The Efficacy of Play Therapy - thesis final copy

Running Head: Efficacy of Play Therapy

Franciscan University of Steubenville

Department of Psychology

The Efficacy of Play Therapy in Building Social Skills in Children with Autism

Submitted by Stephanie K. Bishop

In Fulfillment of Requirements for the course,

Psychology 434, Thesis

February 15, 2016

1 EFFICACY OF PLAY THERAPY

Abstract

Play enables children to learn about the world around them and how to relate to others. However,

the social, affective, and cognitive deficits of autism spectrum disorder causes difficulties in

engaging in play. Children with the disorder often have great difficulties engaging with the world

around them and turn to self-stimulation and other restrictive behaviors. This paper examines

play therapy as a treatment to address these deficits in individuals with autism. The extent of the

social and affective deficits’ impact on the development of children with autism is assessed.

Questions were raised about the development of play therapy and about the roles of parents and

therapists. There are three styles of play therapy examined in this paper: DIR/Floortime, filial

therapy, and the PLAY Project Home Consultation Program (PPHCP). Each of these three styles

of play therapy are designed to help children with autism overcome their deficits; however, each

style has a different approach to accomplish their goal.


The Efficacy of Play Therapy in Building Social Skills in Children with Autism

Introduction

The above image is from the new web-based picture book “We’re Amazing 1, 2, 3!” put

out by the makers of Sesame Street (Sesame Workshop, 2015). The picture book introduces

Sesame Street’s newest character Julia, the girl on the left in the above picture, who has autism.

The picture book is geared to young children with the goal of helping them to learn how to

interact with their peers with autism. Julia is shown in the picture book to be playing differently

from the other children; however, that does not hinder her from having friends like Elmo who try

to understand her. Julia is able to form friendships with Elmo and Abby, the girl in the fairy

costume, through the shared language of play.

Hines shares insights on the impacts of the storybook and the rest of the Sesame

Workshop’s initiative Sesame Street and Autism: See Amazing in All Children. Hines quotes Dr.

Jeanette Betancourt, the senior vice president of community and family engagement at the

Sesame Workshop, who noted that it is five times more likely for children with autism to

experience bullying than their peers without autism (Hines, 2015). Betancourt also stated that the

goal of Sesame Street and Autism: See Amazing in All Children was to “bring forth what all

children share in common, not their differences. Children with autism [CWA] share in the joy of

playing and loving and being friends and being part of a group” (Hines, 2015, para. 6). It is

commendable that the Sesame Workshop is trying to provide tools for helping children


understand that their peers with autism have similar desires to play and make friends, even if it is

in different ways than they themselves would.

The well-regarded animal scientist, Temple Grandin, wrote a book on autism entitled

Thinking in Pictures: My Life with Autism in which she shares her experiences with the disorder.

Grandin (2006) explains that it was her governess playing with her that kept her engaged with

the world outside her Technicolor daydreams. Play can be a powerful tool for education and can

even help individuals discover possible careers. For example, Grandin’s elementary school

catalyzed her interest in science through activities such as science experiments and visiting

science museums to bolster hers and other students’ interest. From her experience, Grandin

(2006) asserts that learning can be bolstered by broadening the fixations and obsessions of CWA.

Grandin conveyed that Dr. Leo Kanner, one of the nation’s first child psychiatrists and the first

to recognize autism as a disorder (John Hopkins, n.d.), encourages clients to channel their

fixations into successful careers, as well as tools to gain a social life and friends (Grandin). Thus,

play is a method through which fixations can be broadened to allow for greater learning and

engagement.

Why should play be used as a form of therapy? Fred Rogers, better known as Mr. Rogers,

had great insight on play’s importance for children. He said that “(p)lay is often talked about as if

it were a relief from serious learning. But for children play is serious learning. Play is really the

work of childhood”. It is through play that children first learn about the world around them and

how to form relationships. However, the many social-affective deficits of autism impact

children’s abilities to enter into the world of others. Play on the individual child’s developmental

level can enable them to overcome their social-affective deficits.


This paper will discuss autism and play therapy. To begin, section one describes criteria

for a diagnosis of autism. The way CWA experience loneliness and friendship, along with how

emotions affect a child’s development will also be examined in the first section. Section two will

begin with an overview of the history of play therapy’s development and applicable settings for

use. The role of parents and therapists will then be examined, followed by a discussion of three

play therapy styles. Discussion of the efficacy and a critique of the play therapy styles will

conclude the paper.

Autism

Diagnostic criteria

Autism spectrum disorder, as described in the fifth edition of the Diagnostic Statistical

Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013), is

a disorder comprised of symptoms that limit and impair everyday functioning since early

childhood, usually before 36 months. Males are more likely than females to be diagnosed with

autism at a rate of 4 to 1 (APA). Symptoms of autism spectrum disorder include: “persistent

deficits in social communication and social interaction across contexts, not accounted for by

general developmental delays”, “restricted, repetitive patterns of behavior, interest, or activities”

(APA, 2013, p. 50). Symptoms of the disorder typically begin manifesting between the ages of

12 and 24 months; however, if deficits are severe a child may be diagnosed before 12 months of

age. On the other hand, a diagnosis may not be made until after 24months of age if symptoms are

less severe (APA).

Children’s developmental levels plateau or regress during the age range of diagnosis, and

social behaviors or language use deteriorates either gradually or relatively rapidly. This

deterioration of skills is extremely uncommon with other disorders so these loses can serve as a


red flag for autism spectrum disorder (APA). The loss of language and/or social skills occurs in

about a third of CWA (Karande, 2006). Autism frequently is comorbid (co-occurring) with

intellectual disability (APA). Autism is considered a spectrum disorder due to the different ways

in which it manifests depending on severity, level of development, and chronological age (APA).

