying to answer? This is a 2 part question.
Tip: All studies have a research question that drives the investigation (what the researchers are trying to learn). Sometimes this is formally stated while other times the reader must discover this information which can usually be found in the Abstract or the Introduction section. Usually there is a section that is named “Purpose of the study”. The Results section or the Discussion section will provide the answer(s) to the research question. Research studies can use either quantitative, qualitative or mixed methods to investigate the question. Sometimes researchers are investigating more than one intervention and so research questions may include multiple parts. Be sure to review all parts of the inquiry or use multiple questions to explain.
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3. Describe the sample/participants in the study. Be sure to include how many participants were included in the study.
Tip: Participants are also known as the sample. Quantitative studies generally have larger samples sizes than qualitative studies. Case studies may have one main “case” which may include a single person, a family, a group, or community. You want to describe who (e.g., demographics) and how many persons participated in the study.
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4. Did the researchers secure permission to conduct the study and/or secure informed consent from the participants? Were there any cultural concerns noted or do you have any concerns about bias?
Tip: Cultural considerations are related to research procedures. Consider whether there were cultural elements that may have changed the way the study took place such as language barriers, the need for an interpreter, and whether the sample matches the population that the researchers say they are studying.
The key is to consider what cultural factors are pertinent to the research question. If you say you are studying an intervention for depression, the sample needs to include persons with depression. If a study is not specific to race or gender, for example, that does not make it culturally insensitive if the researches didn’t set out to learn about that intervention specifically applied to race or gender.
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5. Identify exactly what data was collected by the researchers in the study.
Is the data quantitative (numeric data such as scores on assessments like the Iowa Basic Skills Test (IBST) or the Beck Depression Inventory (BDI)? If there are assessment instruments used – are they numerical results or narrative results?
Is the data qualitative (for example, clinical intake interviews or a narrative behavioral observation?
Tip: The variables (e.g., substance abuse) or characteristic (e.g., geographic location) being investigated is usually found in the Introduction and Method sections (and sometimes the Abstract). For example: if a researcher is investigating an intervention for the treatment of depression. The variable may be “level of depression” and the data collected could be scores on the Beck Depression Scale.
All data points represent something the researcher is trying to investigate. Data can be quantitative (like a measurement, frequency, or score that is represented by a numeral) or qualitative (data captured using written or spoken words, observations or photos). This includes things like student academic or behavioral records, historical documents, records, or artifacts like diaries or case notes.
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6. What was the outcome or the general result of the research study?
What is the answer to the research question?
Tip: The Discussion section is where what the authors present how the results can be applied when working with clients or students. The authors will articulate their greatest take away from the study outcomes and what they view as most important to know to meet the needs of clients or students with similar needs.
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7. Based on your understanding of the results of the research study presented, discuss how the outcomes can be generally applied to your future counseling practice.
Tip: The authors identify if the results of the investigation support their hypothesis and present the major findings. The Results section and the Discussion section present the answer to the question the researchers were trying to learn. Keep in mind that when you are investigating an intervention, the results could be mixed. In other words, the intervention might be successful, not successful, or partially successful.
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8. How does this research article apply to the case study at the top of the worksheet?
Tip: While there are similarities and differences between the article and the case study on the worksheet, describe how the general outcomes from the article relate to the case study. Explain your insights into how the information from the article could be useful to meet the needs of the case study.
NOTE: As a counselor, what did you interpret from the outcomes of the research study in the article that you could use in developing treatment goals or action plans for the child in the case study on the worksheet?
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Your Answer here should include the steps and process you took to find the selected research article. Explain how you know your selected article is peer reviewed.
Your Answer here should include details about the participants, or information about the population (sample) used in the research study.
Your Answer here should provide a snapshot of the participants.
© 2020 Walden University
1
Child-Centered Play Therapy With Children Affected by Adverse
Childhood Experiences: A Single-Case Design
Sara C. Haas
Northern Arizona University
Dee C. Ray
University of North Texas
We conducted single-case research with 2 participants to explore the influence of
child-centered play therapy (CCPT) on children who had 4 or more adverse childhood
experiences (ACEs) and analyzed data collected from the Strength and Difficulties
Questionnaire on a weekly basis and the Trauma Symptoms Checklist for Young
Children at pre- and posttest. Both participants demonstrated significant improvement
in total difficulties and prosocial behaviors, revealing potential therapeutic benefits for
the use of CCPT with children who have 4 or more ACEs. The discussion of study
results includes implications for practice, suggestions for future research, and
limitations.
Keywords: child-centered play therapy, adverse childhood experiences, single-case
design
Adverse childhood experiences (ACEs) can
be defined as traumatic and stressful experi-
ences occurring in childhood (Felitti et al.,
1998). Categories for ACEs include physical
abuse, sexual abuse, emotional abuse, emo-
tional neglect, physical neglect, mental illness,
substance abuse, separation/divorce, domestic
violence, incarceration, and living in foster care
(Felitti et al., 1998; Wade et al., 2016). The
commonality between all of the categories is a
self-report of feeling maltreated or living in
household dysfunction during childhood. The
Centers for Disease Control and Prevention
(CDC, 2019) noted that over 50% of adults in
the United States have reported experiencing at
least one ACE, and 15% have reported experi-
encing four or more ACEs. Adverse experi-
ences occurring in childhood have been found
to have a profound influence on the health and
well-being of children and adults (Clarkson
Freeman, 2014; Felitti et al., 1998; Wade et al.,
2016). The resulting trauma that, over multiple
events, leads to complex trauma is a common
outcome and response to the experiencing of
adverse experiences (Substance Abuse and
Mental Health Services Administration [SAM-
HSA], 2018). Although various mental health
interventions have been proposed to address the
symptoms resulting from ACEs and childhood
trauma, there is still little evidence to support
positive treatment outcomes for children who
have experienced ACEs. Child-centered play
therapy (CCPT) fosters connections and rela-
tionships in a safe, therapeutic environment,
lending to the potential of CCPT being an ef-
fective intervention with children who have ex-
perienced multiple ACEs.
