Herbert H.G. Wettig & Ulrike Frofke 2004 Herbert H.G. Wettig & Ulrike Frofke Evaluation of the Effectiveness of Theraplay on toddlers and preschool children

Herbert H.G. Wettig & Ulrike Frofke Herbert H.G. Wettig & Ulrike Frofke

Evaluationof the Effectiveness of Theraplay on toddlers and preschool children

with dual diagnoses of autistic-like lack of social mutuality

and receptive language disorder

2 Studies on the Effectiveness of Theraplayon toddlers and preschool children with

dual diagnoses of language developmental disorder and social interaction disorder via coincidence

January 20042004

Copyright 2004 Theraplay Insitut

The Effectiveness of Theraplay on autistic-like lack of social mutuality

2

Overview• Symptoms and Multi morbidity

of toddlers and preschool children with autistic-like lack of social mutuality within interaction behaviour

• Research: Evaluation of the Effectiveness of Theraplay– Total sample of the controlled longitudinal and multi-centre study– Selected samples of toddlers and preschool children with

autistic-like lack of social mutuality within interaction behaviour

• Results: Evaluation of the Effectiveness of Theraplay– History, parents‘ concerns over child‘s behaviour– Markedness of the symptoms of toddlers and preschool children

with autistic-like lack of social mutuality within interaction behaviour– Reduction of symptoms in toddlers and preschool children with

autistic-like lack of social mutuality within interaction behaviour– Duration of therapy in number of necessary sessions– Lasting effect of the reduction of symptoms of children with

autistic-like lack of social mutuality within interaction behaviour



3

Autistic-like lack of social mutualitywithin interaction behaviour of children

based on CASCAP-D (Doepfner et al., 1999)

• The child avoids eye-contact, is unable to mimic or make gestures in order to regulate social interaction.

• The lack of social (and emotional) mutuality is shown in various of impairments or deviant reactions towards others.

• Döpfner et al. (1999) hypothize that these children have a lack of behaviour modulation within a social context or an instable integration of social, emotional and communicative behaviour.

• Interestingly these children do not have general ratioships with those of the same age with suitable interests / activities.

• These characteristics are shown in all situations.



4

Multi morbidityof the toddlers and preschool children

with autistic-like lack of social mutuality within interaction behaviour

Examples

• Dual diagnoses of lack of social mutuality and inattentiveness.

• Dual diagnoses of lack of social mutuality and uncooperative behaviour.

• Dual diagnoses of lack of social mutuality and play disorder.

• Dual diagnoses of lack of social mutuality and receptive language disorder.



5

Total sampleof the two research studies CLS and MCS

CLS Controlled Longitudinal Study Total sample of the controlled longitudinal study

• N=60 clinically conspicuous toddlers and preschool children* with coincidence of language developmental- and various social interaction disorders.

• N=29 follow-up study of children* 2 years after individual discharge from therapy.

N=30 clinically not symptomatic toddlers and preschool children in same age and gender (matched control sample).

MCS Multi-Centre Study Total sample of the multi-centre study

• N=251 clinically conspicuous toddlers and preschool children*with dual diagnoses of language communication- and various social interaction disorders.



6

Selected Samplesof toddlers and preschool children with dual diagnoses*

of autistic-like lack of social mutuality and receptive language disorder

CLS• N= 14 (rd. 23%) toddlers and preschool children*

with autistic-like lack of social mutuality and receptive language disorders Sub samples of these

• N= 9 (rd. 15%) toddlers and preschool children* diagnosed with „early childhood autism” (Kofner)

• N= 30 clinically not symptomatic toddlers and preschool children in same age and gender (matched sample)

MCS• N= 42 (rd. 17%) toddlers and preschool children*

with autistic-like lack of social mutuality and receptive language disorders



7

Age, Gender and Statusof toddlers and preschool children

with autism-like lack of social mutualityand receptive language disorder

• CLS: N=14 children • 86% boys (N=12)

14% girls (N= 2) 6 :1 general ratio b:g

• 3;11 average years of age 3;10 average years - boys4,06 average years - girls

• 86% 12 legitimate children 7% 1 illegitimate child 7% 1 adopted/foster children (1 no answer)

• 64% 9 early childhood autism 7% 1 boy of these is mentally incurable

• MCS: N=42 children • 71% boys (N=30)

29% girls (N=12) 2,5 :1 general ratio b:g

• 3;11 average years of age4;00 average years - boys3;08 average years - girls

• 85% 34 legitimate children 10% 4 illegitimate children 5% 2 adopted/foster children

(2 no answer.)