The social communication deficits of autism manifest in a wide range of communication

and behavior. First, a child may have a range of deficiencies in reciprocal social and emotional

interactions. For example, they may differ from the normal manner of back-and-forth

communications; exhibit a reduced amount of sharing of their interests, emotions, or mood

(affect); or failing to initiate or reply to social interactions (American Psychiatric Association,

2013). Communication issues can also lie in non-verbal means such as lack of correspondence

between eye contact and verbal communication, poor understanding of uses of body language

and gestures, as well as a lack of facial expressions (APA). Children may also exhibit difficulties

in adapting their behavior to meet the context of social interactions, such as when partaking in

imaginative play with peers (APA). Children may also lack interest in their peers (APA). These

deficits need to be examined in light of the individual’s age, gender, and culture. Friendships for

individuals with autism may be one-sided or based solely on special shared interests (APA).

Discerning what behavior is appropriate in one social context but not in others may present

difficulties for older individuals with the disorder (APA).

Social issues in depth

CWA often have difficulties engaging in play. This difficulty in playing can be caused by

fine (small muscle) and gross (large muscle) motor movement issues. CWA may exhibit

repetitive and restrictive behavior patterns or repetitive motor movements, such as lining up toys

or flipping objects over. These repetitive motor movements and different play styles can inhibit


CWA’s ability to play with other children and/or their parents. From an early age, CWA also

show difficulties integrating their verbal and non-verbal communication; for example, there may

be a lack of corresponding eye contact, gesturing, facial expressions, or their tone of voice may

not match what the individual is discussing (APA). CWA also find play difficult due to issues

with expressive (ability to communicate using language; SERVE Center, n.d.) and receptive

(ability to listen to and understand language; SERVE Center, n.d.) communication skills (Hess,

2012). The communication issues may in part be due to the theory of mind capabilities of CWA.

O’Toole (2014) notes that theory of mind, which is the intuitive ability to see the perspective of

another and react accordingly, may pose challenges for CWA. Difficulties with understanding

theory of mind may limit CWA’s ability to play with other children. Baron-Cohen and

Bauminger and Kasari studied the theory of mind capabilities of CWA.

Baron-Cohen (1989) examined the theory of mind capabilities of children with autism.

The goal of the study was to determine if CWA were able to make what is called “second-order

belief attributions (i.e. ‘Mary thinks John thinks the ice-cream van is in the park’)” (Baron-

Cohen, 1989, p. 288). Typical children are capable of second-order belief attribution by the time

they are between the ages of six and seven. Baron-Cohen hypothesized that even if the CWA

were able to make first-order belief attributions (“i.e. “Mary thinks the marble is in the basket’”;

Baron-Cohen, 1989, p. 287), they would have impairments in making second-order belief

attributions.

Subjects of the study consisted of three groups of ten: a group of CWA, children with

Down Syndrome, and typical children (Baron-Cohen). The CWA all came from special schools

for CWA near or in London, except for one who completed mainstream education. The children

with Downs Syndrome attended a school for people with learning disabilities in inner London.


The typical children were selected from a primary school in inner London. The chronological

age (CA), expressive verbal mental age (MA), receptive verbal MA, and nonverbal MA for the

three groups are given in the table below. The typical children chosen were all between 7.5 and

7.8 years of age, as children in that age range generally are able to make second-order belief

attributions. The verbal and nonverbal MA for the typical children were not examined as it was

assumed they would be in line with their CA.

Group Chronological

Age (CA)

Expressive verbal

Mental Age (MA)

Receptive Verbal

MA

Nonverbal MA

CWA 10.9-18.9yrs 7.3-17.7yrs 2.8-17.9yrs 8.3-17.9yrs

Down Syndrome 9.3-17.6yrs 6.1-9.9yrs 2.5-6.8yrs 5.0-8.5yrs

Typical children 7.5-7.8yrs -- -- --

A toy village set on a 2ft.sq. table-top consisting of a Church, two houses, a park and

road separated by a fence, an ice-cream van, and four 3in. people were used in the study. Rows

of trees were also included so that the characters in the story were unable to see either the Church

or John’s house from the park. Each child was tested individually and was asked questions about

the scenario. The two children in the story, John and Mary, were initially in the park interacting

with the ice-cream man. The children in each group were given a scenario where John and Mary

go to buy ice-cream in different locations they are told by the ice-cream man, but the two

children are not together when he tells where he is going each time. As the scenario unfolded the

children were asked five prompt questions to make sure that they knew what was taking place; a

question about where the characters believed the other went to buy ice-cream and a justification

for it; and a question about where the character had actually gone to buy ice-cream. The scenario

and questions were given again in a second trial, but with a different order of locations.


All but one of the typical children passed both of the belief questions, about where one

character believed the other would look for the ice cream truck, as did six of the ten children

with Down Syndrome (Baron-Cohen). However, none of the CWA passed the belief question.

The children’s responses to the justification questions were examined in order to determine what

order of belief attribution they were able to make. Responses were coded as second-order if the

children took into account the beliefs of both Mary and John; as first-order if only John or

Mary’s beliefs were considered; or zero-order if neither of their beliefs were accounted for. Any

ambiguity in responses resulted in them being downgraded in level of belief attribution. One

child from both the Down Syndrome and CWA groups did not respond to the justification

question. The children who had passed the belief question were able to give responses to the

justification question that showed they were using second-order belief attribution. Those who

failed the belief question, however, responded with first-order attribution. Also, five of the CWA

gave possible zero-order responses by say where the van actually was instead of where either

John or Mary believed it to be (Baron-Cohen).

Baron-Cohen reached several conclusions from the study. First, even though they were

able to make first-order belief attributions, the CWA were unable to make second-order

attributions; however, children in the typical and Downs Syndrome groups were able to make

second-order attributions. What is interesting about this is that the children with Downs

Syndrome had lower MAs than the CWA. Second, the CWA may have failed due to the

conceptual complexity of the belief question which required the ability to make second-order

attributions in order to pass; justification question responses support this idea.