Broad Spectrum of ACEs Outcomes
Adverse experiences occurring in childhood
have been found to have a profound influence
on the health and well-being of adults (Felitti et
al., 1998; Wade et al., 2016). ACEs have long-
term effects on physical and mental health, ad-
dictive behaviors, criminal activities, and adult
relationships. As a result of ACEs, adults may
This article was published Online First July 6, 2020.
X Sara C. Haas, Department of Educational Psychology,
Northern Arizona University; X Dee C. Ray, Department
of Counseling and Higher Education, University of North
Texas.
Correspondence concerning this article should be ad-
dressed to Sara C. Haas, Department of Educational Psy-
chology, Northern Arizona University, 15451 North 28th
Avenue, Phoenix, AZ 85053. E-mail: sara.haas@nau.edu
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International Journal of Play Therapy
© 2020 Association for Play Therapy 2020, Vol. 29, No. 4,
223
–236
ISSN: 1555-6824 http://dx.doi.org/10.1037/pla000013
5
223
https://orcid.org/0000-0002-6894-6092
https://orcid.org/0000-0002-2587-317X
mailto:sara.haas@nau.edu
http://dx.doi.org/10.1037/pla0000135
have a higher risk for health symptoms that lead
to death and a shortened life span, as well as
fatigue and lack of energy that impact the per-
ceived quality of life (Felitti et al., 1998). Sub-
sequent mental health issues, such as posttrau-
matic stress, depression, anxiety, hopelessness,
stress, and even suicidal behavior, appear to be
linked to a person’s ACEs. Generally, affective
disorders, as well as depressive and anxiety
disorders, in adulthood are likely to be corre-
lated with adverse experiences in childhood
(Spinhoven et al., 2010). Grasso, Dierkhising,
Branson, Ford, and Lee (2016) found that if
children had multiple types of ACEs during any
time of childhood, early childhood, middle
childhood, or adolescence, the participants were
affected developmentally and had a persistent
amount of stress into adolescence and adult-
hood.
Additionally, ACEs appear to be linked to
later substance abuse and criminal activity. Sub-
stance abuse issues are highly correlated with an
increased number of ACEs (Felitti et al., 1998),
a consistent finding across cultures (Brockie,
Dana-Sacco, Wallen, Wilcox, & Campbell,
2015; Giordano, Ohlsson, Kendler, Sundquist,
& Sundquist, 2014). Regarding criminal activ-
ity, researchers have linked juvenile offenders
and an increased number of ACEs (Baglivio &
Epps, 2016). Fox, Perez, Cass, Baglivio, and
Epps (2015) found that the number of ACEs
experienced by serious, violent, and chronic
offenders was statistically significantly higher
than the number of ACEs for offenders who had
one violation, suggesting that the identification
of ACEs could be one indicator in determining
youth who are at a higher risk of becoming
serious, violent, and chronic offenders.
ACEs Outcomes During Childhood
Although research has been conducted on the
effects of ACEs in adulthood, there are substan-
tially fewer studies exploring the effects of
ACEs during childhood. Burke, Hellman, Scott,
Weems, and Carrion (2011) found that children
who experienced four or more ACEs had a
significantly higher probability of having learn-
ing and behavior problems. Utilizing the Na-
tional Survey of Child and Adolescent Well-
Being (NSCAW) and the Child Behavior
Checklist (CBCL; Achenbach, 1991), Clarkson
Freeman (2014) examined the prevalence and
relationship between ACEs and internalizing,
externalizing, and total problems for 2,830 chil-
dren 6 years of age and younger. Overall, chil-
dren who had four or more ACEs were more
likely to exhibit problematic behaviors than
children who did not experience ACEs (Clark-
son Freeman, 2014). Escueta, Whetten, Oster-
mann, O’Donnell, and the Positive Outcomes
for Orphans Research Team (2014) examined
the psychosocial well-being and cognitive de-
velopment of orphaned and abandoned children
who experienced ACEs in five low-income
countries. They found that exposure to poten-
tially traumatic events was determined to be a
predictor of emotional difficulties. Child re-
search on ACEs reveals a dose– effect response
whereby the more ACEs reported, the higher
the number and intensity of negative outcomes
(Grasso et al., 2016; Jimenez, Wade, Lin, Mor-
row, & Reichman, 2016; Thurston, Bell, &
Induni, 2018). Although research on ACEs
while participants are still in childhood is lim-
ited, there is evidence to suggest that children
exhibit the deleterious consequences of ACEs
during and immediately following adverse
events.
The CCPT and ACE Connection
As children grow and develop, influences
from caregivers have the potential to disconnect
them from their natural organismic valuing pro-
cess. Although the organismic valuing process
still remains, children begin to rely more on
external messages from caregivers and become
less attuned to their organismic valuing process,
placing greater emphasis on what others value
(Turner, 2012). Children’s self-structure
changes to integrate the way they view them-
selves and their actual experiences (Wilkins,
2010). Children strive to be protected, nurtured,
and cared for by others. Because of the need to
be positively regarded by others, children rely
on an external locus of control and create con-
ditions of worth. Conditions of worth are mes-
sages created to earn love or acceptance from
others by conforming to demands, expectations,
and positive evaluations from others (Wilkins,
2010). Children may begin to have beliefs of
only being accepted when their conditions of
worth are met. Children experience incongruity
because they no longer take in all experiences
through their organismic valuing process; in-
224 HAAS AND RAY
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stead, experiences are taken in through the filter
of a rigid self-perception influenced by the val-
ues of others (Wilkins, 2010).
Because of the nature of the conditions pro-
vided to children who have experienced ACEs,
they may develop extremely negative and abu-
sive self-regard, which can become the focus of
their self-concepts and influence their decisions
and attitudes toward themselves (Power, 2012).
Children who experience ongoing adverse and
traumatic experiences likely live in a world of
fear (Hawkins, 2014). Whereas typical self-
structures are fluid and allow for new experi-
ences to help shape the way children view ex-
periences (Rogers, 1957), the self-structures of
children who have ongoing adverse or traumatic
experiences are rigid (Wilkins, 2010). The ri-
gidity of self-structure occurs because their con-
ditions of worth continue to contribute to their
negative self-regard. Children’s understanding
of the world and reality might be altered and
viewed through a more negative lens. Ongoing
confirmation of negativity serves the purpose of
maintaining the rigidity of the self-structure.