8

Family Status of Mother and Upbringing Behaviourof the language disordered children

with autism-like lack of social mutuality

• CLS: N=14 children • 100% 14 married mothers

• 93% 13 both involved 7% 1 single parent involved

• 86% 12 Country of birth Germany• 93% 13 mother tongue is German • 14% 2 bilingual Upbringing

• 69% 9 in Kindergarten

• MCS: N=42 children • 71% 29 married mothers

7% 3 unmarried living together 10% 4 separated mothers

• 12% 5 single mothers (1 k.A.)• 85% 35 both involved

15% 6 single parent involved (1 k.A.)

• 73% 29 Country of birth is Germany• 88% 36 mother tongue is German

26% 11 bilingual Upbringing

• 56% 23 in Kindergarten



9

Degree of Markednessof symptoms in toddlers and preschool children

with dual diagnoses of autism-like lack of social mutualityand receptive language disorders

A Comparisonwith the ‘norm‘ of clinically not symptomatic children



10

Autism-like Lack of Social Mutuality in language disordered children

Average degree of markednessAssessment methods: CASCAP-D (Döpfner et al., 1999)

Average degree of markedness of clinically conspicuous children compared to clinically not symptomatic children

3,1

3,0

1,0

1 2 3 4

Lack of social mutuality inN=30 clinically not

symptomatic children (CLS-control group) (M=1.0; s=0)

Lack of social mutuality inN=42 children with receptivelanguage disorder (MCS)

(M=3.0; s=0.8)

Lack of social mutuality inN=14 children with receptive

language disorder (CLS) (M=3.1; s=0.8)

Symptom's average degree of markedness1 = clinically not symptomatic strongly impaired symptom = 4

CLS-therapy group MCS-therapy group CLS-control group



11

Uncooperative Behaviourof toddlers and preschool children

with dual diagnoses of an autism-like lack of social mutualityand receptive language disorder

Average Degree of markednessAssessment methods: CASCAP-D (Döpfner et al., 1999)

Comparing the average degree of markedness of clinically conspicuous children with the control group of clinically not symptomatic children

3,5

2,9

1,1

1 2 3 4

uncooperative behaviour of N=30 clinically notsymptomatic children (CLS-control group) (M=1.1;

s=0.3)

uncooperative behaviour of N=42 children withreceptive language disorder and lack of social

mutuality (MCS) (M=2.9; s=1.2)

uncooperative behaviour of N=14 children withreceptive language disorder and lack of social

mutuality (CLS) (M=3.5; s=0.8)





12

InattentivenessInattentivenessof toddlers and preschool children

with dual diagnoses of an autism-like lack of social mutualityand receptive language disorder

Average Degree of markednessAssessment methods: CASCAP-D (Döpfner et al., 1999)


3,1

3,0

1,2

1 2 3 4

Inattentiveness of N=30 clinically not symptomaticchildren (CLS-control group) (M=1.2; s=0.4)

Inattentiveness of N=42 children with receptivelanguage disorder and lack of social mutuality (MCS)

(M=3.0; s=0.8)

Inattentiveness of N=14 children with receptivelanguage disorder and lack of social mutuality (CLS)

(M=3.1; 0.8)





13

Playing Disorder of toddlers and preschool children

with dual diagnoses of an autism-like lack of the social mutualityand receptive language disorder

Average degree of markednessAssessment methods: CASCAP-D (Döpfner et al., 1999)

Comparing the average degree of markedness of clinically conspicuous children with the control group of clinically unobtrusive children

3,1

2,8

1,0

1 2 3 4

Playing disorder of N=30 clinically not symptomatic children(CLS-control group) (M=1.0; s=0)

Playing disorder of N=42 children with receptive languagedisorder and lack of social mutuality (MCS) (M=2.8;

s=1.2)

Playing disorder of N=14 children with receptive languagedisorder and lack of social mutuality (CLS) (M=3.1; s=1.1)


