1. 22 nd Annual Association for Play Therapy International Conference October 4-6, 2005, Nashville, Tennessee, USA Ulrike Franke & Herbert H.G. Wettig The Effectiveness of Theraplay ® on Young Children Experiencing Receptive Language Disorders (Verbal Comprehension Disorder) ® Copyright 2005

2. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 2 Overview Theraplay ® What is Theraplay? The model for Theraplay. Therapeutic dimensions. Setting. Theoretical background. Receptive Language Disorders What are receptive language disorders? Level of knowledge. Body of research. The Effectiveness of Theraplay on young children with receptive language disorders Research objective. Methods. Samples. Repeated measurement. Evaluation of the effectiveness of Theraplay on receptive language disordered toddler and preschool children...... being oppositional defiant... being shy... suffering an autistic-like lack of social mutuality. Statistically significant symptom reduction by Theraplay. Duration of treatment. Number of therapeutic sessions until success.

3. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 3 What is Theraplay?

4. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 4 Historical highlights of Theraplay ® ® 1996. The term Theraplay is legally protected by Wz. 39518465. Halfway through the 1960s: Theraplay was developed by the Heidelberg-born clinical psychologist Ann M. Jernberg, Ph. D., to support the Head Start Project of Chicago. 1967: Jernberg founds The Theraplay Institute in Chicago. 1979: Ann M. Jernbergs first book about Theraplay:Theraplay. A New Treatment Using Structured Play for Problem Children and Their Families (German: Franke, 1987) 1999: Ann M. Jernberg & Phyllis B. Booths book:Theraplay. Helping Parents and Children Build Better Relationships Through Attachment-Based Play 1998 – 2005: Ulrike Franke & Herbert H. G. Wettig. Scientific research in Germany and Austria evaluating the effectiveness of Theraplay on toddler and preschoolers.

5. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 5 What is Theraplay ® ? ® 1996. The term Theraplay is legally protected by the European Patent Office, Wz. 39518465, and world-wide for The Theraplay Institute, Wilmette, IL, USA. Theraplay is a special kind of play therapy. It is a family therapy for hard to treat children creating fun to the children and plucking up their parents courage. Theraplay is an interactive play therapy. Theraplay is a play therapy without any toys. Theraplay is based on the pattern of a natural, healthy parent-child interaction. Theraplay is a structured play therapy. Structured play and rituals give the child a secure base. Theraplay is a directive play therapy. The therapist guides the therapeutic play.

6. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 6 Theraplays orientation Theraplay is developmentally oriented. Theraplay as a treatment is oriented to the developmental age of the child, not the chronological one. Theraplay is need oriented. The treatment is oriented to the clinical needs of the child. Theraplay is affect regulating. Nurturing, touch, interactive care are quieting and soothing. Theraplay is a short-term play therapy. Practice-based evidence shows that a disordered child treated with Theraplay significantly reduces his symptoms within 19–20 30-minute therapeutic sessions on average. (Children diagnosed with Pervasive Developmental Disorders need 26-27 such sessions in average to achieve the therapeutic aim.)

7. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 7 The model of Theraplay Model for Theraplay...... is a healthy mother-infant relationship (Jernberg, 1979), including Winnicotts idea of a good enough mother (Winnicott, 1958). Basis for the model... are Jernbergs observations of behavior pattern of around 400 observed mother-infant dyads. (Munns, E., cited in Schaefer, 2003. Foundations in Play Therapy) The mother is the example for the therapist reacting empathetically to the needs of her child, regulating his or her affect, being attuned to her child, and being touching and playful.

8. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 8 Therapeutic dimensions of Theraplay Jernberg found by observation four important natural dimensions of behavior in mother-child relationships: – structure, – engagement (stimulating the child to become engaged), – challenge, and – nurturing the child. These are also the therapeutic dimensions of the interactive short-term play therapy Theraplay.

9. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 9 Structure as a therapeutic dimension of Theraplay Structure helps the child to feel secure, - e.g., because the therapist is responsible for guidance, - building limits, that the child can learn to control himself, - mediating well-ordered and easily comprehensible rules. Structure helps children experiencing externalized or internalized disturbances, –helps especially hyperactive, over-stimulated children, –helps especially oppositional defiant children, –helps especially children seeking self-efficacy, –helps especially shy, socially withdrawn children, –helps especially socially anxious children, too.

10. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 10 Engagement stimulation to become engaged as a therapeutic dimension Engaging, playful activities establish a connection between therapist and child. The how to do of the stimulation is important, to engage the child in his or her emotional and cognitive functions. Children need different kinds of stimulation, to get engaged and involved in a relationship – powerful, active, gentle, soothing ones, etc.

11. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 11 Challenge as a therapeutic dimension Challenging activities help the child, –to develop his or her sense of self, self-reliance, self-esteem, –to feel competent and self-sufficient, –to go into risks appropriate for his or her age. Challenging activities are especially useful with shy, bashful, socially withdrawn, non-flexible, anxious children, who may think of themselves as not being capable.

12. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 12 Nurturing as a therapeutic dimension Quieting, calming, soothing, nurturing activities –give the child the warm feeling of a secure, certain, safe surrounding, in which a caregiver offers comfort and stability, –fulfills unsatisfied needs of the early childhood, –helps the child to relax, –relieves emotional grief and physical pain, –builds an internal image on his or her own mind, of being lovable, endearing, and being worthy of others. Nurturing is especially essential for hyperactive, oppositional defiant, and aggressive children.

13. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 13 Attitudes and activities of the therapist (some examples) Sensitive empathizing with the needs of the child, sensitively building a relationship with the child, playful interpersonal activities (without toys), directive guidance of the interaction with the child, silently ignoring aggressive activities of the child, intervening paradoxically in case of resistance by the child, gently reinforcing the self-confidence of the child, solicitously taking care of small injuries of the child, lovingly imitating sounds of an autistic child, playfully stimulating activities of a shy, withdrawn child, emotionally addressing the right hemisphere of the brain.

14. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 14 Therapeutic Setting (The picture of the boy is approved by his parents) TheTherapist (hidden by the small picture) is guiding the therapy, structures, interacts, plays with the child, and is nurturing him; The Co-Therapist gives the child a warm feeling of being safe, acts for and together with the little child, speaks for the non- comprehending child, protects the therapist from injuries by aggressive children.

15. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 15 Example of a child manifesting receptive language disorder Thomas at the beginning of the therapy. Clip from the 2 nd therapeutic session (30 min. duration of the session plus preparation and evaluation afterwards) Start of Video 1

16. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 16 Example of a child manifesting receptive language disorder Thomas halfway through the therapy. Clip from the 9 th therapeutic session (30 min. duration of the session plus preparation and evaluation afterwards) Start of Video 2

17. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 17 Neurobiology as a background to understand the effectiveness of Theraplay The neural network of the infants brain –develops particularly fast during the first 18-24 month after birth due to interpersonal interaction with his or her empathetic caregiver. –The kind of positive or negative emotional interaction between the caregiver and the brain of the child forms neural pathways that determine who the child will be and how he or she will behave in later life. –That is the root position of intellectual development of the child. Daniel J. Siegel, 1999, School of Medicine, UCLA Los Angeles und Childrens Mental Health Alliance, N.Y. Affect regulation –origins in the self of the child. Allan N. Schore, 1994 Affect dys-regulation –origins in disorder of the socio-emotional self of the child. –Negative experiences in the early childhood have a long-term effect on emotional affect dys-regulation of the child. Allan N. Schore, 2003

18. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 18 Attachment theory as a background to understand the effectiveness of Theraplay Neuronal self-organization of the childs developing brain is based on the relationship of the context with the caregivers brain. Affect regulation is a main principle of organizing the human development and motivation. Learning to regulate affect is connected to the development of attachment with others. Attachment theory shows that empathetic turn-taking and engaged interaction between caregiver and child will... –build a secure attachment between caregiver and child, –form the childs internal working model of himself and his world positively, –and determine the regulation of the childs emotions and activities. (e.g., Bowlby, 1988, 1995; Brisch, 2003; Stern, 1974, 1986, 1995) Secure or non-secure attachment between the child and his or her caregiver significantly influences the later life of the child. (e.g., Goldberg, 2000; Hughes, 1998; Rutter, 1994; Waters, Weinfield, & Hamilton, 2000; Ziegenhain & Jacobsen, 1999. Cross-cultural: van Ijzendorn & Sagi, 1999)

19. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 19 Touch as a therapeutic element of Theraplay The positive effect of loving, nurturing, soothing touch is evidence-based by scientific research. (e.g., Field: Touch, 2001; Montagu, 1988) Touching the child by his or her caregiver produces an increased release of endorphins in the childs brain. The raised endorphin level increases the pleasure of both brains and the interpersonal interaction between them. Research, for example, has shown, that premature children who are touched repeatedly in a loving, nurturing, soothing way will grow faster in body weight and overall maturation than children who are not touched in this way. (Field: Touch, 2001)

20. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 20 Play as a therapeutic element of Theraplay Play smoothes the way for a relationship with the child. Play improves the childs attention and concentration, - motivates the childs cooperation, - loosens up the childs efforts and stressors, - takes away the oppressiveness of a severe situation, - possibly lessens the childs depressing reality. Play lets the childs neuronal system blossom out, - optimizes the neuronal organization of his brain, - breaks the cascade of negative social influences which would otherwise possibly shape the childs brain

21. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 21 Therapeutic perspectives of Theraplay The perspective into the childs disorder. The view of the childs symptoms to be treated. The perspective into the childs development. The view of the level of the childs current development. The perspective into the childs resources. The view of the childs capability to develop aptitudes. The perspective into the childs relationships. The view of the childs interactive behavior and his or her change in the therapeutic relationship. The perspective into the childs motivation. The view of the childs willingness to cooperate, to get involved in therapeutic play, and with that, to change his behavior patterns.

22. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 22 Symptoms in which Theraplay is particularly effective (examples) Symptoms of external behavior or conduct disorders –e.g., hyperactive, impulsive, inattentive children, –non-cooperative, oppositional defiant, aggressive ones. Symptoms of internal disorders in interactive behavior –e.g., shy, bashful, socially withdrawn children, –suffering a lack of confidence in themselves and others. Symptoms of affective attachment disorders –traumatized, hospitalized, foster and adoptive children. Symptoms of pervasive and developmental disorders –e.g., autistic-like lack of social mutuality in interaction, –e.g., developmental delay, receptive language disorder.

23. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 23 What is a receptive language disorder? Another term for receptive language disorder is Verbal comprehension disorder

24. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 24 Verbal comprehension Literature: Amorosa & Noterdaeme (2003). Rezeptive Sprachstörungen. Manual Verbal comprehension in the broader sense...... is the ability to include former experiences and the situation in which words are spoken, aside from the words contents, and to react in accordance with the words meaning. (This definition is similar to the ordinary term to understand.) Verbal comprehension in the narrow sense...... is the ability to understand the sense and meaning of remarks based on a words meaning and on the use of the grammatical rules, i.e. to understand decontextualized language

25. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 25 Description of receptive language disorder ICD-10 International Classification of Diseases, Chapter V Mental Disorders (F80.2) DSM-IV Diagnostic and Statistical Manual of Mental Disorders, 4 th Edition (315.31) Receptive language disorder is a specific developmental language disorder. The childs language comprehension is below the level of the childs developmental age. Research criteria on basis of ICD-10: The childs language comprehension measured by a standardized test score which is below the limits of... - 2 standard deviation from the childs chronological age - 1 standard deviation from the childs non-verbal IQ.

26. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 26 The problem of inconspicuousness of the receptive language disorder 1 ) Literature: Amorosa & Noterdaeme (2003). Rezeptive Sprachstörungen. Manual 2 ) Lit.: Knoelker, Mattejat & Schulte-Markwort (2000). Kinder- und Jugendpsychiatriee Receptive language disorder is a developmental disorder 1. Developmental disorders of speech and language are narrowly tied to the biological maturation of the brain 2. The common pattern of speech and language development of receptive language disordered children is deviant from the early stages of development on 1. Nevertheless receptive language disorder is often failed to be noticed by parents and physicians 1. Most parents recognize their childs receptive language disorder much too late. It is suspected that parents are accustomed to communicating with their children using facial expressions and gestures, and that their children learned to say Yes, yes... to give the impression that they understood their parents words. Often the children have just interpreted the gestures of their parents.

27. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 27 Significance of language comprehension (Some statements) Language comprehension is closely connected with the childs whole development. (K. Sarimski, 1984, 29, zit. in Mathieu, 1995, 37) The development of language comprehension is embedded in the development of the mind and cognition. (K. Sarimski, 1984, 29, zit. in Mathieu, 1995, 37) With lacking or impaired language comprehension it is impossible for the child to have important experiences and because of that to make good (developmental) progress. (S. Mathieu, 1995. Vergleichende Untersuchung. In: VHN 64, 36-52) The estimated rate of prevalence is around 3 % of children. (Knoelker, Mattejat & Schulte-Markwort (2000). Kinder- und Jugendpsychiatrie)

28. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 28 Consequences of receptive language disorder 1 ) Literature: Amorosa & Noterdaeme (2003). Rezeptive Sprachstörungen. Manual 2 ) Lit.: Knoelker, Mattejat & Schulte-Markwort (2000). Kinder- und Jugendpsychiatrie Receptive language disorder interferes not only with the childs total language development, but also with the cognitive and emotional development 1. Receptive language disorder results in negative effects both on social interaction with caregivers and others, and in the childs academic development as well 1. Children with receptive language disorder are at high risk, to develop emotional, social and behavior disorders later 2. In nearly all cases the expressive language is distinctly impaired, as well 2.

29. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 29 Missing approaches to treat receptive language disorders Literature: Amorosa & Noterdaeme (2003). Rezeptive Sprachstörungen. Manual Specific therapeutic approaches are missed to a large extent. At least in the German speaking area of Western Europe there are no specific approaches to treating young childrens verbal comprehension disorder. Logopaedia is found in practice to be a lengthy treatment. Speech-language intervention is not effective until the receptive language disordered child starts to be cooperative, attentive and able to concentrate. There is very little literature. In scientific literature there are very few recommendations for the therapeutic needs of such children.

30. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 30 Very little research has been done with verbal comprehension disorder Lit.: B. Zollinger, 1995. Störungen des Sprachverständnisses. Edition SZH, 109-122 Literature about development of verbal comprehension. In fact, there is a great number of authors describing how and when children start to speak their first words and sentences. However, there is only a very small body of publications about the basics of childrens development of verbal comprehension. There is nearly no research on verbal comprehension. Nearly no research reports are published about the results of controlled studies to evaluate the effectiveness of treatments to improve receptive language disorder. The reason why studies are missed? Receptive language disorder is not observable. Only the childs reaction to requests can be observed to compare children with and without verbal comprehension deficits.

31. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 31 Research evaluating the effectiveness of Theraplay on toddler and preschool children diagnosed with receptive language disorder (Verbal comprehension disorder)

32. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 32 Research approach and objective Two field studies with repeated measurement in treatment settings. 1998-2005 A controlled Longitudinal Study (CLS) with a follow-up 2 years after termination of the treatment 2000-2004 A nation-wide Multi-Center Study (MCS) in 9 quite different treatment facilities Objective of the studies: Evaluation of the effectiveness of Theraplay on toddler and preschool children with dual diagnoses of developmental speech-language disorders and different kinds of behavior disorders, e.g. external, internal, pervasive ones.

33. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 33 Method of the Controlled Longitudinal Study Controlled Longitudinal Study (CLS) 1998 – 2003 N = 60 toddler and preschool children (gross sample N = 68) with dual diagnoses of developmental language disorder and clinically symptomatic behavior disorder, whose treatment with Theraplay was terminated in 2003. N = 30 clinically non-symptomatic, normal control children of the same age and sex (equally matched sample) 2000 – 2005 N = 40 follow-up two years after individual discharge from therapy. Advantages: –Repeated measurement (waiting time begin - 2 years after therapy) –High internal validity of the results in this patient cohort. Disadvantages: –Generalization to other groups of patients is impossible, because... –of being carried out in only one region, the wider area of Heidelberg, –of being carried out in only one facility (Phoniatric Paedaudiologic Center), –of being carried out by only one Theraplay therapist. Therefore, in 2000 a nation-wide Multi-Center-Study (MCS) was started.

34. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 34 Method of the Multi-Center Study A nation-wide Multi-Center Study (MCS) 2000 – 2004 N = 319 clinically symptomatic toddler and preschoolers whose treatment with Theraplay terminated in 2004. Nation-wide in Germany and Austria by 14 therapists of different professions carried out in 9 different therapeutic facilities as... –an out-patient department of an early intervention facility, –a kindergarten, department of a center for handicapped children, –a ward, department of a child and adolescent psychiatric unit, –a kindergarten of a child welfare unit in an area of social deprivation, –an out-patient department of a phoniatric paed-audiologic unit, –a speech therapy unit in an early intervention facility, –a private practice of childrens psychological psychotherapist, –a private practice of childrens speech-language therapists, etc.

35. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 35 Research instruments The only instruments described here are those which were needed for this part of the study. In addition to these, other observation sheets, diagnostic tests, and questionnaires were used. Data referring to the child and his or her family or caregiver Questionnaire gathering data regarding the childs history and the socio-demographic data of his amily/caregiver. Diagnosis, formation, and change of the childs symptoms Repeated clinical evaluation of the childs symptoms using CASCAP-D, the German version of the Clinical Assessment Scale for Child and Adolescent Psychopathology (Doepfner et al., 1999) Comment: At the beginning of this research in 1998 CASCAP-D was part of the basic documentation in child and adolescent psychiatry and childrens hospitals. Data about the duration of the treatment with Theraplay Questionnaire: completed by the therapist on basis of patients record.

36. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 36 Points in time of measurement Points in time of the Controlled Longitudinal Study (CLS) –t 1 = at the beginning of the therapy using Theraplay –t 6 = after the end of the therapy using Theraplay –t 7 = 2 years after end of the therapy using Theraplay CASCAP-D was not used at the beginning of the waiting time (time t 0 ). Results measured at points during the process of therapy t 2 – t 5 are not reported. Normal, clinically non-symptomatic Control Group (CG-N) –t 1 = at the beginning of a 16-week waiting time –t 6 = after the end of the 16-week waiting time Points in time of the Multi-Center study (MCS) –t 1 = at the beginning of the therapy using Theraplay –t 6 = after the end of the therapy using Theraplay.

37. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 37 Sub-samples of children demonstrating receptive language disorder CLS Controlled Longitudinal Study 1998-2005 N= 52 children in total* with receptive language disorder of these N= 19 oppositional defiant children N= 19 shy children N= 14 children with an autistic-like lack of social mutuality N= 30 clinically non-symptomatic toddler and preschoolers of the same age and sex (matched control sample) MCS Multi-Center Study since 2000 (9 different facilities) N=193 children in total* with receptive language disorder of these N=109 oppositional defiant children Kinder N= 99 shy children N= 45 children with an autistic-like lack of social mutuality *All sub-samples are toddler and preschool children with dual diagnoses of both receptive language disorder and behavior disorders.

38. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 38 Age and sex of the children with receptive language disorders Mean of age (M). Sex in % CLS: Age in years: month M = 4;03 N= 52 in total language disordered toddler, preschooler Boys Girls 4;04 years 4;03 years N = 38 N = 14 M = 4;06 N= 30 matched clinically non-symptomatic toddler, preschooler Control sample N MCS: Age in years: month M = 4;02 N=193 in total language disordered toddler, preschooler Boys Girls 4;02 years 4;02 years N = 133 N = 60 CLS: Sex in % Boys Girls Ratio 2,7:1 73% 27% N= 52 in total language disordered toddler, preschooler N = 38 Boys N = 14 Girls 70% 30% N= 30 clinically non-symptomatic toddler, preschooler Cóntrol sample N MCS: Sex in % Boys Girls Ratio 2,2:1 69% 31% N=193 in total language disordered toddler, preschooler N = 133 Boys N = 60 Girls

39. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 39 Marital status of household and upbringing of the children with receptive language disorder CLS: N=52 receptive language disordered children Social status of the mothers 90% married mothers 10% unmarried mothers (unmarried living together, been separated, single mothers) Social status of the children 85% legitimate children 11% illegitimate natural Kinder 4% adopted and foster children Upbringing of the child 88% by both parents 12% by one parent 69% in kindergarten MCS: N=193 receptive language disordered children Social status of the mothers 69% married mothers 31% unmarried mothers (unmarried living together, been separated, widowed, single mothers) Social status of the children 79% legitimate children 15% illegitimate natural children 6% adopted and foster children Upbringing of the child 80 % by both parents 20% by one parent 77% in kindergarten

40. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 40 Initial Degree of receptive language disorder (point in time t 1 at the beginning of therapy) Evaluation of the symptoms using CASCAP-D, Doepfner et al., 1999: *4=severe..., 3=moderate..., 2=mild symptoms; 1=clinically non-symptomatic Sub-samples of toddler and preschool children with receptive language disorder N mean* M t1 sd s t1 N= 52 Toddler and preschool children, Controlled Longitudinal Study (CLS) = Initial degree of symptoms severity on average 523.120.81 N=193 Toddler and preschool children, Multi-Center Study (MCS) 4 = initially severe degree of symptoms 734.000.00 3 = initially moderate degree of symptoms 683.000.00 2 = initially mild degree of symptoms 522.000.00 = initial degree of symptoms severity on average1933.110.78 N= 30 Clinically non-symptomatic toddler and preschoolers Control Group N (CGN) = initial degree of symptoms severity on average 301.000.00

41. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 41 The effectiveness of Theraplay on receptive language disorders MCS: N = 193 receptive language disordered of 291 behavior disordered children CLS: N = 52 receptive language disordered of 60 behavior disordered children. CGN: N = 30 clinically non-symptomatic children ( = Control group N).

42. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 42 Initial mean degree (M t1 ), change (M t1 M t6 ) and statistical significance (p) of the change of receptive language disorders with Theraplay (Evaluation of the degree of symptoms using CASCAP-D, Doepfner et al., 1999) Sub-samples of toddler and preschool children with receptive language disorder Change of symptoms N M t1 M t6 s t6 significance prob. N= 52 Toddler and preschool children, Controlled Longitudinal Study (CLS) = degree of symptoms severity on average 52 3.12 1.55 0.9p<.0001 N=193 Toddler and preschool children, Multi-Center Study (MCS) Scale: 4 = severe degree of symptoms 73 4.00 2.42 0.9p<.0001 3 = moderate degree of symptoms 68 3.00 1.97 0.7p<.0001 2 = mild degree of symptoms 52 2.00 1.46 0.5p<.0001 = degree of symptoms severity on average193 2.11 2.01 0.8p<.0001 N= 30 Clinically non-symptomatic toddler and preschooler, Control Group N (CGN) = degree of symptoms severity on average 301.00............0.0-

43. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 43 The effectiveness of Theraplay on receptive language disordered toddler and preschool children with oppositional defiant behavior

44. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 44 What is oppositional defiant behavior? Example case in point: Bastian The child provokes arguments. Frequently saying NO, irrespective of being useful - or not. Frequently ignoring rules or instructions of adults. Frequently fighting with adults and with other children. Exceptionally frequent and severe tantrums. Frequently shifting own failings onto other children. Frequently feeling bothered by others. Frequently being mad at and filled with wrath against others. Frequently being spiteful and vindictive toward others. The child punches, kicks, or bites adults and other children.

45. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 45 The effectiveness of Theraplay on relevant symptoms in social interaction of oppositional defiant, receptive language disordered children The effectiveness of Theraplay on symptoms such as... the childs oppositional defiant behavior the childs non-cooperative behavior the childs attention deficit, and the childs receptive language disorder. Comparing the treated receptive language disordered toddler and preschool children with matched clinically non-symptomatic, normal control children (CG-N).

46. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 46 Sub-samples of children with both oppositional defiant and receptive language disorders MCS: N=109 oppositional defiant, language disordered children Mean: children with receptive language disorder N= 54 oppositional defiant, language disordered children with severe marked symptoms N= 38 oppositional defiant, language disordered children with moderate marked symptoms N= 26 oppositional defiant, language disordered children with mild marked symptoms CLS: N= 19 oppositional defiant, language disordered children Mean: children with receptive language disorder CGN: N= 30 clinically non-symptomatic, normal control sample matched in age and sex

47. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 47 The effectiveness of Theraplay on oppositional defiant interactive behavior of oppositional defiant, receptive language disordered children MCS: N = 109 receptive language disordered, oppositional defiant children CLS: N = 19 receptive language disordered, oppositional defiant children CGN: N = 30 clinically non-symptomatic children of same age and sex ( )

48. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 48 The effectiveness of Theraplay on non-cooperative behavior of oppositional defiant, receptive language disordered children MCS: N = 109 receptive language disordered, oppositional defiant children CLS: N = 19 receptive language disordered, oppositional defiant children CGN: N = 30 clinically non-symptomatic children of same age and sex ( )

49. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 49 The effectiveness of Theraplay on attention deficit of oppositional defiant, receptive language disordered children MCS: N = 109 receptive language disordered, oppositional defiant children CLS: N = 19 receptive language disordered, oppositional defiant children CGN: N = 30 clinically non-symptomatic children of same age and sex ( )

50. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 50 The effectiveness of Theraplay on receptive language disorder of oppositional defiant, receptive language disordered children MCS: N = 109 receptive language disordered, oppositional defiant children CLS: N = 19 receptive language disordered, oppositional defiant children CGN: N = 30 clinically non-symptomatic children of same age and sex ( )

51. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 51 Statistical significance of the symptom reduction after Theraplay on oppositional defiant, receptive language disordered children M=Mean using CASCAP-D, =change of symptom, sd=standard deviation 4-grade scale: 4= severe..., 3=moderate..., 2=mild marked; 1=clinically non-symptomatic symptoms CLS: N=19 oppositional defiant, receptive language disordered toddler and preschool children MCS: N=109 oppositional defiant, receptive language disordered toddler and preschool children M t1 M t6 sd t6 Significance prob. M t1 M t6 sd t6 Significance prob. oppositional defiant behavior 3.2 1.4 0.5p<.0001 3.2 1.4 0.8p<.0001 non-cooperative behavior 3.1 1.7 0.9p<.0001 3.0 1.5 1.0p<.0001 attention deficit 2.9 1.9 1.0p<.0025 3.1 2.0 0.7p<.0001 receptive langu- age disordered 2.9 2.1 0.8p<.0010 3.0 2,0 0.8p<.0001

52. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 52 Duration of the Theraplay treatment of oppositional defiant, receptive language disordered children Number of therapeutic 30-minute sessions Mean number of sessions required to achieve the therapeutic aim

53. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 53 Improvement of the childs verbal comprehension Research instrument: Pizzamiglio verbal comprehension-test (see B. Zollinger, CH) Repeated testing of the childs verbal comprehension –at the beginning of the waiting time (t 0 ) –at the beginning of the Theraplay therapy (t 1 ) –at the end of the Theraplay therapy (t 6 ) –two years after the end of the Theraplay therapy (t 7 ) (only investigated in the controlled longitudinal study CLS)

54. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 54 Improvement of the childs verbal comprehension of oppositional defiant, receptive language disordered children Research instrument: Pizzamiglio verbal comprehension test (see B. Zollinger) Mean

55. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 55 The effectiveness of Theraplay on receptive language disordered toddler and preschool children demonstrating shy interactive behavior

56. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 56 Shy behavior in situations of social interaction Outlining the term shy based on CASCAP-D (Doepfner et al., 1999) Obviously the child feels very insecure and unwell in many situations. The child speaks – if at all – generally weakly, faltering, turning red, in short: is shy. The child avoids eye contact in social interaction. The child avoids almost any contact with peers. In most situations the child is unable to maintain his or her rights in the presence of peer demands. Shyness is not a clinically classified disorder, but is frequently the beginning of later learning disorders.

57. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 57 The effectiveness of Theraplay on relevant symptoms in social interaction of shy, receptive language disordered toddler- and preschool children The effectiveness of Theraplay on symptoms such as... the childs oppositional defiant behavior the childs non-cooperative behavior the childs attention deficit, and the childs receptive language disorder. Comparing the treated receptive language disordered toddler and preschool children with matched clinically non-symptomatic, normal control children (CG-N).

58. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 58 Sub-samples of shy, receptive language disordered children MCS: N= 99 shy, language disordered children Mean: children with receptive language disorder N= 33 shy, language disordered children with severe marked symptoms N= 34 shy, language disordered children with moderate marked symptoms N= 32 shy, language disordered children with mild marked symptoms CLS: N= 19 shy, language disordered children Mean: children with receptive language disorder CGN: N= 30 clinically non-symptomatic, normal control sample matched in age and sex

59. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 59 The effectiveness of Theraplay on the interactive behavior of shy, receptive language disordered children MCS: N = 109 receptive language disordered, shy children CLS: N = 19 receptive language disordered, shy children CGN: N = 30 clinically non-symptomatic control children of same age and sex ( )

60. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 60 The effectiveness of Theraplay on non-cooperative behavior of shy, receptive language disordered children MCS: N = 109 receptive language disordered, shy children CLS: N = 19 receptive language disordered, shy children CGN: N = 30 clinically non-symptomatic control children of same age and sex ( )

61. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 61 The effectiveness of Theraplay on inattentive behavior of shy, receptive language disordered children MCS: N = 109 receptive language disordered, shy children CLS: N = 19 receptive language disordered, shy children CGN: N = 30 clinically non-symptomatic control children of same age and sex ( )

62. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 62 The effectiveness of Theraplay on receptive language disorders of shy, receptive language disordered children MCS: N = 109 receptive language disordered, shy children CLS: N = 19 receptive language disordered, shy children CGN: N = 30 clinically non-symptomatic control children of same age and sex ( )

63. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 63 Statistical significance of the symptom reduction after Theraplay with shy, receptive language disordered children M=Mean using CASCAP-D, =change of symptom, s=standard deviation 4-grade scale: 4= severe..., 3=moderate..., 2=mild marked; 1=clinically non-symptomatic symptoms CLS: N=19 oppositional defiant, receptive language disordered toddler and preschool children MCS: N=109 oppositional defiant, receptive language disordered toddler and preschool children M t1 M t6 sd t6 Significance prob. M t1 M t6 sd t6 Significance prob. shy 2,5 1.1 0.3p=.0025 3.0 1.3 0.6p<.0001 non-cooperative 2.0 1.4 0.6p=.0051 2.3 1.3 0.6p<.0001 inattentive 2.4 1.9 0.7p=.0099 2.8 1.8 0.7p<.0001 receptive language disordered 3.0 2.2 0.9p=.0013 3.1 1.9 0.7p<.0001

64. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 64 Duration of Theraplay treatment of initially shy, receptive language disordered children Number of therapeutic 30-minute sessions Mean number of sessions required to achieve the therapeutic aim

65. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 65 Improvement of the childs verbal comprehension Research instrument: Pizzamiglio verbal comprehension-test (see B. Zollinger, CH) Repeated testing of the childs verbal comprehension –at the beginning of the waiting time (t 0 ) –at the beginning of the Theraplay therapy (t 1 ) –at the end of the Theraplay therapy (t 6 ) –two years after the end of the Theraplay therapy (t 7 ) (only investigated in the controlled longitudinal study CLS)

66. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 66 Improvement of the childs verbal comprehension of shy, receptive language disordered children Research instrument: Pizzamiglio verbal comprehension test (see B. Zollinger) Mean

67. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 67 The effectiveness of Theraplay on receptive language disordered toddler and preschool children with an autistic-like lack of social mutuality

68. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 68 Autistic-like lack of social mutuality in situations of social interaction Outlining the term autistic-like lack of social mutuality based on CASCAP-D (Doepfner et al., 1999) Lack of social mutuality is found particularly often in autistic children. Frequently such children are unable to maintain eye contact and to use facial expression, gestures and body language in situations of social interaction. Such children are nearly unable to establish an appropriate mutual contact with others in situations of social interaction. Such children have nearly no contact with peers.

69. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 69 The effectiveness of Theraplay on operationally defined symptoms of receptive language disordered children with an autistic-like lack of social mutuality The effectiveness of Theraplay on symptoms such as... the childs autistic-like lack of social mutuality the childs playing disorder the childs non-cooperative behavior the childs attention deficit, and the childs receptive language disorder. Comparing the treated receptive language disordered toddler and preschool children with matched clinically non-symptomatic, normal control children (CG-N).

70. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 70 Sub-samples of receptive language disordered children with an autistic-like lack of social mutuality MCS: N=45 language disordered children lacking social mutuality Mean: children with receptive language disorder N=12 language disordered children lacking social mutuality with severe marked symptoms N=19 language disordered children lacking social mutuality with moderate marked symptoms N=14 language disordered children lacking social mutuality with mild marked symptoms CLS: N=14 language disordered children lacking social mutuality Mean: children with receptive language disorder CGN: N=30 clinically non-symptomatic, normal control sample matched in age and sex

71. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 71 The effectiveness of Theraplay on an autistic-like lack of social mutuality of receptive language disordered children lacking social mutuality MCS: N = 45 receptive language disordered children lacking social mutuality CLS: N = 14 receptive language disordered children lacking social mutuality CGN: N = 30 clinically non-symptomatic children matched in age and sex ( )

72. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 72 The effectiveness of Theraplay on playing disorder of receptive language disordered children lacking social mutuality MCS: N = 45 receptive language disordered children lacking social mutuality CLS: N = 14 receptive language disordered children lacking social mutuality CGN: N = 30 clinically non-symptomatic children matched in age and sex ( )

73. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 73 The effectiveness of Theraplay on non-cooperative behavior of receptive language disordered children lacking social mutuality MCS: N = 45 receptive language disordered children lacking social mutuality CLS: N = 14 receptive language disordered children lacking social mutuality CGN: N = 30 clinically non-symptomatic children matched in age and sex ( )

74. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 74 The effectiveness of Theraplay on attention deficit of receptive language disordered children lacking social mutuality MCS: N = 45 receptive language disordered children lacking social mutuality CLS: N = 14 receptive language disordered children lacking social mutuality CGN: N = 30 clinically non-symptomatic children matched in age and sex ( )

75. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 75 The effectiveness of Theraplay on receptive language disorder of receptive language disordered children lacking social mutuality MCS: N = 45 receptive language disordered children lacking social mutuality CLS: N = 14 receptive language disordered children lacking social mutuality CGN: N = 30 clinically non-symptomatic children matched in age and sex ( )

76. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 76 Statistical significance of the symptom reduction after Theraplay on receptive language disordered children lacking social mutuality M=Mean using CASCAP-D, =change of symptom, s=standard deviation 4-grade scale: 4= severe..., 3=moderate..., 2=mild marked; 1=clinically non-symptomatic symptoms CLS: N=14 receptive language disordered toddler and preschool children with an autistic-like lack of social mutuality MCS: N=45 receptive language disordered toddler and preschool children with an autistic-like lack of social mutuality M t1 M t6 sd t6 Significance prob. M t1 M t6 sd t6 Significance prob. an autistic-like lack of social mutuality 3.1 2.1 1.0p=.0013 3.0 1.9 0.9p<.0001 playing disorder 3.1 1.9 0.9p<.0001 2.9 1.8 0.9p<.0001 non-cooperativeness 3.5 1.8 0.7p<.0001 2.8 1.7 0.7p<.0001 attention deficit 3.5 2.6 1.1p=.0104 3.1 2.0 0.9p<.0001 receptive language disorder 3.8 2.9 0.7p=.0002 3.5 2.4 0.9p<.0001

77. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 77 Duration of Theraplay treatment of receptive language disordered children diagnosed with an autistic-like lack of social mutuality Number of therapeutic 30-minute sessions Mean number of sessions required to achieve the therapeutic aim

78. Copyright 2005 by Theraplay Institut The Effectiveness of Theraplay on Receptive Language Disorders 78 Theraplay Institut Ulrike Franke und Herbert Wettig KG Obere Burghalde 42, D-71229 Leonberg www.theraplay-institut.org Questions about Theraplay treatment Ulrike Franke, RPT-S, CTT-T, SLP Mozartstr. 1, D-68723 Oftersheim (Germany) Phone ++49-6202-54051 Fax ++49-6202-54958 Franke.Theraplay@t-online.de Ulrike.Franke@theraplay-institut.de www.theraplay.de www.theraplay-institut.de Questions about Theraplay research Herbert H.G. Wettig, Diplompsychologe Obere Burghalde 42, D-71229 Leonberg (Germany) Phone ++49-7152-27062 Fax ++49-7152-22602 Herbert.Wettig@t-online.de Herbert.Wettig@theraplay-institut.de www.theraplay-institut.de Theraplay is legally protected by Wz. 39518465 and The Theraplay Institute, Wilmette IL Franke.Theraplay@t-online.deUlrike.Franke@theraplay-institut.de www.theraplay.dewww.theraplay-institut.de Herbert.Wettig@t-online.deHerbert.Wettig@theraplay-institut.de www.theraplay-institut.de