The utilization of negative behaviors ensures
that others will treat them in ways matching
their current self-concept (Clarkson Freeman,
2014).
Children who have experienced multiple or
ongoing ACEs are likely to need experiences
that contradict the traumatic experiences that
have influenced their rigid self-structures.
CCPT is an intervention that promotes the rela-
tionship between therapist and child as the pri-
mary healing agent in therapy (Landreth, 2012).
Child-centered play therapists hold the belief
that children innately have the capacity within
them to work through and make sense of mal-
adaptive behaviors when provided with the nec-
essary environment (Landreth, 2012). CCPT
therapists provide the core conditions of person-
centered theory— congruence, empathic under-
standing, and unconditional positive regard
(UPR)—to create a therapeutic relationship
with children (Landreth, 2012). As a child
slowly perceives and integrates the therapist
attitudinal conditions, the child is able to form a
new self-structure. When counselors are free of
expectations while unconditionally positively
regarding clients, children are able to grow and
develop (Rogers, 1957). Although the self-
actualizing tendency may have been halted
through adverse events, it is still a dynamic
force inside of a child. By experiencing UPR
and empathic understanding, a child can begin
to integrate new experiences and establish a
more fluid self-structure (Ray, 2011). The flu-
idity of self-structure will provide the child with
the ability to accept more positive experiences
without rejecting them fully. In essence, CCPT
offers an alternative positive childhood experi-
ence to counteract the negative impact of con-
ditions and disrupted relationships experienced
during adverse events. Additionally, CCPT in-
volves the facilitation of parent consultation in
order to address the environmental facilitation
of relationships and stability for the child.
Although CCPT research has not been con-
ducted on ACEs as a singular construct, histor-
ical and recent research on CCPT supports the
use of intervention with children with individ-
ual ACEs. Intervention research has been con-
ducted on the individual ACEs of sexual abuse,
witnessing domestic violence, and refugee trau-
ma. Kot, Landreth, and Giordano (1998) uti-
lized intensive CCPT with children who wit-
nessed domestic violence. The experimental
group demonstrated a statistically significant in-
crease in self-concept and a statistically signif-
icant reduction of externalizing and total behav-
iors. Scott, Burlingame, Starling, Porter, and
Lilly (2003) conducted 7 to 13 CCPT sessions
with 26 participants aged 3 to 9 years old who
were sexually abused and found that whereas
the child self-report results showed progress,
the parent reports did not show significant
changes. Scott et al. hypothesized that children
began to feel different before external changes
were observable by parents. Schottelkorb, Dou-
mas, and Garcia (2012) compared the effective-
ness of CCPT to trauma-focused cognitive–
behavioral therapy (TF-CBT), finding that
CCPT had a statistically significant impact with
children who suffered from refugee trauma.
CCPT research was also conducted with chil-
dren living in poverty. Although poverty is not
considered an ACE, Wade et al. (2016) demon-
strated that living in poverty was correlated with
experiencing ACEs. Bratton et al. (2013) exam-
ined the effectiveness of CCPT with 54 children
enrolled at a low-income preschool and found
that the CCPT group had a statistically signifi-
cant decrease of disruptive behaviors, aggres-
sion, and attention problems. Bratton et al. dem-
onstrated the effectiveness of using CCPT to
reduce the problem behaviors of children in
225CCPT WITH CHILDREN AFFECTED BY ACES
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lower-socioeconomic-status preschools. CCPT
has been shown to be effective with selected
individual ACEs, lending to the hypothesis that
CCPT may be effective with children who have
experienced multiple ACEs.
Purpose of Study
The purpose of this study was to investigate
the impact of CCPT on children who have ex-
perienced four or more ACEs. Specifically, we
examined the effect of CCPT on the child’s
emotional symptoms, interpersonal relation-
ships, and problem behaviors. A single-case
design was implemented, and data were col-
lected throughout baseline, intervention, and
follow-up phases for two children participating
in CCPT. The guiding research question for this
study was as follows: What is the impact of
CCPT on the emotional symptoms, conduct
problems, hyperactivity and inattention, peer
relationship problems, prosocial behavior, and
posttraumatic stress of children who experi-
enced four or more ACEs?
Method
Participants
Research participants included two children
recruited from a university-based counseling
clinic that serves community clients located in
the southwestern United States. The clinic is an
instructional and training-based clinic that
serves clients across the life span. The majority
of clients (60%) are children under the age of
12. Child clients served through the clinic typ-
ically come from families of low socioeco-
nomic status and low educational attainment.
Participants met the following inclusion crite-
ria: (a) between the ages of 4 and 9 years old,
(b) score of 4 or higher on the Adverse Child-
hood Experiences Checklist, and (c) not partic-
ipating in other forms of counseling over the
course of the study. Four participants were ini-
tially identified for participation. However, two
of the participants, who were also siblings, were
dropped from the study because of home dis-
ruption during the course of the study, resulting
in the completion of the study by two partici-
pants. The individual information for each par-
ticipant is provided in the following sections.
Pseudonyms were used to maintain confidenti-
ality.
Participant 1
Justin is an 8-year-old White American male
who resides with his biological mother, sister,
and maternal grandmother. Background infor-
mation was reported by Justin’s mother. Justin
qualified for the study because of his exposure
to eight categories of ACEs: emotional abuse,
emotional neglect, physical neglect, domestic
violence, household substance abuse, household
mental illness, parental separation, and incar-
cerated household member.
Prior to the divorce between Justin’s mother
and father, Justin’s mother reported that Justin
witnessed the perpetration of domestic violence
upon his mother by his father. Justin’s father
was incarcerated multiple times for drugs and
violence against Justin’s mother and her prop-
erty. Justin’s father had a history of depression
and was openly suicidal in Justin’s presence.
Justin also verbalized negative thoughts about
his self-worth and felt responsible for mediating
between his parents. At intake for participation
in the current study, Justin’s mother reported
that Justin verbalized wanting to live with his
father despite his fears and often blamed his
mother for his father’s behavior. Justin’s mother
reported that Justin had difficulty regulating
emotions and cried and screamed at school. She
was often asked to pick him up from school
because of his difficulty.