Bauminger and Kasari (2000) examined the possible experiences of loneliness and

friendship in CWA. They wondered if CWA would have the theory of mind capabilities to


experience loneliness and to form friendships. Bauminger and Kasari focused on two forms of

loneliness: emotional and social-cognitive loneliness. They defined emotional loneliness as “the

subjective responses to the lack of affective bonding with particular others, leading to sadness,

fear, restlessness, and emptiness” (Bauminger & Kasari, p. 447). They defined social-cognitive

loneliness as children’s feeling excluded, bored, and meaningless because of dissatisfaction with

their relationships or lacking groups of peers. It is debated whether issues with cognitive process

or emotional/affective processes which underline autism (Bauminger and Kasari). This debate

about the underlying cognitive or emotional process issues leads to differing views of children

with autism’s experiences of loneliness.

Bauminger and Kasari’s (2000) study consisted of direct interviews and self-report

measures from 22 participants with high-functioning autism selected research centers and 19

typical children selected from local public schools. The ages of the participants with high-

functioning autism ranged from 7 year, 11 months to 14 year, 8 months; whereas the ages of the

typical children ranged from 7 year, 8 months to 14 years, 8 months (Bauminger & Kasari,

2000).

Bauminger and Kasari (2000) examined the loneliness experienced by children in both

groups using three different measures. First, they had the children define what loneliness meant

to them; inclusion of both the affective and social-cognitive dimensions was looked for. Both

groups were then asked to give accounts of times where they felt lonely. Accounts were assessed

based on three dimensions: 1) internal v. external locus of control; 2) audience; and 3) general

versus specific examples (Bauminger and Kasari). The Loneliness Rating Scale, a 24 question

standardized self-report questionnaire, was used as a measure of the children’s loneliness.

Sixteen of the items focused on feelings of loneliness and social discontentment (Bauminger &


Kasari). CWA reported greater feelings of loneliness than typically developing children

(Bauminger & Kasari).

Bauminger & Kasari then examined children’s friendships. Children were asked to define

what friendship meant for them; three dimensions were looked for in the definitions:

companionship, intimacy, and affection. Bauminger and Kasari (2000) also used the twenty-three

item Friendship Qualities Scale self-report questionnaire developed by Bukowski, Boivin, and

Hoza which asks children to identify their best friend and describe qualities of their relationship.

Bauminger and Kasari’s study revealed that CWA did in fact experience loneliness, more

so than the typically developing children reported. However, their study did reveal a difference

between the way typical children and CWA define loneliness. The typically developing children

studied gave complete definitions with both types of loneliness. On the other hand, most of the

CWA only included the social-cognitive aspect of loneliness in their definitions. Bauminger and

Kasari (2000) also proposed that for CWA there might not be the same link between friendship

and loneliness as there is for typically developing children. Typically developing children see

closeness and companionship in friendships as lessening loneliness; however this was not seen

with CWA (Bauminger & Kasari). CWA may not be able to emotionally link friendship and

loneliness (Bauminger & Kasari). These findings show that CWA do have some capacity for

developing a theory of mind.

Baron-Cohen and Bauminger and Kasari’s studies pose differing views of theory of mind

capabilities in CWA. Baron-Cohen proposed that CWA either lack a theory of mind or have a

very limited one. Bauminger and Kasari’s study questions this idea by suggesting that if CWA

experience loneliness, which their study indicates is the case, then CWA would in fact have to


possess a theory of mind. It is fair to say, however, that the affective deficits of CWA may

impact the full development of their theory of mind.

The findings of both Baron-Cohen and Bauminger and Kasari’s studies have implications

for the abilities of CWA to partake in play. Possession of a theory of mind enables one to see the

perspective of others. A theory of mind helps in play because children can put themselves in the

place of characters and/or the people they are playing with. This allows children to learn from

others and develop more fully. Typical children are able to spend hours using their theory of

mind to learn about the world through imaginative play. However, the play of CWA is different

than that of typically developing children; for example, CWA tend to play with toys by

repetitively spinning moveable pieces or lining them up. This difference in play is partly due to

CWA’s compromised theory of mind development, which makes imaginative play difficult.

Because of this, CWA do not receive the same benefits from play and their development of

communication and other skills is affected.

Difficulties in linking emotions to movements may cause deficits in socializing in

children with autism. Greenspan and Wieder (2006) discuss six functional developmental levels

(FDLs) of relating and communicating skills. Children with autism often have issues in the first

four FDLs; they may make progress through the first few but then regress and lose abilities.

The foundation of the first of Greenspan and Wieder’s FDLs is shared attention and

regulation. This FDL is reached around the ages of 0-3 months. Involved in this FDL is showing

“calm interest in and purposeful responses to sights, sound, touch, movement, and other sensory

experiences (e.g., looking, turning to sounds)” (Greenspan & Wieder, 2006, p. 30). At this FDL,

a child developing typically is able to link their emotions to their actions and sensations they


experience. However, a child who may develop autism can have difficulty with moving with

purpose or with coordinating movements at all.

Greenspan & Wieder’s (2006) second FDL is based on engagement and relating, and is

attained between two and five months of age. Children at this FDL typically show an increase in

expressions of relatedness and intimacy though sustained joyful smiles. CWA who are having

issues connecting their emotions to their actions may not be able to show their feelings of

pleasure in their facial expressions.

The basis of third FDL is purposeful emotional interactions, and typically is reached

between four and ten months of age (Greenspan & Wieder, 2006). Children who reach the third

FDL are able to engage in a range of back-and-forth interactions where sounds and hand gestures

are used to convey emotions and intentions. Typically developing children are usually able to

continually engage in back-and-forth interactions; however, for children developing autism this

may be too difficult so they have more fleeting responses.