CLS-therapy group MCS-therapy group MCS-therapy group



14

Langauge Comprehension Disorder / Receptive Language Disorder

of toddlers and preschool children with dual diagnoses of an autism-like lack of the social mutuality

and receptive language disorder Average Degree of markedness

Assessment methods: CASCAP-D (Döpfner et al., 1999)


3,8

3,5

1,0

1 2 3 4

N=30 clinically not symptomatic children (CLS-control group) (M=1.0; s=0)

N=42 children with receptive language disorder andlack of social mutuality (MCS) (M=3.5; s=0.8)

N=14 children with receptive language disorder andlack of social mutuality (CLS) (M=3.8; s=0.4)





15

Reductionof symptoms of toddlers and preschool children

with dual diagnoses of autism-like lack of social mutuality and receptive language disorder

based on treatment with Theraplay




16

Reduction of the autism-like lack of social mutuality

of language disordered children Assessment methods: CASCAP-D (Döpfner et al., 1999)

Means

Average Reduction of Symptomsafter being treated with Theraplay

2,1

1,0

3,13,0

2,0

1

2

3

4

start of therapy (TT-B) end of therapy (TT-E)

4 = strongly impaired3 = impaired

2 = slightly impaired symptom

1 = not noticeable

Reduction of lack of social mutuality inN=14 children with receptive languagedisorder (CLS) (TT-B:M=3.1;s=0.8)>(TT-E:M=2.1;s=1.0)

Reduction of lack of social mutuality inN=42 children with receptive languagedisorder (MCS) (TT-B:M=3.0;s=0.8)>(TT-E:M=2.0;s=0.9)

Lack of social mutuality in N=30 clinicallynot symptomatic children (CLS-controlgroup) (M=1.0; s=0)



17

Reduction of Uncooperative Behaviourof language disordered children

with an autistic-like lack of social mutualityAssessment methods: CASCAP-D (Döpfner et al., 1999)

Means

Average reduction of symptoms after being treated with Theraplay

3,5

1,8

3,0

1,1

2,0

1

2

3

4




1 = not noticeable

Reduction of uncooperative behaviour inN=14 children with receptive languagedisorder and lack of social mutuality (CLS)(TT-B:M=3.5;s=0.8)>(TT-E:M=1.8;s=0.7)

Reduction of uncooperative behaviour inN=42 children with receptive languagedisorder and lack of social mutuality(MCS) (TT-B:M=3.0;s=0.8)>(TT-E:M=2.0;s=0.9)

Uncooperative behaviour in N=30clinically not symptomatic children (CLS –control group) (M=1.1;s=0.3)



18

Reduction of Inattentivenessof the language disordered children

with an autism-like lack of social mutualityAssessment methods: CASCAP-D (Döpfner et al., 1999)

Means

Average reduction of symptoms after Theraplay

3,1

2,6

3,1

1,2

2,0

1

2

3

4




1 = not noticeable

Reduction of inattentiveness in N=14children with receptive language disorderand lack of social mutuality (CLS) (TT-B:M=3.1,s=0.8)>(M=2.6;s=1.1)

Reduction of inattentiveness in N=42children with receptive language disorderand lack of social mutuality (MCS) (TT-B:M=3.1;s=1.1)>(TT-E:M=2.0;s=1.0)

Unaufmerksamkeit der N=30 rezeptivsprachgestörten Kinder mit mangelndersozialer Gegenseitigkeit (LSS-Kontrollgruppe) (M=1.2;s=0.4)



19

Reduction of Play Disorder of the language disordered children


Means


3,1

1,9

2,8

1,0

1,8

1

2

3

4




1 = not noticeable

Reduction of playing disorder in N=14children with receptive language disorderand lack of social mutuality (CLS) (TT-B:M=3.1;s=1.1)>(TT-E:M=1.9;s=0.9)

Reduction of playing disorder in N=42children with receptive language disorderand lack of social mutuality (MCS) (TT-B:M=2.8;s=1.2)>(TT-E:M=1.8;s=0.9)

Playing disorder of N=30 clinically notsymptomatic children (CLS–controlgroup) (M=1.0;s=0)



20

Reduction of Social Isolation of the language disordered children


Means


2,2

1,1

2,2

1,0

1,3

1

2

3

4




1 = not noticeable

Reduction of social isolation in N=14children with receptive language disorderand lack of social mutuality (CLS) (TT-B:M=2.2;s=1.3)>(TT-E:M=1.1;s=0.4)