Participant 2
Megan is a 9-year-old White American fe-
male who resides with her biological father,
stepmother, and multiple siblings who are step-
siblings or half-biological siblings. Background
information was reported by Megan’s father and
stepmother. Megan qualified for the study be-
cause of her exposure to eight categories of
ACEs: sexual abuse, emotional neglect, physi-
cal neglect, domestic violence, household sub-
stance abuse, household mental illness, parental
separation, and incarcerated household mem-
ber.
Megan’s biological mother and father were
separated when she was an infant. Her biolog-
ical mother accused her father of sexually abus-
ing Megan, resulting in invasive medical exam-
inations. However, there were no findings that
226 HAAS AND RAY
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Megan’s biological father was physically abu-
sive. Megan’s father and stepmother reported
that as a young child, Megan witnessed her
mother being physically abused by her mother’s
boyfriend. During custodial visits with her
mother, Megan was often unsupervised and
found with dirty clothes and diapers when
picked up by her father. Megan’s biological
mother died from a drug overdose when Megan
was 3 years old. At intake for the present study,
Megan’s father reported that Megan frequently
expressed low self-worth and a lack of belong-
ing in her family.
Instruments
Adverse Childhood Experiences Checklist.
The original Adverse Childhood Experiences
(ACE) Checklist (Felitti et al., 1998) is a 10-
item checklist that assesses adults for the past
experiences of ACEs. The total number of
ACEs checked provides participants with their
ACE numbers. Felitti et al. (1998) introduced
the original ACEs adult checklist, which in-
cluded items related to physical abuse, sexual
abuse, emotional abuse, emotional neglect,
physical neglect, mental illness, substance
abuse, separation/divorce, domestic violence,
and incarceration. Wade et al. (2016) modified
the adult checklist to incorporate extended
ACEs, including witnessing violence, felt dis-
crimination, lack of neighborhood safety, feel-
ing bullied, and living in foster care. The orig-
inal checklists were designed for adults to
answer about their childhoods. For the purposes
of the present study, the ACE Checklist was
modified for language in order to use present-
tense language for parents to complete items
regarding their children. For example, the orig-
inal ACE Checklist (Felitti et al., 1998) asked,
“Did you live with anyone who was a problem
drinker or alcoholic or who used street drugs?”
The question was rewritten to state, “Has your
child lived with anyone who is/was a problem
drinker or alcoholic or had a problem with street
drugs or prescription drugs?” The ACE Check-
list (Cronholm et al., 2015) included the origi-
nal 10 ACEs (Felitti et al., 1998) and foster care
as identified by Wade et al. (2016).
Strengths and Difficulties Questionnaire.
The Strengths and Difficulties Questionnaire
(SDQ; Goodman, 2001) is a 25-item assessment
completed by parents/caregivers and used to
identify the behavioral problems and interper-
sonal strengths of children 4 to 17 years of age.
The SDQ Total Difficulties score is a composite
of four subscales: Emotional Symptoms, Con-
duct Problems, Hyperactivity and Attentional
Difficulties, and Peer Relationship Problems.
The Total Difficulties score can range from 0 to
40. An additional fifth subscale indicates Proso-
cial Behavior. Higher Total Difficulties scores
have been correlated to greater psychopathol-
ogy (Goodman & Goodman, 2009). Goodman
(2001) reported internal consistency reliability
coefficients for the scales ranging from .41 to
.87, with .82 for the total parent score. The
reported mean test–retest reliability for the SDQ
is r � .72, and the mean internal consistency is
� � .71 (National Center for Child Traumatic
Stress [NCTSN], 2018). For the current study,
the SDQ total score was used as the weekly
measurement of behaviors for the participants.
The Trauma Symptom Checklist for
Young Children. The Trauma Symptoms
Checklist for Young Children (TSCYC; Briere,
2005) is an assessment used to evaluate post-
traumatic stress and consists of 90 questions and
the following eight subscales: Anxiety, Depres-
sion, Anger/Aggression, Posttraumatic Stress—
Intrusion, Posttraumatic Stress—Avoidance,
Posttraumatic Stress—Arousal, Dissociation,
and Sexual Concerns. The subscales result in an
overall Posttraumatic Stress score (Briere,
2005). Internal-consistency alphas were re-
ported as ranging from .73 to .86. The test–
retest reliability for the TSCYC correlation co-
efficients ranged from .68 to .96, with a median
of r � .88 (Briere, 2005). For the purposes of
the current study, the TSCYC total score was
used as a descriptive measurement of change
from pre- to posttest across the duration of the
study.
Procedure
Following approval by the University of
North Texas Institutional Review Board (IRB),
we examined the intake documentation of chil-
dren ages 4 to 9 who presented to the clinic for
services. Upon determination of the children
having a strong probability of having experi-
enced ACEs based on intake caretaker report,
we contacted the caregivers to provide an over-
view of the study and inquire about interest in
participation. If parents indicated interest, we
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set up parent interviews in which we gained
background information, gained consent to par-
ticipate, and determined eligibility through the
use of the ACE Checklist–modified. Of 6 chil-
dren identified as potential participants, 4 met
the criterion of reporting four or more ACEs.
For those four children, parents/guardians com-
pleted the initial TSCYC and SDQ. Parents
continued to complete the SDQ weekly for a
minimum of 3 weeks to establish a baseline,
during which time the participants received no
treatment. Over the course of the study, two of
the participants were removed from the study as
a result of a disruption in the home environ-
ment. For both participants completing the
study, a consistent baseline was established at 6
weeks. Once a consistent baseline was estab-
lished, the treatment phase began.
During the treatment phase, participants par-
ticipated in 24 play therapy sessions held bi-
weekly for 45 min each. Occasionally, partici-
pants only engaged in one play therapy session
because of participant or play therapist illness.