Greenspan and Wieder’s (2006) fourth FDL has a foundation of long chains of back-and-

forth emotional signaling and shared problem solving. Children attain the fourth FDL between

the ages of ten and eighteen months of age. Children at this FDL typically are able to problem

solve by linking many emotional and social interactions. Difficulties with social interaction and

problem-solving with others are often seen in CWA during this stage. Greenspan and Wieder

stated that children developing autism cannot sustain long enough chains of emotional and social

interactions necessary for cooperative problem-solving; usually they can only handle five or six

at a time. This deficiency creates problems developing a sense of self, recognizing patterns, and

using symbols.


The fifth FDL has a foundation of abilities to create ideas, and begins between eighteen

and thirty months (Greenspan & Wieder, 2006). Typically developing children at the fifth FDL

are able to use words or phrases meaningfully in pretend play with parents or peers. The sixth

FDL is based on logical thinking and being able to build bridges between ideas. The sixth FDL

begins around thirty and forty-two months of age. Abilities in logically connecting ideas with

meaning are seen in typically developing children in at the sixth FDL. Children developing

autism rarely master the skills of the fourth FDL, so they do not progress to the other stages.

Progressing to FDL five or six is dependent on children learning to “exchange emotional and

social signals and use ideas in an emotionally meaningful manner” (Greenspan & Wieder, 2006,

p. 32).

Play Therapy

Overview

O’Toole (2014) states that children learn how to sort through information and relate to

others through play. However, autism’s sensory and social issues make engaging in open ended

group play feel more difficult than fun. Thus, play in a style that the children with autism enjoy

can be used to teach interpersonal skills.

Play therapy dates back to the work of Anna Freud and Melanie Klein who both

incorporated play into their analytical work with children (Trice-Black & Bailey, 2013). This

understanding of children’s cognitive development is the basis of play therapy. In 1947, Virginia

Axline brought play therapy into the scope of counseling for children as an empirically supported

and effective intervention (Trice-Black & Bailey).

Play therapy is used by many of the theoretical approaches. As noted earlier, Freud and

Klein used play in their psychoanalytical work, and out of their work came non-directive


approaches of play therapy (Trice-Black & Bailey). Carl Jung’s principles of the unconscious

being accessible through play were used to develop sandtray therapy (Kalff, 1991). Axline began

child-centered play therapy and in 2012 it was expanded by Landreth. Gestalt, Adlerian, and

cognitive-behavioral are some of the other counseling approaches that have been incorporated

into play therapy (Trice-Black & Bailey).

There are a variety of setting in which play therapy can be implemented. Trice-Black and

Bailey (2013) discuss how play therapy can be used in school counseling programs. School

counselors are able to use play therapy in addition to their other interventions and programming

(Trice-Black & Bailey). Various theoretical approaches can incorporate play, art, and other

activities in different settings including classrooms, individual and group counseling sessions,

and in preventative programs addressing academic and developmental concerns (Trice-Black &

Bailey, 2013). Play therapy can also be used at home to build on the interaction skills of CWA

and strengthen the relationships in the family. For example, Sheperis, Sheperis, Monceaux,

Davis, and Lopez (2015) examined how Parent-Child Interaction Therapy (PCIT) can be used to

help reduce behavioral issues in children with special needs. The goal of PCIT is to teach parents

strategies to build relationships with their children with special needs using techniques of

therapeutic play (Sheperis et al.). PICT is designed to be used by families with children in pre-

school and thus extends the therapy into everyday life for CWA.

Roles of family and therapist

O’Toole (2014) remarks that it is the responsibility of parents to help their children

overcome their “blindness” to the minds of others and reduce their anxiety, confusion, and rigid

thinking. Parents can work with their children’s teachers and clinicians to use play to teach the

skills they need. How can parents effectively teach their children interpersonal skills?


Greenspan and Wieder (2006) instituted the Family First Initiative to help parents work

with their children who show signs of autism early on in their development to assist in the

development of emotional and social skills. The Family First Initiative has steps that follow each

of the six FDLs. To help parents work with their children at each FDL, Greenspan & Wieder

(2006) suggest games to build on the skills of each FDL.

Greenspan & Wieder (2006) stated that it is important for parents to observe the child’s

individual manner of reacting to sensory information to help facilitate shared attention and

regulation. Observing what sensory stimuli make the child feel at ease or overwhelmed gives

parents clues on how to engage the child and calm them. In order to assist in developing

engagement and relating, it is important to observe what interests the children with autism and

follow their lead. By following the child’s lead and partaking in what interests them you show

them that you are interested in sharing what gives them joy. Greenspan (2006) discussed how he

made a game of interacting with a child who was only interested in rubbing a spot on the floor

during their session. Parents can also do the same when trying to interact with their children.

Therapists also play important parts in play therapy. Landreth explains that one of the

roles of a play therapist is to empathetically guide a child through experiences that are painful. In

an interview with Carnes-Holt (2014), Landreth said that by stepping in and solving the child’s

problem for them therapists teach them that they are too weak to handle it themselves. The role

of therapists in play therapy is not to correct children’s problems, but to “relat(e) to children in

ways that release their inner directional, constructive, forward-moving, creative, self-healing

power” (Carnes-Holt, 2014, p. 60).

Play therapists use children’s language of play to engage them on their level, rather than

attempting to counsel children as if they were adults. Russo (2005) cautioned against the


partaking in adultism, the disregard and disqualification of young people leading to resentment

and/or loss of a sense of self. By engaging the children in play, therapists validate the child’s

perspective and experiences. In the sessions, play is used as a way for therapists and children to

deconstruct maladaptive behaviors and experiences and reconstruct them into more adaptive

ways of engaging the world.

Specific therapies

There are various versions of play therapies available for children with autism. Some of

these therapies that will be discussed include: the DIR/Floortime, filial therapy, and the PLAY

Project Home Consultation Program (PPHCP). DIR stands for developmental, individual-

difference, relationship-based and was developed by Greenspan and Wieder (2006).