Reduction of social isolation in N=42children with receptive language disorderand lack of social mutuality (MCS) (TT-B:M=2.2;s=1.1)>(TT-E:M=1.3;s=0.6)

Social isolation of N=30 clinically notsymptomatic children (CLS – controlgroup) (M=1.0;s=0)



21

Reduction of Receptive Language Disorder of the receptive language disordered children


Means

Average reduction of symptoms after being treated Theraplay

3,8

2,9

3,5

1,0

2,4

1

2

3

4




1 = not noticeable

Reduction of receptive language disorderin N=14 children with receptive languagedisorder and lack of social mutuality (CLS)(TT-B:M=3.8;s=0.4)>(TT-E:M=2.9;s=0.7)

Reduction of receptive language disorderin N=42 children with receptive languagedisorder and lack of social mutuality(MCS) (TT-B:M=3.5;s=0.8)>(TT-E:M=2.4;s=0.9)

receptive language disorder of N=30clinically not symptomatic children (CLS –control group) (M=1.0;s=0)



22

Clinical and Statistical Significance of the reduction of symptoms

based on the treatment with TheraplayM=means based on CASCAP-D, =change, s=Standard deviation

4-point scale: 1=not symptomatic; Symptom: 2=slightly...,3=impaired, 4= strongly impaired

Symptoms

CLSN=14 receptive language

disordered children with lack of social mutuality

MCSN=42 receptive language

disordered children with lack of social mutuality

TT-BTT-EM M s prob.> F TT-BTT-E

M M s prob.> F

receptive language disorder 3.8 2.9 0.7 0.0002 3.5 2.4 1.1 0.0001

uncooperative 3.5 1.8 0.9 0.0001 3.0 2.0 1.3 0.0001

playing disorder 3.1 1.9 0.9 0.0001 2.8 1.8 1.1 0.0001

lack of social mutuality 3.1 2.1 0.8 0.0013 3.0 2.0 0.8 0.0001

inattentiveness 3.1 2.6 1.0 0.0104 3.1 2.0 1.3 0.0001

socially isolated 2.2 1.1 1.1 0.0032 2.2 1.3 1.1 0.0001



23

Duration of Therapy Reduction of the symptoms of toddlers and preschool children

with dual diagnoses of autism-like lack of social mutualityand receptive language disorder

(Number of 30-minutes therapeutic sessions)

MeansAverage number of sessions necessary to reduce autism-like lack of

social mutuality of originally receptive language disordered children.

26,6

25,2

0 5 10 15 20 25 30

Number of therapeutic sessions of N=42 children withreceptive language disorder and lack of social mutuality

(MCS: Min=12; D=25,2;s=12; Max=60)

children with receptive language disorder and lack of socialmutuality (CLS: Min=10; D=26,6 s=10; Max=43)

Average number of 30-minute therapeutic sessions

CLS: number of therapeutic sessions MCS: number of therapeutic sessions



24

The Lasting Effect of Reduction of Symptomsof autism-like lack of social mutuality

and receptive language disorders

2 years after treatment with Theraplay




25

The Lasting Effect of Reduced Autism-like Lack of Social Mutuality

of the language disordered children Assessment methods: CASCAP-D (Döpfner et al., 1999)

Means

Average reduction of symptoms after treatment with Theraplay

3,1

2,1 2,0

1,01

2

3

4

start of therapy(TT-B)

end of therapy (TT-E)

2 years afterdischarge from

therapy(2JnTT)



1 = not noticeable

Solely assessed in the longitudinal study!

Reduction of lack of social mutuality inN=14 children with receptive languagedisorder (CLS) (TT-B:M=3.1;s=0.8)>(TT-E:M=2.1;s=1.0)

statistical significance of change: (TT-B ~ TT-E: prob.>F=0.0013) (TT-E ~ 2JnTT: not significant)

Lack of social mutuality of N=30 clinicallynot symptomatic children (CLS–controlgroup) (M=1.0; s=0)



26

The Lasting Effect of Reduced Uncooperative Behaviour

of language disordered toddlers and preschool children with an autism-like lack of social mutuality

Assessment methods: CASCAP-D (Döpfner et al., 1999)Means


3,5

1,8 1,8

1,11

2

3

4



2 years afterdischarge from

therapy(2JnTT)