The participants did not engage in play therapy
for 2 weeks because of holiday vacations. Par-
ents continued to complete the SDQ weekly. At
the 12-session midpoint and following the 24th
session, parents/guardians completed the
TSCYC. After completion of the 24th session,
final interviews were conducted with the care-
givers to gather information about caregivers’
and children’s experiences of CCPT. Following
the 24th session, the SDQ was completed
weekly for 4 weeks during the follow-up phase,
during which parents/guardians and children
did not receive services.
CCPT Intervention
The CCPT intervention was facilitated by an
advanced doctoral student in a counselor edu-
cation doctoral program accredited by the
Council for Accreditation of Counseling and
Related Educational Programs (CACREP) who
completed 2.5 years of doctoral work in coun-
seling, had 23 hr of graduate-level coursework
in play therapy, had and 5 years of experience
utilizing CCPT. Additionally, the counselor was
a licensed professional counselor intern and cer-
tified school counselor, and she participated in
weekly supervision of play therapy with a doc-
toral-level faculty member who is a licensed
professional counselor supervisor and a regis-
tered play therapist supervisor.
Each child was scheduled to receive 45 min
of individual CCPT twice a week for 12 weeks.
In order to ensure treatment adherence, a rater
trained in the Child-Centered Play Therapy-
Research Integrity Checklist (CCPT-RIC; Ray,
Purswell, Haas, & Aldrete, 2017) rated 15 min
of each session using the CCPT-RIC. Fidelity
adherence was 96%, exceeding recommenda-
tions by Ray et al. (2017).
For the play therapy sessions, the playroom
was equipped according to Ray’s (2011) Child-
Centered Play Therapy Manual. Each room
used was equipped with a video camera to pro-
vide the opportunity to check for fidelity. The
rooms varied in size but were equipped with
toys and materials recommended by Landreth
(2012).
Parent Consultation
Typically, regular and consistent parent con-
sultations are a part of CCPT implementation.
In order to ensure consistency with CCPT, par-
ent consultations were conducted for 30 min
biweekly, in addition to the CCPT sessions.
Parent consultations were conducted following
every four play therapy sessions and were held
at a separate time from the play sessions. Schot-
telkorb, Swan, and Ogawa (2015) created a
child-centered parent consultation model that
was used to maintain consistency for the thera-
pist. The five components of the parent consul-
tation model are (a) creating and maintaining
the therapeutic relationship with parents, (b)
demonstrating an awareness and understanding
by listening and responding, (c) honoring par-
ents as the experts on their children, (d) provid-
ing pertinent knowledge, and (e) teaching ther-
apeutic skills. Parent consultations followed the
five components of the model in order to pro-
vide parents with information about their child
and the therapeutic process while teaching skills
deemed necessary to help facilitate the child–
parent relationship. Schottelkorb et al. (2015)
suggested a session format in order to ensure the
five components are met. The first parent con-
sultation session focused on the building of the
relationship and gathering a deeper understand-
ing of the child. Each subsequent session con-
tinued with building the relationship, gaining
and providing an understanding of the child,
228 HAAS AND RAY
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and teaching therapeutic techniques relevant to
each individual. Final parent consultation ses-
sions consisted of the parents and therapist re-
porting progress and changes witnessed
throughout the process (Schottelkorb et al.,
2015).
Data Analysis
Using weekly data gathered from the SDQ,
we used visual data analysis to examine predict-
able baseline patterns, data within each phase,
data between each phase, and integration of data
between all phases (Ray, 2015). Following the
standards from the What Works Clearinghouse
on single-case-design studies (Kratochwill et
al., 2013), we analyzed and reported the follow-
ing: (a) the level of each phase, which is the
mean of each phase; (b) the trend, which is the
slope of data between each phase; (c) the vari-
ability, which is the difference between the
trend and individual data points; (d) the imme-
diacy of effect, which measures how quickly
there was an effect with the intervention; (e) the
consideration of overlap, which compares how
much one phase overlaps with another one; and
(f) the consistency of data patterns across the
phases (Ray, 2015). In order to find the strength
of the relationship between variables, we calcu-
lated effect size using nonoverlap of all pairs
(NAP; Parker & Vannest, 2009) and interpreted
according to the following criteria: 0 –.65, weak
effect size; .66 –.92, medium effect size; and
.93–1.0 strong effect size (Parker & Vannest,
2009). Data from the TSCYC were used de-
scriptively to provide further information on
change over the duration of the study.
Results
Participant 1: Justin
Justin participated in 6 weeks of a noninter-
vention baseline phase, 13 weeks of an inter-
vention phase where he participated in 24 play
therapy sessions, and 4 weeks of a noninterven-
tion follow-up phase. Table 1 provides the
means and standard deviations for each subscale
in each phase of the study. For five subscales,
Emotional Symptoms, Conduct Problems, Hy-
peractivity and Attentional Difficulties, Peer
Relationship Problems, and Total Difficulties,
the means continually decreased across all
phases of the study, demonstrating improve-
ment. The means of Prosocial Behavior in-
creased across all phases, demonstrating im-
provement. Figure 1 provides a graphical
representation of all data. In addition to visual
analysis, we calculated the NAP for Total Dif-
ficulties. Because data for individual scales can
be found in Table 1, we limited our narrative
results to the Total Difficulties score on the
SDQ and the TSCYC.
Total Difficulties score. Level analysis of
the graph indicated a decrease from a mean of
26.5 in the baseline phase to 11.69 in the treat-
ment phase, followed by another decrease to 3
in the follow-up phase. Trend analysis revealed
a downward trend across the baseline and treat-
ment phases of the study, with a large correla-
tion (R2 � .78), indicating a large relationship
between the play therapy phase and Justin’s
decrease in overall difficulties. Analysis of vari-
ability between conditions revealed large vari-
ability between phases, with standard deviations
(SD) of 1.22 in the baseline phase, 7.66 in the
Table 1
Means and Standard Deviations for Justin’s SDQ Scores
Subscale
Baseline Intervention Follow-up
M SD M SD M SD
Emotional Symptoms 7.83 .75 2 3.32 .25 .5
Conduct Problems 4.33 .52 1.77 1.17 .5 .58
Hyperactivity and Attentional Difficulties 9.67 .52 5.78 1.89 2.25 1.26
Peer Relationship Problems 4.5 .84 2.08 1.66 0
0
Prosocial Behavior 5.44 .79 7.23 1.48 9.5 1
Total Difficulties 26.5 1.22 11.69 7.60 3 .82
Note. SDQ � Strengths and Difficulties Questionnaire.