DIR/FloortimeTM is focused on helping CWA form relationships with their families and others

rather than on merely managing the symptoms of autism. Filial therapy was initially developed

by the Guerneys to train parents to be therapeutic agents in the lives of their CWA. Filial therapy

is a form of child-centered play therapy that is focused on the parent-child relationship. The

PLAY Project Home Consultation Program (PPHCP) was founded by Solomon and is a

community-based model adapting Greenspan’s DIR/Floortime model. Each will be reviewed in

its own section.

DIR/FloortimeTM Model

Greenspan and Wieder were unsatisfied with treatment programs that focused solely on

limiting the surface level symptomatic behaviors of autism with a limited prognosis of the

children’s potential development. Because of this dissatisfaction, Greenspan and Wieder

designed the DIR/FloortimeTM to be tailored to each individual child to build on their strengths

and to treat the underlying causes of their deficits. The developmental (D) refers to the functional


developmental levels (Greenspan & Wieder), which were discussed earlier in this paper. The

individual-difference (I) component of DIR refers to the child’s distinctive information

processing abilities (Greenspan & Wieder). Relationship-based (R) refers to relationships

through which children are able to learn and progress in their development (Greenspan &

Wieder). Floortime is a specific strategy within the DIR that helps CWA increase skills in

communicating with purpose and meaning, thinking logically and creatively, and interacting

with warmth and pleasure.

There are two main focuses of Floortime: following the child’s lead and joining in the

world of the child in order to draw them into shared interactions. By following the child’s lead,

parents learn what interests their child and use that interest to engage them. Additiona lly, this

allows parents to help the child stay calm and able to learn by avoiding meltdowns caused by

their CWA being unable to communicate their interests. Joining the child’s world stems from

following the child’s lead. Parents are taught how to engage their child on their developmental

level in what interests them, and to create opportunities for learning how to have back-and-forth

interactions. Parents are also shown ways to make playful obstructions in order to combine the

two focus areas of Floortime. For example, Hess (2013) discussed how parents can playfully

obstruct their CWA from exiting a room by engaging them in activities that interest them.

Playful obstructions follow the child’s lead while at the same time creating challenges they must

solve; this allows CWA to progress in their functional developmental levels.

There are four levels of Floortime that correspond with the first four FDLs (Pajareya &

Nopmaneejumruslers, 2011). The first level is used for children who initially cannot express love

and warmth or calm themselves. Floortime level 2 is used for children who were unable to

engage in two-way communication using gestures or express many subtle emotions. The third


level is used for children who are unable to verbally express their wishes or engage in pretend

play. The fourth level is used for children who are unable to connect thoughts logically or hold

conversations.

Filial Therapy

Filial therapy is a form of child-centered play therapy that trains parents to be therapeutic

agents. Filial therapy was first developed by Bernard and Louise Guerney in the early 1960s as a

long-term training program for parents, which normally was a year in length (Garza, Watts, &

Kinsworthy, 2007). Guerney was in opposition to the common view of the time that parents

caused their children’s issues, and instead believed that parents could be primary therapeutic

agents (Ryan, 2007). Guerney argued that the reason parents can actually be therapeutic agents is

that children show faster benefits from the continuity of interventions based on the parent-child

relationship (Ryan, 2007). Filial therapy strengthens the parent-child relationship, decreases

problematic behaviors in children, and increases parental acceptance of children. Filial therapy is

based on didactic instruction, and supervision by therapists who give play demonstrations using

kits of selected toys (Carnes-Holt, 2014).

Landreth developed a filial therapy model known as Child Parent Relationship Therapy

(CPRT): A 10-Session Model of Filial Therapy. Landreth developed his ten session model in

order to make filial therapy more affordable for families who could not manage the cost of

longer-term treatments. The focus of CPRT is to build on the parents’ and children’s relationship

so it can be a therapeutic force to help the child fully become who they are meant to be. Filial

therapy, in particular CPRT, has few limitations and is effective with a vast range of parents and

children’s behavioral problems (Carnes-Holt, 2014).


Parents participating in filial therapy receive training in a group format with a didactic

component. In the group sessions, six to eight parents along with a facilitator and cofacilitator

meet to discuss issues about themselves as parents or of experiences in their families. The

didactic component consists of simple teaching points, “rules of thumb”, and engaging

metaphors and stories. Parents are taught and practice in the group sessions child-centered play

skills the facilitators model. In the group sessions, parents are taught how to engage in

imaginative play led by their child and how to develop empathetic listening skills. Parents create

30-minute long videotapes weekly of them playing with their children using the play techniques

they learned; the tapes are brought to the group sessions where feedback is given on the parent’s

play skills.

The PLAY Project Home Consultation Program

The PLAY Project Home Consultation Program (PPHCP) was developed by Dr. Richard

Solomon, a developmental and behavioral pediatrician. PLAY is an acronym standing for Play

and Language for Autistic Youngsters. The PPHCP is based in southeast Michigan and is used in

treatment centers in several different States. There are several clinical components to the PPHCP

(Solomon et al., 2007). First, CWA receive medical consultation at the Ann Arbor Center for

Developmental and Behavioral Pediatrics clinic and are referred to community centers. Second,

parents and professionals receive training in the PPHCP partially through community-based

workshops. Third, parents receive support and advocacy services through the Michigan Autism

Partnership (MAP). The PPHCP is an affordable treatment plan costing around $2500/year

depending on the number of visits, as opposed to between $25,000 and $60,000 per year for

other treatment plans (Solomon et al., 2007).


The PPHC is an autism intervention model mediated by parents based on Greenspan and

Wieder’s DIR model (Solomon et al., 2007). PLAY consultants teach parents principles of play

intervention and how to implement them. Parents are also instructed on how to recognize their

child’s preferred way of relating along with their sensory motor preferences and deficits. PLAY

consultants also assist parents in learning how to follow their child’s lead, observe their cues, and

how to increase reciprocal interactions. The PCHP differs from the DIR/Floortime model in that

it is a community-based intervention model with a manual, training, and evaluation method

(Solomon et al., 2007).

