Effect of play therapy on behavioral problems of mal-adjusted pre-school children

Headnote

Objective: The present research was conducted to study the effect of play therapy on reducing behavioral problems of mal-adjusted children (children with oppositional defiant disorder).

Method: By using multistage cluster sampling, regions 6, 7, and 8 in Tehran were selected, and among kindergartens of these areas, 3 kindergartens under the support of welfare organization were randomly selected. From pre-school children of these 3 kindergartens, 40 children that could have behavioral disorder according to their teachers and parents complaints, were carefully tested, and among them, by the results obtained from child symptom inventory questionnaire (CSI-4), teacher's form, and a researcher-made self-control checklist, 16 children who showed severe symptoms of oppositional defiant disorder were selected, and they were randomly divided into control and experimental group. This research is quasi-experimental, and is done by the use of pre-test, posttest, and control group.

Results: values of calculated F for oppositional defiant disorder in control and experimental group is meaningful after fixing the effect of pre-test (F(1,12)=74/94, P<0/001) so there is a meaningful difference between means of disobedience disorder post-test scores in experimental and control group by having the fixed effect of pre-test effect. Comparison of adjusted means of 2 groups shows that the mean of attention-deficit hyperactivity disorder (ADHD) in experimental group (M=14/09) is lower than control group (M=36/66). Therefore, applying play therapy in experimental group in comparison with control group, who did not receive these instructions, caused reduction in attention-deficit hyperactivity disorder (ADHD) in pre-school children.

Conclusion: Results of this research show that the children's disobedience is reduced by benefiting from play therapy.

Keywords: Children (child), play therapy, oppositional defiant disorder (ODD), hyperactivity (Attention Deficit Disorder with Hyperactivity), child symptom inventory questionnaire (CSI-4)

Iran J Psychiatry 2011; 6:37-42

Direct effects of problems such as perceptual, physical, emotional, and social changes are stress; contradictions are followed by learning and behavioral problems that the child will experience. On the other hand, social conditions are changing rapidly that they all cause serious and deep effects on the psychological and personal world of a child (1).

Some of the most common problems of children in this range of age, which are often said to be parents' complaints, are disobedience, defiance, rebelliousness with aggression, and whenever adults cannot face informatively with these problems, and treat this trait of children well, they may lead to disobedient conducts in children. Therefore, disobedient children in preschool ages are those that are usually

recognized by oppositional defiant disorder and some disorders with it.

Oppositional defiant disorder is an ongoing pattern of disobedient, impudence negative activity, hostile and defiant behavior toward authority figures that lasts for longer than a 6-month period. It is recognized by continuous occurrence of at least 4 of these behaviors: losing control, having argument with grownups, deliberately doing what makes others annoyed, being sensitive and easily annoyed, being often irritated and indignant, criticizing others for their own mistakes or bad behaviors, hostility and being spiteful or vindictive. For diagnosing oppositional defiant disorder, frequency of symptoms should be more than the frequency of the same behaviors in people with the same biological and mental age, and in addition it must cause significant destruction of individual and social functions. If disorders in behavior happen only in psychotic or in temperamental disorders, or if the evidences concord with behavioral disorders or antisocial disorders (for people above 18), it is not diagnosed as oppositional defiant disorder (2)

Simultaneity of oppositional defiant disorder (ODD) with other disorders

Attention deficit hyperactivity disorder (ADHD) is prevalent in children with oppositional defiant disorder (ODD). Learning and communicational disorders are also observed with (ODD) (2).

Symptoms of oppositional defiant disorder may happen with symptoms of behavioral disorder. Although all children with ODD do not show severe annoying behavior that is a feature of behavioral disorder, most children which are diagnosed to have oppositional defiant disorder before puberty, will have symptoms of behavioral disorder or are potential to have them in higher ages (3).

Etiology:

Defying one's own tendencies and opposing other's have essential importance to natural development. This is related to being independence, identity creation, and adjusting inner criterions and controls. The most evident example of ODD shows up between the ages of 18 to 24 months when a toddler does an oppositional behavior as a sign of growing self-determination. Pathology starts when this stage of development has unusual permanence, authorities show severe reaction, or oppositional behavior appears much more than what is seen in children with the same mental age (4).