229CCPT WITH CHILDREN AFFECTED BY ACES
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intervention phase, and .82 in the follow-up
phase. The decrease was not immediate because
the data did not visibly decrease until the third
data point of the intervention phase. Addition-
ally, there were overlapping data between these
two phases. The mean of the last three data
points in the baseline (M � 27.33) was similar
to the mean of the first two data points in the
intervention phase (M � 28). In addition to
visual analysis, we calculated the NAP statistic
to examine the degree of the treatment’s effec-
tiveness. The NAP effect size comparing the
data from the baseline phase and the data from
the intervention phase was a medium effect size
of .87, whereas the effect-size calculation of the
data from the baseline phase compared with the
data from the follow-up phase was a strong
effect size of 1 (Parker & Vannest, 2009).
Posttraumatic Stress score. The TSCYC
was completed by Justin’s mother prior to the
baseline, at the 12th intervention session, and at
the 24th session. The Posttraumatic Stress T
scores were 98 prior to the intervention, 48 at
the 12th session of the treatment phase, and 46
at the 24th session. The Posttraumatic Stress
scores decreased over the time of the study,
with substantial improvement reported after 12
sessions.
Follow-up parent interview. Upon com-
pletion of the intervention phase, Justin’s
mother participated in a follow-up interview.
She reported that Justin demonstrated less anger
and was more carefree than when the study
began. He was no longer displaying sadness at
school or home, and he was verbalizing his
feelings and opinions. He no longer erupted in
tears and anger; instead, he spoke up and shared
what he was thinking and feeling. Justin’s melt-
downs at school stopped, and his teachers re-
ported that he was no longer displaying problem
behaviors. Justin’s mother reported that he was
helpful and kind at home and more readily used
his manners. In regard to peer relationships, she
reported that Justin had better relationships with
peers and that he was able to problem solve
when he was upset. Justin’s mother reported
positive changes to their parent– child relation-
ship. She previously felt that Justin hated her
and blamed her for the divorce, yet at the final
interview, she reported feeling reconnected to
him. Additionally, Justin’s mother reported that
he had demonstrated nurturing behaviors to-
ward her. Overall, she reported that Justin
looked forward to coming to play therapy dur-
ing the intervention phase.
Participant 2: Megan
Megan participated in 6 weeks of a noninter-
vention baseline phase, 12 weeks of an inter-
vention phase where she participated in 24 play
therapy sessions, and 4 weeks of a noninterven-
tion follow-up phase. Table 2 provides the
means and standard deviations for each subscale
in each phase of the study. For two subscales,
Emotional Symptoms and Hyperactivity and
0
5
10
15
20
25
30
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Total Difficul�es Emo�onal Symptoms Conduct Problems
Hyperac�vity and Ina�en�on Peer Problems Prosocial
Baseline Interven�on Follow-Up
Figure 1. Justin’s Strengths and Difficulties Questionnaire (SDQ) scores during baseline,
intervention, and follow-up phases.
230 HAAS AND RAY
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Attentional Difficulties, the means continually
decreased across all phases of the study, dem-
onstrating improvement. For Conduct Prob-
lems, the means remained the same during the
baseline and intervention phases and decreased
during the follow-up phase. For Peer Relation-
ship Problems and Total Difficulties, the means
increased between the baseline and intervention
phases and decreased during the follow-up
phase. The means of Prosocial Behavior de-
creased between the baseline and intervention
phases and increased during the follow-up
phase. Figure 2 provides a graphical represen-
tation of all data.
Total Difficulties score. Level analysis of
the graph indicated an increase from a mean of
15.5 in the baseline phase to 16.18 in the treat-
ment phase, followed by a decrease to 9.25 in
the follow-up phase. Trend analysis revealed a
consistent trend across the baseline and treat-
ment phases of the study, with a small corre-
lation (R2 � .03), indicating a weak relation-
ship between the play therapy phase and
Megan’s decrease in overall difficulties.
Analysis of variability between conditions re-
vealed variability between phases, with stan-
dard deviations of 1.64 in the baseline phase,
3.59 in the intervention phase, and 1.71 in the
follow-up phase. The decrease was not imme-
diate because the data did not visibly decrease
until the 17th data point of the intervention
phase. Additionally, there were overlapping
data between these two phases. The mean of
the last three data points in the baseline (M �
15.67) was smaller than the mean of the first
three data points in the intervention phase
(M � 19). In addition to visual analysis, we
calculated the NAP statistic to examine the
Table 2
Means and Standard Deviations for Megan’s SDQ Scores
Subscale
Baseline Intervention Follow-up
M SD M SD M SD
Emotional Symptoms .83 .41 .75 .86 0 0
Conduct Problems 4.83 .75 4.83 1.33 2.25 .96
Hyperactivity and Attentional Difficulties 8.83 .98 8.25 2.01 5.25 .5
Peer Relationship Problems 1 .63 2.5 1 1.75 .95
Prosocial Behavior 8.5 .55 7.83 1.93 9.5 .58
Total Difficulties 15.5 1.64 16.18 3.59 9.25 1.71
Note. SDQ � Strengths and Difficulties Questionnaire.
0
5
10
15
20
25
30
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Total Difficul�es Emo�onal Symptoms Conduct Problems
Hyperac�vity and Ina�en�on Peer Problems Prosocial
Baseline Interven�on Follow-Up
Figure 2. Megan’s Strengths and Difficulties Questionnaire (SDQ) scores during baseline,
intervention, and follow-up phases.
231CCPT WITH CHILDREN AFFECTED BY ACES
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degree of the treatment’s effectiveness. The
NAP effect size comparing the data from the
baseline phase and the data from the interven-
tion phase was a weak effect size of �.35 in
the negative direction, whereas the effect-size
calculation of the data from the baseline
phase compared with the data from the fol-
low-up phase was a large effect size of 1,
indicating that a substantial amount of im-
provement was revealed toward the end of the
intervention and following the intervention.