There are three typical settings where the PPHCP can be implemented. The first setting

on which research studies have been based is at home visits. The second setting the PPHCP is

typically implemented is at the clinician’s office. The third option is a hybrid of home and office

settings. Most families who partake of the home visits have a 3-hour session every 4 to 6 weeks,

totaling 10-12 visits a year (The PLAY Project, 2016). Families who go to the clinician’s office

have 60 to 90 minute sessions two to four times a month. The PPHCP involves coaching,

modeling, video recording of play sessions, and written feedback to the videos.

The PPHCP has benefits for children of different ages. It is most effective as an early

intervention, especially for CWA between the ages of 15 months to 6 years of age (The PLAY

Project, 2016). There are also benefits for children over 6 years of age, as well as for adults with

developmental disabilities. Children with other special needs or developmental delays can also

benefit from the PPHCP.

Experts in child development teach the parents how to build engaged relationships with

their CWA through play. Parents and therapists work together to follow the child’s lead in order

to improve on their social impairments. Parents always have access to one-on-one training,


coaching, and support from their PLAY Project consultant. At the start of the program, parents

and PLAY Project consultants work together to create a PLAY plan that is individualized and

tailored to the needs of the child. There are seven things included in PLAY plans: 1) education

on the PLAY Project principles and strategies; 2) assessment of the child’s comfort zone,

sensory motor profile, and Functional Developmental Levels (FDLs); 3) a list of recommended

activities specific to the child’s profile; 4) education on the PPHCP methods, including practical

communication tips and how to follow the child’s lead; 5) a list of recommended PPHCP

techniques suited to the individual child; 6) video recording and analysis; and 7) ongoing

evaluation and updates (The PLAY Project, 2016).

Efficacy

Each of the three play therapy styles explored in this paper have different levels of

efficacy. A discussion of the efficacy of play therapy as a general treatment will precede the

discussion of the three specific styles’ efficacy. In order to determine the efficacy of play therapy

in general and the three styles, research studies will be examined. The three styles will be

discussed in the same order as in the previous section.

Play Therapy as a General Treatment

Barton, Ray, Rhine, and Jones (2005) conducted a meta-analysis of 93 controlled

outcome studies of play therapy in order to determine the effect size (ES) of play therapy. There

is a range of ES that was proposed by Baron-Cohen: 0.20 is small effect, 0.50 is medium, and

0.80 is a large effect (Barton et. al., 2005). The studies included in the meta-analysis were

conducted between 1953 and 2000. Barton et al. examined studies that were published and ones

that were unpublished in order to avoid publication bias.

Eleven characteristics of the studies where examined, including:


1) treatment modality/theoretical model used; 2) treatment provider, either mental

health professionals or paraprofessionals (predominantly parents, but also

teachers or peer mentors) overseen by professionals; 3) setting of treatment; 4)

duration of treatment; 5) treatment format (group v. individual); 6) presenting

issues/target problem behavior; 7) type, number, and source of outcome measures;

8) ethnicity, gender, and age of the participating children; 9) published v.

nonpublished document; 10) study design; and 11) source of child participants

receiving treatment (clinical v. analog) (Barton et al., 2005).

The studies in the meta-analysis were either humanistic-nondirective or nonhumanistic-directive

(nonhumanistic meaning behavioral). There was a larger ES for studies that were humanistic-

nondirective (0.92) than for nonhumanistic-directive (0.71).

Studies where paraprofessionals administered treatment used filial therapy to train them.

Studies with paraprofessionals had a very large ES (1.05) compared with a moderate ES of 0.72

for studies with mental health professionals. Additionally, studies focused solely on parents

trained in filial therapy showed an even larger ES (1.15).

Settings for the studies included schools, outpatient clinics, residential, and critical

incident (i.e., hospitals, prisons, domestic violence shelters and natural disasters). The studies in

residential settings had the largest ES (1.01), compared with a more moderately sized ES of 0.69

for school settings. Outpatient settings had an ES of 0.81, and critical incident settings had an ES

of 1.00.

Studies in the meta-analysis had three different treatment formats: group therapy led by

professionals, individual therapy led by professionals, and individual therapy led by

paraprofessionals who were mostly parents trained in filial therapy. Studies of individual therapy


led by paraprofessionals had a large ES of 1.05. Studies of professional led group therapy had an

ES of 0.73, whereas those focused on individual therapy led by professionals had an ES of 0.70.

Barton et al. (2005) found a relationship between the number of sessions and ES. Studies

where treatment duration was between 35 to 40 sessions showed optimal ESs; however, studies

that were either much longer or shorter had diminished ESs. On the other hand, treatments in

crisis settings with 14 sessions produced medium to large ESs. What can be drawn from this is

that large ESs may be generated by shorter treatment durations, but the most benefit comes from

durations of around 35 sessions.

The studies in the meta-analysis overall did not show much relationship between the age

or gender of the children and ES. The studies did suggest that play therapy is effective with a

range of ages and for both genders. However, Barton et al. did caution that heterogeneous

samples, large age ranges, and incomplete date did complicate interpretations of findings.

The studies had different target problem behaviors and outcome measures. Studies that

focused on internalizing problems had an ES of 0.81, while those that focused on externalizing

problems had an ES of 0.78. Some studies focused on both internalizing and externalizing

problems and had an ES of 0.93. Some studies did not focus on either internalizing or

externalizing problems but on the adjustment, academic achievement, or personality; these

studies had an ES of 0.79. Eight different treatment outcome measures were included by the

studies: behavior, social adjustment, personality, self-concept, anxiety-fear, family

functioning/relationships, developmental-adaptive, and other. Studies with family

functioning/relationships as an outcome measure produced the largest ES (1.12). A large ES

(0.90) was also generated by studies with developmental-adaptive as an outcome measure. Effect


sizes of the other treatment outcomes ranged from 0.51 for self-concept to 0.83 for social

adjustment.