Oppositional defiant disorder is more common in families that childcare is harmed due to the continuous change of child minders or in families that children upbringing methods are violent, unstable, or rejected. Prevalence of the disorder in males is more than females before puberty but the same in both after that. Symptoms are the same in both male and females except that oppositional behavior is more in males and symptoms are more persistent.

Symptoms and concomitant disorders are different according to age and severity of oppositional defiant disorder. It was observed that disorders in males are more prevalent among those who had problematic behaviors (for example too much reaction,

unappeasable) or too much physical activity (2).

Treatment

Counselling children is different from counselling adults. This issue is even obvious for people other than counsellors. We counsel adults by having meeting sessions and inviting them to talk, but if we use the same method for children, it is unlikely that they talk about something important with us (5)

One of the important responsibilities of a clinical psychologist is to see if the disturbing behaviour, that a child is referred to psychologist for treating them, is normal and temporary and what are their importances from clinical view. They also have to specify if these behaviours of the child are going to continue and get worst or not (6).

Pre-school children are not able to understand the points in a therapeutic relationship, for they do not see asking for help and trusting others as what adults or older children have perceived. Recognizing operation of pre-school children is specified with self centred and non-reflective thinking. (7)

Treatment of ODD consists of individual psychotherapy of child, counseling, Pscho-education of parents in skills of controlling children, and careful assessment of family interactions. Children with oppositional defiant behaviors can use individual psychotherapy to the extent that the child can face a situation in which he/she can practice adaptive responses with a grown up person (4).

Bennet et al., (8) has suggested using "treatment by play therapy" instead of Freudian phrase "treatment by talking" especially when we are talking about children's treatment. Revised approaches toward psychoanalysis of children have been used a lot. Some therapists investigate child's psychological life instead of using other approaches. Girolametto et al., (2000) believes that playing is children's secret language and they can express their experience and emotions in a natural and self-treatment way.

Play therapy is a technique during which child would be given an opportunity to try and experience development under the most ideal circumstances. Because playing is a natural way for children to express himself/herself, the child has such an opportunity to gradually release suppressed emotions and tensions, disappointments, feeling of insecurity, aggression, and his/her fear of confusion (10).

Behavior therapy, as a technique for treating ODD, emphasizes on reinforcing and making compliment of proper behavior and disregarding or not reinforcing the undesirable behavior (4).

One of the suggested techniques for behavior therapy of this disorder is "withdrawing reinforcement" that is consists of omitting positive reinforces for a short period of time. During withdrawing, child does not have access to positive reinforces that are naturally available in that environment. Withdrawing typically includes social seclusion, in which child is sent out for a short period of time (for example 5 minutes). Long periods of withdrawal are not essentially effective (11). Nelson (12) investigated the effect of training skills of revised behavior from behaviors of dialectical behavior therapy in forms of a therapeutic group about teenagers with oppositional defiant disorder. 32 teenagers completed a 16-week program with assessment before and after treatment. Treatment was not only effective in reduction of negative behavior but had an impact on increasing positive behaviors.

Webster, Stratton & Hammond (13) designed a general video plan which is consisted of the following skills (1) controlling anger, (2) problem solving, (3) making friends, (4) getting along with being scoffed at and rejected, (5) paying attention to teachers, (6) finding other solutions for problems, (7) having cooperation with parents, (8) whispering with him/herself as a guild line for getting along (14).

Boulanger (15) in a research investigated the effect of group play therapy on five year-old boys for solving lack of social skill problems. Group members, in addition to communicative problems with children of the same age, had attention deficit hyper activity disorder (ADHD), intensive anxiety disorder, and childhood avoidance disorder. Result obtained from the research showed that there was a salient improvement in solving lack of social skill problems after treatment. Ray and Bratton (16) studied effect of play therapy on treatment of children conduct disorder. 96 researches was studied and results show that using techniques of play therapy in most cases could have positive effect on treatment of these disorders, Moreover, studies show that effects of play therapy will be more with parents' intervention and cooperation.