1 = not noticeable


Reduction of uncooperative behaviour in N=14children with receptive language disorder andlack of social mutuality (CLS) (TT-B:M=3.5;s=0.8)>(TT-E:M=1.8;s=0.7)


Uncooperative behaviour of N=30 clinically notsymptomatic children (CLS–control group)(M=1.1;s=0.3)



27

The Lasting Effectof Reduced Inattentiveness

of language disordered toddlers and preschool children with autism-like lack of social mutualityAssessment methods: CASCAP-D (Döpfner et al., 1999)

Means


3,1

2,6

2,9

1,21

2

3

4



2 years afterdischarge fromtherapy (2JnTT)


2 = slightly impaired symptom1 = not noticeable


Reduction of inattentiveness in N=14 children withreceptive language disorder and lack of socialmutuality (CLS) (TT-B:M=3.1,s=0.8)>(M=2.6;s=1.1)

statistical significance of change: (TT-B~TT-E: prob.>F=0.0104, significant) (TT-E~2JnTT: prob.>F=0.9588, not significant)

Inattentiveness of N=30 clinically not symptomaticchildren (CLS – control group) (M=1.2;s=0.4)



28

The Lasting Effect of Reduced Autism-like Playing Disorder

of language disordered children with autistic-like lack of social mutuality

Assessment methods: CASCAP-D (Döpfner et al., 1999)Means


3,1

1,91,8

1,01

2

3

4






1 = not noticeable


Reduction of playing disorder in N=14children with receptive language disorder andlack of social mutuality (CLS) (TT-B:M=3.1;s=1.1)>(TT-E:M=1.9;s=0.9)

statistical significance of change: (TT-B ~ TT-E: prob.>F=0.0001) (TT-E ~ 2JnaTT: significant)

Playing disorder of N=30 clinically notsymptomatic children (CLS–control group)(M=1.0;s=0)



29

The Lasting Effect of Reduced Social Isolation of language disordered children

with autistic-like lack of social mutualityAssessment methods: CASCAP-D (Döpfner et al., 1999)

Means


2,2

1,11,2

1,01

2

3

4

start of therapy (TT-B)


2 years afterdischarge fromtherapy(2JnTT)



1 = not noticeable


Reduction of social isolation in N=14 childrenwith receptive language disorder and lack ofsocial mutuality (CLS) (TT-B:M=2.2;s=1.3)>(TT-E:M=1.1;s=0.4)


Social isolation of N=30 clinically notsymptomatic children (CLS–control group)(M=1.0;s=0)



30

The Lasting Effect of Reduced Receptive Language Disorder

of language disordered children with autistic-like lack of social mutualityAssessment methods: CASCAP-D (Döpfner et al., 1999)

Means


3,8

2,92,7

1,01

2

3

4






1 = not noticeable


Reduction of receptive language disorder inN=14 children with receptive language disorderand lack of social mutuality (CLS) (TT-B:M=3.8;s=0.4)>(TT-E:M=2.9;s=0.7)

statistical significance of change: (TT-B ~ TT-E: prob.>F=0.0002 significant) (TT-E ~ 2JnTT: prob.>F=0.1996 not significant)

Receptive language disorder of N=30 clinicallynot symptomatic children (CLS–control group)(M=1.0;s=0)



31

Theraplay InstitutD-71229 Leonberg (Germany) Obere Burghalde 42

Questions about Theraplay: Ulrike Franke

speech-language pathologist (SLP) reg. Play Therapist and Supervisor (RPT-S/APT)

certified Theraplay Therapist and Trainer (CTT-T/TTI)Phone: +49-(0)6202-54051, Office: +49-(0)6221-88-2055, Fax: +49-(0)6202-54958

e-Mail: [email protected]

Questions about the evaluation research: Herbert H.G. WettigClinical Psychologist

Phone: +49-(0)7152-27062 Fax: +49-(0)7152-22602e-Mail: [email protected]

® 1996 Theraplay is legally protected by 39518465 and 39518466

mailto:[email protected]

mailto:[email protected]

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Herbert H.G. Wettig & Ulrike Frofke 2004 Herbert H.G. Wettig & Ulrike Frofke Evaluation of the Effectiveness of Theraplay on toddlers and preschool children