Barton et al. (2005) found a relationship between publication status of the studies and

their ES. Published studies had a large ES of 1.04, compared with more moderate 0.77 for

unpublished studies. They remarked that the studies did appear to show a publication bias, and

also noted that perhaps only the studies that yielded higher ESs were published.

Three different designs were used in the studies included in the meta-analysis: play

therapy v. control, play therapy v alternate treatment, and play therapy v alternate treatment v.

control. Studies with either play therapy v. control or play therapy v. alternate v. control designs

produced large ESs; 0.89 for the former, and 0.82 for the latter. Studies that used play therapy v.

alternate designs showed a slightly moderate ES of 0.79.

The source of participants did have some impact on ESs. Studies with participants drawn

from clinical sources (those already seeking help from clinical services) produced a large ES of

0.82. Studies with participants drawn from analog sources (volunteers recruited for the study)

produced a slightly more moderate ES of 0.78.

DIR/Floortime

There were two measures of outcomes used in Pajareya and Nopmaneejumruslers’ (2011)

pilot study. The first was the Functional Emotional Assessment Scale (FEAS). The FEAS was

developed by Greenspan in 2001 and is an observational measure of children’s functional

developmental. To determine FEAS scores, a 15-minute videotape of child-parent interactions

using a standard set of toys (symbolic, tactile, and movement toys) (Pajareya &

Nopmaneejumruslers). The other measure used was the Childhood Autism Rating Scale (CARS)

and the Thai language version of the Functional Emotional Developmental Questionnaire


(FEDQ). CARS rates autism symptoms on a 15-60 scale. The FEDQ is related to Greenspan’s

six functional developmental levels (FDLs), and was completed by the parents as a pre- and post-

test.

Results showed great improvements for the DIR/Floortime group over the control group.

The CWA in the DIR/Floortime group had an overall improvement score of 7.0 on the FEAS

compared to only 1.9 for CWA in the control group. CWA in both groups showed improvements

in the severity of their autism based on their CARS scores; however, CWA in the DIR/Floortime

group showed statistically significant decreases in severity than controls.

Pajareya and Nopmaneejumruslers (2012) also conducted a yearlong study of

DIR/Floortime. Thirty-four CWA between the ages of 2 and 6 years of age were requited, as in

the pilot study. Baseline FEAS scale score was 3.5 (Pajareya and Nopmaneejumruslers). The

yearlong study did not contain a control group based on the ability of the pilot study to show

results with the DIR/Floortime intervention in only three months.

Parents met in groups with the investigators for three hours every month to discuss

progress or concerns. Additionally, the parents had one-on-one follow up meetings with the

investigators. The follow ups occurred at the end of the first and third month, and then were

made every three months. During the follow up meetings, the investigators gave the parents

feedback on their child’s progress and adjusted the techniques accordingly.

As in the pilot study, The FEAS and CARS were used to measure improvements in the

CWA. Forty-seven percent of the children made good improvement of 1.5 or more FDLs based

on FEAS scores. Twenty-three percent made fair progress of 1 FDL. Twenty-nine percent made

poor progression of only 0.5 FDLs.


The results of the two studies show that the DIR/Floortime is an effective treatment.

However, it is possible that there was so great an improvement in the children’s scores because

they initially did not have many opportunities for interaction with their parents of the kind

necessitated by DIR/Floortime. Also, the pilot study used the FEAS which is specific to DIR

theory, and no other measures for cognitive skills or social functioning. Using other measures of

outcomes would have been beneficial in order to gain a broader perspective of how the

DIR/Floortime can improve the social and cognitive skills of CWA.

Filial Therapy

Beckloff (1997) conducted a study of filial therapy for families with CWA using

Landreth’s ten session model of filial therapy. He wanted to establish the efficacy of filial

therapy in five different areas. These include: 1) increasing parents’ empathy and acceptance of

their children; 2) reducing parents’ problems with their children; 3) decreasing children’s social

difficulties; 4) reducing the parents’ stress caused by parenting CWA; and, 5) parents’

measurement of reduction in their children’s stressors.

The participants included 28 families with CWA. There were fourteen families divided

into two groups who received filial therapy training: a group of four families who had day time

meetings, and a group of ten who met in the evening. Some families in both groups dropped out

bringing the total to 33 families who completed the study, 12 in the experimental group and 11 in

the control group. The children in both groups were between the ages of 3 and 10 years old. The

experimental group met for two hours every week for ten weeks where they received training in

filial therapy methods, and then they were instructed to have 30-minute play sessions at home

with their CWA.


There were four different testing measures used at the beginning and conclusion of the

study. Subscales of the Porter Parental Acceptance Scale (PPAS) was used to determine the

effectiveness of filial therapy in increasing parents’ empathy and acceptance. The Child

Behavior Checklist (CBCL) was used to determine the reduction of parents’ problems with their

children, as well as for decreasing children’s social difficulties. The Parenting Stress Index (PSI)

was used to measure reductions in child stressors as parents reported.

Results of the study were mixed, but overall positive. The only subscale where the

experimental group saw statistically significant improvement on the PPAS was the “Recognition

of the Child’s Need for Autonomy and Independence” subscale. Parents in the experimental

group showed a positive trend of improvement on the rest of the subscales of the PPAS

(“Respect for the Child’s Feelings and Right to Express Them”, “Appreciation of the Child’s

Unique Makeup”, and “Unconditional Love”), but did not reach statistical significance. Behavior

problems began to show reductions on the CBCL; however, there was no statistically significant

level of improvement which may be due to a need for more sessions. Parents in the experimental

group did remark that their children were beginning to show greater attempts at verbal

communication and more imaginative play. Parents and CWA did not report significant

reductions in stress on the PSI, which normally occurred in other filial therapy studies; this could

be due to the study taking place near to the end of the children’s school year, or a need for more

sessions in order to see more significant stress reduction. On the other hand, some parents in the

experimental group did report that transitions were becoming more manageable for their CWA.