Daly and Grieger (17) in a case study reported the process of treatment period of a 4 year-old child with ODD. Patient's behavior improved considerably after usual sessions of treatment with planning a time for playing with his mother. They believe that some children may respond to unstructured play sessions in which they are able to express their emotions and have some control on their interaction with adults.

In another research Hood and Eyberg, (18) examined the maintenance and durability of the outcomes of treatment of oppositional defiant disorder (ODD) with parent-child interaction therapy approach. 3 to 6 years after treatment period, 29 out of 50 treatment completers were located for this study. Mothers of 23 children between ages of 6 to 12 were engaged in assessment and pursuit by telephone and E-mail. Results indicated that mothers reported significant changes in their children's behavior and type of locus of control at the end of treatment and after a long-term follow-up. Mothers reported reduction in disordered behaviors since they started treatment. Outcomes of this study reports long-term effects of this parent-child interaction.

Lavinge et al., (19) examined the effect of teaching Webster-Stratton's program to parents of children with oppositional defiant disorder on their children's treatment. 117 parents of children aged 6 to 11 with ODD were taught. After completion of treatment period in a 12 months pursuit, recovery was observed in all groups. After 7 sessions in Eyberg intensity scale and 9 sessions in child behaviour checklist (CBCL), there were effects on a fixed rate.

Larsson and Fossum, (20) studied the efficacy of instructing parents in contacting with oppositional defiant disorder and individual child treatment program in a controlled random study. Sample group was consist of 127 Norwegian children aged between 4 to 8 years old and were diagnosed to have ODD. Children were randomly put in two control and experimental group. For experimental group parents training programme or a combination of training parents and individual treatment was implemented. In both cases of treatment, symptoms of oppositional defiant disorder of two third of experimental group children was significantly reduced and with the same proportion, after a year of treatment, there was no recurrence of symptoms.

Jager and Ryan (21) in a research compared the effect of play therapy in treatment of anxiety disorder and worries with skill learning and miniature learning treatments. Children in experimental group who received play therapy, showed better results in reduction of symptoms of anxiety disorder and worries. Generally, play therapy has been used a lot for children treatments. For example Ahmadi (22) studied the effect of intensive play therapy on reduction of children aggression. Out comes showed that play therapy had positive effect on examinees. Baedi (23) in a research investigated the effects of cognitive-behavioural therapy on reduction of aggression in children with behavioural disorders. Results showed that this way had effect on reduction of aggressive behaviours of this group. Ashrafi Pouri (24) in a research studied the effect of story-therapy in reduction of symptoms of ODD in children. Results showed that story therapy in groups reduced the symptoms of oppositional defiant disorder examinees. Out comes show the applicability of story therapy in the treatment of conduct problems in children.

Yousefi Louyeh (25) in a research studied the effect of story therapy on reduction of emotional problems in children. Results showed that using story therapy was effective for reduction of emotional problems of these children. Alizadeh (26) in a research investigated the effect of play therapy on reduction of children aggression in girls aged 9 to 11. Investigation showed that play therapy was effective on the amount of aggression in examinees. According to the mentioned literature, this question will be raised that:

1-Does play therapy reduce the symptoms of oppositional defiant disorder in pre-school children?

2-Does play therapy reduce the concomitant problems with oppositional defiant disorder like symptoms of attention-deficit hyperactivity disorder (ADHD) in preschool children?

Materials and Method

Population, samples and sampling method Research method used in this research is quasi-experimental, and a pre-test, post-test model and a control group are used. Participants in this research are 6 years old pre-school children in kindergartens under the support of welfare organization in Tehran in 2008-2009.