Posttraumatic Stress score. The TSCYC
was completed by Megan’s stepmother prior to
the baseline, at the 12fth intervention session,
and at the 24th session. The Posttraumatic
Stress T scores were 78 prior to the intervention,
76 at the 12th session of the treatment phase,
and 50 at the 24h session. The Post-Traumatic
Stress scores decreased over the time of the
study, with the most substantial improvement
occurring from the play therapy phase to fol-
low-up.
Follow-up parent interview. Upon com-
pletion of the intervention phase, Megan’s fa-
ther and stepmother participated in a follow-up
interview. They reported that following partic-
ipation in CCPT, Megan appeared happier,
bounced backed more quickly from disappoint-
ments when things did not go as planned, dis-
cussed her feelings with them, and accepted
responsibilities for mistakes. They reported that
Megan had a greater attention span and a better
ability to stay focused at home and at school.
Megan was less impulsive, and she started
thinking before acting. Megan became more
selective with her peer choices; therefore, she
had better relationships with friends. Megan
discontinued physically reacting when she was
upset, and she demonstrated remorse when she
was upset. They reported that Megan had be-
come more affectionate with her stepmother,
whereas prior to the study, she was only affec-
tionate with her father. They reported having a
deeper, stronger relationship and connection
with Megan. Although they reported in the final
interview that they initially had mixed feelings
about seeking counseling, they reported that it
was a positive experience. They reported that
once Megan began feeling heard in the thera-
peutic relationship, she tried calmer ways of
receiving attention at home. Through parent
consultations, they discovered Megan’s desire
for relationships and physical touch and discon-
tinued removing relational activities as conse-
quences. Megan’s father reported seeing grad-
ual changes throughout the study; however, her
stepmother reported that she was unaware of the
gradual changes but recognized the drastic
changes toward the end.
Discussion
The purpose of this study was to examine the
effectiveness of facilitating CCPT with children
who had four or more ACEs. Both of the par-
ticipants in the study had eight ACEs, which
was well over the criteria requirements for the
study. Both participants demonstrated clinical
levels in some or all of the subscales from the
SDQ as well as high levels of posttraumatic
stress at the initiation of the study. Throughout
the duration of the study, both participants sig-
nificantly decreased in all areas of concern and
were not clinical in any area at the end of the
follow-up phase. Although the improvements
occurred at different times of the intervention
phase, both children had lasting change once the
initial change was reported. Through the play
therapy experience, both participants were able
to begin self-actualizing, which allowed them to
build self-acceptance and self-confidence. Jus-
tin demonstrated a rapid decrease in symptom-
ology across subscales within the intervention
phase, and this continued throughout the fol-
low-up phase. Megan’s decrease in symptomol-
ogy for clinically scored subscales occurred fur-
ther into the intervention phase and continued
throughout the follow-up phase. Although both
participants decreased problematic behaviors
and increased prosocial behaviors, the time in
which the changes occurred was different for
the participants.
Process of CCPT for Children With ACEs
Manifestation of change and growth is a slow
process (Landreth, 2012). Children who lived
through difficult situations typically present
with intensified emotions, mostly negative and
no longer tied to the reality of the moment but
filtered through past experiences. When they
enter therapy, their emotions are heightened,
indiscriminate, and easily aroused (Moustakas,
1953). Through qualitative research, Moustakas
(1953) identified four stages of change during
the therapeutic process that lead to improved
232 HAAS AND RAY
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functioning. As children receive faith, accep-
tance, and respect, relationships between thera-
pists and children are strengthened, and children
begin to move through the stages (Moustakas,
1953). Although there are significant shifts, par-
ents and caregivers may not be immediately
aware of the changes outside of the playroom.
When the conditions that created the malad-
justment are still present, healing may take lon-
ger (Axline, 1947). Therapeutic relationships
provide the environment for healing, but when
children are still subjected to the relationships
that facilitated their conditions of worth, discov-
ering their self-worth may take longer (Axline,
1947). Therefore, if children still reside in the
environment where the ACEs occurred, their
maladjusted behaviors may remain persistent
compared with the potential for change in a
stable, nurturing environment.
In Justin’s case, he still had contact with his
father, but he no longer resided in the same
house. Therefore, the majority of the ACEs
were occurring less frequently or were less pres-
ent. Justin was not exposed as often to the
ongoing adverse conditions he had previously
experienced. Justin’s progress was identified by
his mother quickly after the intervention phase
began. Because many of the adverse experi-
ences were less present, when Justin received
the core conditions, his self-structure was able
to adapt more quickly. His movement toward
self-actualization, as evidenced through a desire
to connect to others, became apparent to his
mother, and she observed his self-confidence
change and grow.
In Megan’s case, she continued to live in an
environment where some of the adverse expe-
riences were still present. Throughout the first
half of the study, Megan experienced being
yelled at and ignored by her caregivers. Megan
verbalized her feelings of being unwanted by
her family. Therefore, the healing nature of the
therapeutic relationship took longer than if
those factors had been removed. As Megan
strived to self-actualize during her play ses-
sions, she was met with messages of being
unwanted at home. Therefore, her self-structure
remained rigid for a large portion of the session.
As Megan’s self-structure became more flexi-
ble, in spite of her environment, she began to
demonstrate care and kindness toward her fam-
ily. Megan’s healing relationship with her step-
mother led to alleviating some of the ACEs that
were still occurring, which allowed her to con-
tinue to self-actualize. Megan’s efforts to con-
nect with her stepmother appeared to initiate her
stepmother’s ability to reciprocate affection and
acceptance.
Implications for Practice
The results of this single-case research de-
sign have implications for clinicians who are
working with children who have experienced
multiple ACEs. CCPT is a promising inter-
vention modality for working with children
who have experienced multiple or ongoing
ACEs. Children who have experienced mul-
tiple or ongoing ACEs might have sporadic
healing experiences (Power, 2012). Children
may appear to be healing when negative be-
haviors reoccur. Although their healing may
not be a linear process, children are working
through their difficulties in their own ways
(Landreth, 2012). In addition, this study sup-
ported the practice of working with parents
through consultation as a way to affect the
child’s systemic environment and encourage
therapeutic progress. Yet, it also appeared
that when parents were resistant to change,
CCPT was effective in helping the child de-
velop resources to provide for the parents’
needs, as in the case of Megan and her step-
mother, thereby affecting the parent– child re-
lationship in a positive way.