Solomon, Van Egeren, Mahoney, Quon Huber, and Zimmerman (2014) studied the

effectiveness of the PLAY Project Home Consultation (PPHC) program. The study involved


randomized control groups, which were not present in studies of other parent-mediated

programs, and took place over the course of three years. Two hypotheses were tested: 1) that the

parents in the PPHCP group would show improvement in their interaction skills and their

children’s language, development, interaction skills, and improved symptomatology; and 2) that

the parents in the PPHCP group would experience an increase in stress and depression than the

parents in the control group due to the intensity of the PPHCP interventions.

It was determined that 120 families would be necessary for the study. The families were

broken up into two one year long cohorts, 12 per site of which half would receive PPHCP. To be

included in the study, children had to be between 2yr8mo and 5yr11mo and have a diagnosis of

autism based on DSM-IVTR criteria. Children were excluded from the study if they had a

diagnosis of Asperger syndrome, genetic disorders, or if their parents have cognitive

impairments or severe psychiatric disorders. Goals of the study were: 1) that children would

progress through Greenspan and Wieder’s FDLs and 2) that parents would have decreased levels

of stress and depression.

Results showed improvements for both CWA and their parents. Over half of the CWA in

the PPHCP group improved by at least one category on the Autism Diagnostic Observation

Schedule (ADOS), compared to about 33% of CWA in the control group. The ADOS is an

assessment for social and communication behaviors and is comprised of two modules: Module I

for little to no phrase speech and Module 2 for use of phrase speech but lack of fluency

(Solomon et al., 2014). Twenty-two percent of CWA in the PPHCP group improved so much on

the ADOS that they were no longer considered being on the autism spectrum (Solomon et al.).

Parents in the PPHCP group had significantly improved quality of interactions with their CWA


compared to parents in control groups. Parents in the PPHCP group had decreased levels of

depression more so than control parents.

From the results, it is fair to say that the PPHCP is an effective treatment program. CWA

had improvements in FDLs and on the ADOS. Parents also benefited from the PLAY

interventions in that they were able to learn effective ways of engaging with their CWA, as well

as having reductions in levels of stress and depression. However, Solomon et al. did caution that

the drastic improvements seen on the ADOS in a year do not align with clinical experience.

Critique

There are many strengths of play therapy in general and the play therapy styles examined

in this paper, but there are also several weaknesses in each strategy. Each play therapy styles will

be examined in the order of the proceeding sections.

Play Therapy as a General Treatment

There are several aspects of studies of play therapy that need to be addressed. Studies

need to be designed to include larger sample sizes. Barton et al. (2005) noted that smaller sample

sizes can skew the ES of a study. Play therapy studies with homogeneous groups of children also

need to be conducted. Having heterogeneous groups of both boys and girls in a study may impact

the effectiveness of play therapy. Homogeneous groups of either boys or girls would allow for

determination of which gender play therapy is more effective.

DIR/Floortime

The studies of DIR/Floortime examined in this paper only used measurements specific to

DIR/Floortime theory. This lack of other measurement types, such as those for cognitive

development or social functioning, gives an incomplete picture of other areas where

DIR/Floortime may or may not be effective. Future studies need to incorporate other


measurement types in order to more accurately assess the efficacy of DIR/Floortime. The results

of the studies conducted in Thailand may be due to the parents’ more distant relationships with

their children, as is the norm in Thailand. Studies of DIR/Floortime conducted in countries that

have different approaches to parent-child interactions may see different levels of progress for

CWA. Studies with other children in addition to the CWA should be conducted to in order to

assess the stress implementing DIR/Floortime places on the parents, and to assess the feasibility

of conducting play sessions when other children need attention. In both of Pajareya and

Nopmaneejumruslers’ studies, families primarily only had one child so it is possible that the

results may have been different if the families had more children.

Filial Therapy

Future filial therapy studies should make certain adjustments to Beckloff’s study. Studies

that last longer than the ten weeks of Landreth’s model need to be conducted in order to

determine if greater improvements would be shown for both the CWA and their parents. Studies

should also begin earlier in the school to more accurately assess the ability of filial therapy to

lower the stress of parents and their CWA. Beckloff (1997) noted that the lack of stress reduction

in the experimental group may have been due to his study taking place at the end of the school

year when things are more stressful for both parents and children. Studies that use Landreth’s ten

week model should add a second weekly at home play session in order to produce higher levels

of growth. Language skills should also be examined in future studies to determine if filial

therapy has an impact on CWA’s development of language skills. Future studies with CWA

around the ages of 2 and 3 years old should be conducted to determine if filial therapy as an early

intervention can reduce the severity of social-affective deficits.



There are several aspects future studies of the PPHCP need to address. The parents in the

most recent study by Solomon et al. (2014) all had higher education and of somewhat higher

than average socioeconomic status (SES). A study needs to be conducted with parents with lower

levels of education and SESs in order to determine if the results of Solomon et al.’s most recent

study are generalizable. It is important to conduct studies where there is a clearer distinction

between outside community services received by the families in both the control and

experimental groups in order to clarify that the improvement seen in the PPHCP group came

from the treatment method in question. However, Solomon et al. noted that the combination of

community services with the PPHCP may lower the burden placed on parents. Long-term studies

where child participants are grouped by language and cognitive level may also be beneficial to

generalize the results of Solomon et al.’s study.

Conclusion

Autism spectrum disorder comes with deficits creating great issues in social engagement.

Children with autism, much like their typically developing peers, speak the language of play;

however, CWA speak it in a different dialect – so to speak – making it difficult to socialize with

their peers and families. Play therapy is a means for children to learn the dialects of their peers

and families, and develop further than would be possible with different forms of treatment.

However, greater research needs to be conducted into the ability of play therapy to reduce or

possibly eliminate the many social-affective deficits CWA face.


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