By using multistage cluster sampling, regions 6, 7, and 8 in Tehran were selected, and among kindergartens of these areas, 3 kindergartens were randomly chosen. From pre-school children of these 3 kindergartens, 40 children that could have behavioural disorder were carefully tested, and among them, by the results obtained from child symptom inventory questionnaire (CSI-4), and a self-control checklist 16 children who surely had conduct problem specially oppositional defiant disorder (ODD), stubbornness, and hyperactivity Attention deficit hyperactivity disorder (ADHD) ( as deficiency disorder with disobedience disorder), were selected and randomly divided into 2 groups of experiment and control groups.

Instrument

In the present research for identifying sample group, a child symptom inventory questionnaire (CSI-4), and a self-control checklist (researcher made), and a teacher's form were used. Child symptom inventory questionnaire (CSI-4) is a behaviour gradation scale that was used for the first time by Spiraphkin & Gudo in 1984 according to DSM-III for screening 18 behavioural and emotional disorder designed for children aged 5 to 12. Later in 1978, CSI-3R questionnaire was designed after DSM-IIIR and in 1994 with fourth publication of DSM-IV with little changes it was revised and was published with the name of CSI-4 (27).

Like previous questionnaires CSI-4 had two questionnaires of parent and teacher. Parents' questionnaire has 112 questions and it is designed for 11 major and one extra group of behavioural disorder. Teacher's questionnaire has 77 questions and covers 9 major groups of behavioural disorders. 2 scoring method2 are designed for CSI-4.The inventory offers both screening cut-off score method and symptom severity score method. Screening cut-off score method is used in most studies and is scored in a 14-scale scoring of never=0, sometimes=0, often=1, and most of the time=1. In most of disorders, score of screening cut-off is summation of number of questions answered to be "often" or "most of the times".

Then, obtained score is compared with scale score sign that its source of assessment is DSM-IV and if it is equal or more than criterion score, cut-off score is yes, and in this case the person has disorder. If results are lower than sign criterion, cut-off score will be "NO". Therefore, if a symptom is in this method is graded "never" or "sometimes", that symptom will be considered a clinical problem (27).

In the present research, for estimating the reliability (internal consistency of questions) of sub-scales of symptom questionnaire Chronbakh's alpha coefficient is used for each of 4 sub scale of used in symptom questionnaire, and its result was obtained in a domain of 0.67 to 0.96.

Self-controlling Checklist

According to visual observations of children, and also teachers and parents' complaints, a checklist was prepared. Although the check list was mostly descriptive aspect, its internal reliability was calculated according to Chronbakh's alpha and in the final post test, it was computed ì . Increase in this check list shows disobedience and decrease shows self-control.

Procedure

After preceding the mentioned stages for sampling, in the main stage, the experimental group was under play therapy for 15 sessions and each session 45 minutes and after the last session again CSI-4 questionnaire and self-control check list was given to both groups and results were studied. The experimental group was under play therapy with different techniques (like free and indirect, guiding, and patterning techniques, different positive reinforcing techniques, forming behavior, and problem solving). Contents of Plays are designed in a way that children have the most corporations in doing the plays and the therapist has mostly the role of a guide in sessions. Some sessions were held individually and some in groups.

Data analysis

This research is quasi-experimental, and is done by the use of pre-test, post-test, and control group. For statistical data analysis of research, in descriptive statistics deviation and central, and in inferential statistics covariance analysis is used.

Results

Question 1: Does play therapy decrease the symptoms of oppositional defiant disorder in pre-school children" For investigating the effects of play therapy on oppositional defiant disorder in pre-school children and to fix the effect of pre-test on both groups of experimental and control, inferential statistics test of covariance was used. Results are presented in the Table According to the results of the Table 1, values of calculated F for oppositional defiant disorder in control and experimental group is meaningful after fixing the effect of pre-test (F(1,12)=74/94, P<0/001) so there is a meaningful difference between means of disobedience symptoms post-test scores in experimental and control group by having the fixed effect of pre-test effect. Comparison of adjusted means of 2 groups shows that the mean of oppositional defiant disorder in experimental group (M=5/57) is lower than control group (M=12/63). Therefore, application of play therapy technique in experimental group in comparison with control group that did not received this instruction, caused reduction in oppositional defiant disorder in pre-school children Question 2: Does play therapy reduce symptoms of oppositional defiant disorder and symptoms of attention-deficit hyperactivity disorder (ADHD) in pre-school children"