Children who have experienced ACEs may
still be exposed to the same ACEs while in
play therapy. Children who have endured on-
going or multiple ACEs have had a difficult
childhood prior to entering play therapy, and
the nature of adversities differs based on in-
dividuals (Clarkson Freeman, 2014). Because
of the varying nature of the experiences, it is
difficult to predict how children will present
during play therapy. Sessions with children
exposed to ACEs may differ greatly. Overall,
CCPT appears to be a promising intervention
for children who have experienced multiple
or ongoing ACEs. The results of the current
study indicate that when implementing
CCPT, the number of sessions with children
might vary, and healing might occur quickly
or gradually. Although parents may not report
sudden changes, small changes may be occur-
ring.
233CCPT WITH CHILDREN AFFECTED BY ACES
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Implications for Research
This pilot study provided information for fu-
ture research with children who have experi-
enced multiple ACEs. Following this study, an-
other single-case research design is suggested
with a multiple-baseline design with three or
more participants. By re-creating this study, us-
ing the guidelines from the What Works Clear-
inghouse (Kratochwill et al., 2013), researchers
can assist in building the evidence-based liter-
ature for children who have experienced ACEs.
In addition to evidence-based single-case re-
search designs, correlational research is war-
ranted in order to explore the impact of ACEs
on children during childhood. Although there
are a few studies examining the correlations
between ACEs and children’s behaviors, more
focus on children’s caregiver relationships, self-
concept, and emotional states would serve to
increase researchers’ understanding of assess-
ment measures and the holistic effects of ACEs.
Parent variables and the impact they have on
therapeutic progress, as well as the number and
types of ACEs children experience, are other
necessary areas for inquiry. In particular, re-
searchers might look at parents’ perceived
stress, attachment, and mental health concerns.
The types and numbers of parent ACEs could
also be correlated with the types and numbers of
the children’s ACEs.
To explore the generalizable effect of CCPT,
we recommend randomized controlled trials in
order to test the impact of CCPT for children
who have experienced ACEs. Comparisons be-
tween children who have experienced multiple
ACEs receiving the CCPT intervention and
children who receive no treatment or alternative
treatments will provide researchers a further
understanding of the effects of CCPT with chil-
dren who have experienced ACEs.
One observation regarding the current study
is the difficulty caregivers exhibited in commit-
ting to and arranging for consistent intervention.
On a therapeutic note, we recommend that play
therapists provide extra, reasonable supports
when possible in order to maintain the child’s
participation in treatment, such as convenient
session times, transportation support, and flex-
ibility with parent consultations. On a research
note, we recommend that researchers recruit
more participants than needed. Because of the
nature of ACEs, attrition is likely to occur at a
higher rate than with other studies. In addition
to attrition, recruitment is difficult with this
population because of the nature of the ques-
tions used to determine eligibility. Identification
of children who have experienced ACEs is lim-
ited by the parent/caregiver’s willingness to
provide information that is sensitive and may
possibly have legal repercussions.
Limitations
Because this study is the first to explore the
impact of CCPT on children who have experi-
enced multiple ACEs, there were limitations to
this pilot research. The single-case design has
minimal external validity, which limits the abil-
ity to generalize the findings to the general
population. Although both participants demon-
strated changes within the study, it is difficult to
generalize these findings to all children who
have experienced ACEs because of the individ-
ual nature of single-case designs. Disruptions in
the home environment may have affected the
way in which participants were rated by their
parents. Having one rater per participant may
have inhibited the researchers from gaining a
deeper understanding of the effectiveness of
CCPT. In order to have gained more insight, the
researchers could have utilized more raters per
child or incorporated an observation measure.
Because of the use of caregivers’ reports re-
garding the occurrence of ACEs rather than the
self-reports of the children who had experienced
them, not all of the ACEs may have been re-
ported. Reports were based on the parents’
views of the child’s experiences, and as a result
of changes in home environments, parents may
not have had a full understanding of the depth of
the ACEs. When answering the questions, par-
ents may not have fully grasped how their chil-
dren were experiencing the environments.
Conclusion
ACEs have been shown to have negative
effects throughout the life span beginning in
childhood following the adverse events (Agar-
wal, 2015). This study demonstrated a positive
impact of the use of CCPT with two children
who had experienced four or more ACEs. Al-
though each child’s healing occurred at differ-
ent points, both children demonstrated signifi-
cant changes in symptomology. The process of
234 HAAS AND RAY
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CCPT with participants who experienced ACEs
appeared to support previous research related to
stages of play therapy, moving from diffused
negative reactions in the playroom to an inte-
grated expression of self with positive emo-
tions. The relationship between child and play
therapist seemed to provide a reparative expe-
rience for children whose primary relationships
have been made vulnerable by ACEs. Although
more research is necessary, CCPT seems to
demonstrate promise as an intervention for chil-
dren who have experienced multiple or ongoing
ACEs.
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Received March 8, 2020
Revision received May 15, 2020
Accepted May 20, 2020 �
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- Child-Centered Play Therapy With Children Affected by Adverse Childhood Experiences: A Single-Ca …
Broad Spectrum of ACEs Outcomes
ACEs Outcomes During Childhood
The CCPT and ACE Connection
Purpose of Study
Method
Participants
Participant 1
Participant 2
Instruments
Adverse Childhood Experiences Checklist
Strengths and Difficulties Questionnaire
The Trauma Symptom Checklist for Young Children
Procedure
CCPT Intervention
Parent Consultation
Data Analysis
Results
Participant 1: Justin
Total Difficulties score
Posttraumatic Stress score
Follow-up parent interview
Participant 2: Megan
Total Difficulties score
Posttraumatic Stress score
Follow-up parent interview
Discussion
Process of CCPT for Children With ACEs
Implications for Practice
Implications for Research
Limitations
Conclusion
References