For investigating the effect of application of play therapy on ADHD in pre-school children for fixing the effect of pre-test on 2 groups of control and experiment, statistical test of analysis of covariance was used. Results are presented on the Table 2

According to the results of the Table 2, size of calculated F for scores of attention-deficit hyperactivity disorder (ADHD) in 2 groups of experiment and control after fixing the effect of pre-test is meaningful F(1,13)= 203/56, P> 0/001). Therefore, there is a meaningful difference between mean of scores of posttest of attention-deficit hyperactivity disorder (ADHD) in experimental and control group by having a fixed effect of pre-test. Comparison of adjusted means of 2 groups shows that the mean of attention-deficit hyperactivity disorder (ADHD) in experimental group (M=14/09) is lower than control group (M=36/66). Therefore, applying play therapy in experimental group in comparison with control group, who did not receive these instructions, caused reduction in attention-deficit hyperactivity disorder (ADHD) in pre-school children.

Discussion

Many studies have investigated therapeutic techniques and processes on children with disorders and the current research is one of those researches that studies the effect of cognitive-behavioral play therapy (CBPT) on reduction of symptoms of disobedience disorder in children.

Recent investigations on literature of results of children behavioral therapy techniques show that intermediation is effective in general. Previously mentioned conclusion is based on conforming outcomes of some ultra analysis, which are based on literature of result of treatment. Extents of effects estimated in this research are consonant and are better than 75 percent of children who are not treated (28).

For children with oppositional defiant disorder various techniques of treatment have been used. Lavinge (19) also believes that teaching social skills are effective in reducing the symptoms of this disorder. In the field of play therapy, many studies have been done which prove its effect in reduction of children's behavioral disorder.

Current research also shows the desirable effect of cognitive-behavioural play therapy on reduction ODD in these children that emphasises on effectiveness of techniques of cognitive-behavioural play therapy on reduction of emotional and behavioural problems of children. Current research investigated and tested 2 hypotheses.

Application of play-therapy reduces symptoms of oppositional defiant disorder in pre-school children. This hypothesis was supported by the results obtained and it was in accordance with results of previous researches.

Application of play therapy reduced the symptoms of attention deficit hyperactivity disorder in pre-school children. This hypothesis was confirmed by the result obtained from this research.

Generally, with result obtained from this research it can be claimed that play therapy is effective in reducing oppositional defiant disorder in children. Findings of this research support other studies about effectiveness of play therapy in reduction of behavioural disorder in children. For example results of this study are in concordant with research results of Jager and Ryan (21), Alizadeh (26), Ahmadi (22). Therefore, using this technique is effective in reduction of behavioural disorders of these children.

Limitations

1-parents' cooperation in this research was very limited.

2-Because this research was conducted in kindergartens, researcher had limitations of place and proper time for holding sessions.

Impossibility of conducting this research project for a larger sample size caused less generalizability of research result for a more extended population.

Further researches

Based on research result, following suggestions are made:

1-If it is possible to have a real situation with natural environment out of kindergarten and unreal clinical situation, play therapy sessions will be held with better quality and more effective.

2-Inviting parents to cooperate actively when sessions of play therapy is held can be of special importance in persistency of treatment effects.

Repetition of this research with necessary changes about children with other disorders seems beneficial.

3-It will be beneficial to have pursuing program when sessions of play therapy are finished.

4-Performing projects from A-B-A-B type is also suggested.

5-Conducting projects to compare effectiveness of different kinds of treatment techniques with children play therapy are beneficial.

Acknowledgment

The authors would like to thanks the personnel's of Child and Adolescent Psychiatry clinic, 372-Dastgardi Street, ValiAsr Avenue and Psychiatry and Psychology Research Centre (Roozbeh Hospital), Tehran University of Medical Sciences. We thank Dr. Gholam Reza Askarifar for his helps.

References

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