1. Herbert H.G. Wettig & Ulrike Franke Evaluation of the Effectiveness of Theraplay on Attention Deficit Disorder (ADD) 2 studies on the Effectiveness of Theraplay on toddlers and preschool children with dual diagnoses of receptive language disorder and oppositional defiant or shy interaction behaviour or an autistic-like lack of social mutuality in interaction. January 2004

2. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 2 Overview Symptoms of Inattentiveness (Attention Deficit) Evaluation of the Effectiveness of Theraplay on ADD –Total samples of both studies CLS and MCS –Selected samples of the inattentive children Results of two Research Studies in Germany –Degree of impairment of the symptoms of inattentiveness –Reduction of the symptoms and the lasting effect of the reduced symptoms of the inattentive children on inattentive, oppositional defiant children on inattentive, shy children on inattentive children with an an autistic-like lack of social mutuality –Duration of Therapy in number of necessary sessions

3. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 3 Symptoms of Inattentiveness Reference: Knölker, Mattejatt, Schulte-Markwort (2000), Remschmidt (2000) Inattentive Children Show Pathological Symptoms… –for at least 6 months –to such a degree, that is does not coincide with the age and the developmental status of the child, –and they show inattentiveness in situations which are inadequate. Typical Symptoms of Inattentiveness are: –The child is constantly distracted by external stimuli, –he or she is not unable to concentrate for longer periods of time, –he or she is inattentive towards details: has a lack of precision, –the child acts like he or she is not listening to what is being said, –the child defies instructions, –he or she is unable to comprehend instructions, –the child avoids activities that call for endurance, –and frequently loses important objects.

4. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 4 Symptoms of Inattentiveness in the Therapeutic Interaction Reference: Doepfner et al, 1999 Clinical Assessment Scale for Child and Adolescent Psychopathology (CASCAP-D) The researcher/therapist observes, –that the child is often distracted during testing, e.g. by irrelevant stimuli (sounds, objects, etc.), –e.g. that the child looks out of the window or to someone else, –e.g. that the child always needs to be brought back to the situation, –e.g. that the child always interrupts his or her exercises. The primary caretaker describes, –e.g. that the child is easily interrupted, –e.g. that the child is often imprecise, –e.g. that the child often loses things, –e.g. that the child easily forgets things that were said, –e.g. that the child is easily distracted when playing, –e.g. that the child is unable to concentrate.

5. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 5 Total Sample of both research studies CLS and MCS CLS Total Sample of Controlled Longitudinal Study N= 60 clinically conspicuous toddlers and preschool children with dual diagnoses of developmental language disorder and social interaction disorders. N= 29 of these children 2 years after end of the therapy. N= 30 clinically not symptomatic toddlers and preschool children of the same age and gender (matched). MCS Total Sample of the Multi-Center Study N=251 clinically conspicuous toddlers and preschool children with dual diagnoses of communication disorders and social interaction disorders.

6. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 6 Selected Samples with Attention Deficit Disorder (ADD) CLS N= 50 toddlers and preschool children in total with Attention Deficit Disorder (ADD) –N= 21 inattentive, oppositional defiant children N= 18 inattentive, shy children N= 13 inattentive children with an autistic-like lack of social mutuality –N= 24 of these 50 children 2 years after treatment with Theraplay N= 30 clinically not symptomatic toddler and preschool children of the same age and gender (matched) MCS N=183 toddlers and preschool children in total with Attention Deficit Disorder (ADD) –N=105 inattentive, oppositional defiant children N= 86 inattentive, shy children N= 40 inattentive children with an autistic-like lack of social mutuality

7. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 7 Socio-demographic Structure (1) CLS- and MCS-Samples of toddlers and preschool children with attention deficit disorder First contact with primary caretaker/diagnostic of children N=50 or N=183 inattentive children with social interaction disorder = 100% CLS: Mother’s Family Status 90% married mothers no unmarried living together 8% separated mothers 2% single mothers Child’s Family Status 90% legitimate children 10% illegitimate, physical child no adopted/foster children Child’s Upbringing 85% both parents involved 15% single parent involved MCS: Mother’s Family Status 66% married mothers 8% unmarried living together 10% separated mothers 14% single mothers Child’s Family Status 79% legitimate children 17% illegitimate, physical child 4% adopted-/foster children Child’s Upbringing 76% both parents involved 24% single parent involved

8. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 8 Socio-demographic Structure (2) CLS- and MCS-Sample of toddlers and preschool children with attention deficit disorder First contact with primary caretaker/diagnostic of children N=50 or N=183 inattentive children with social interaction disorder = 100% CLS: Language relevant Criteria 94% Country of birth is Germany 6% other Country of birth 90% mother tongue is German 10% other mother tongue 81% one language Upbringing 19% bilingual Upbringing socially relevant Criteria 73% in Kindergarten 27% not yet in Kindergarten MCS: Language relevant Criteria 88% Country of birth is Germany 12% other Country of birth 93% mother tongue is German 7% other mother tongue 85% one language Upbringing 15% bilingual Upbringing socially relevant Criteria 76% in Kindergarten 24% not yet in Kindergarten

9. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 9 Average Age of Children toddlers and preschool children with dual diagnoses of inattentiveness and other social interaction disorders (years; months) CLS: average age in years; months. 4;03 N=50 inattentive children total of these: 4;03 N=21 inattentive, oppositional defiant children 4;01 N=18 inattentive, shy children 4;00 N=13 inattentive children with autistic-like lack of social mutuality 4;05 N=30 clinically not symptomatic children (control group) MCS: average age in years; months. 4;06 N=183 inattentive children total of these: 4;06 N=105 inattentive, oppositional defiant children 4;04 N= 86 inattentive, shy children 4;02 N= 40 inattentive children with autistic-like lack of social mutuality 4;05 N= 30 clinically not symptomatic children (control group)

10. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 10 Gender of children toddlers and preschool children with dual diagnoses of inattentiveness and other social interaction disorders CLS: % Boys; Girls (general ratio 2.8 : 1) 74%;26% N=50 inattentive children in total Sub samples of these: 76%;24% N=21 inattentive, oppositional defiant children 67%;33% N=18 inattentive, shy children 85%;15% N=13 inattentive children with an autistic-like lack of social mutuality 70%;30% N=30 clinically not symptomatic children (controls) MCS: % Boys; Girls (general ratio 2.7 : 1) 73%;27% N=183 inattentive children in total Sub samples of these: 74%;26% N=105 inattentive, oppositional defiant children 72%;28% N= 86 inattentive, shy children 70%;30% N= 40 inattentive children with an autistic-like lack of social mutuality 70%;30% N= 30 clinically not symptomatic children (controls)

11. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 11 Results The Effectiveness of Theraplay on toddlers and preschool children with dual diagnoses of attention deficit disorder and (1) oppositional defiant interaction behaviour (2) shy interaction behaviour (3) an autistic-like lack of social mutuality.

12. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 12 Inattentiveness (Attention Deficit) is a symptom combined with various disorders Attention Deficit Disorder... with Hyperactivity and Impulsiveness (ADHD): –with Hyperactivity as well as physical restlessness, –with Impulsiveness as well as a lack of impulsive control.... without Hyperactivity and Impulsiveness (ADD): –with oppositional defiant interaction behaviour, –with shy social interaction behaviour, –with affective disorders, e.g. depression or anxiety, –with pervasive developmental disorder, e.g. autism –with receptive language disorder, etc.

13. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 13 Degree of Inattentiveness varies depending on social interaction behaviour Degree of impairment: 1=not symptomatic 2=slightly... 3=impaired... 4=strongly impaired

14. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 14 Degree of Inattentiveness varies depending on social interaction behaviour Degree of impairment: 1=not symptomatic 2=slightly... 3=impaired... 4=strongly impaired

15. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 15 Degree of Uncooperative Behaviour varies depending on social interaction behaviour Degree of impairment: 1=not symptomatic 2=slightly... 3=impaired... 4=strongly impaired

16. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 16 Degree of Uncooperative Behaviour varies depending on social interaction behaviour Degree of impairment: 1=not symptomatic 2=slightly... 3=impaired... 4=strongly impaired

17. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 17 The Effectiveness of Theraplay (part 1) on inattentive toddlers and preschool children, with oppositional defiant interaction behaviour.

18. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 18 Characteristics of Oppositional Defiance in the Therapeutic Interaction Reference: Doepfner et al, 1999 Clinical Assessment Scale for Child and Adolescent Psychopathology (CASCAP-D) The child constantly refuses to do what was requested by the therapist. The child constantly ignores therapist’s instructions. The child often talks back to the therapist. The child does not obey rules and regulations. The child breaks rules often. The child refuses to participate, but without being dominant or aggressive in any way. Differential Diagnosis: aggression, dominance, irritability.

19. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 19 Reduction of Oppositional Defiant Behaviour of inattentive children Assessment methods: CASCAP-D (Doepfner et al., 1999), survey time period: start and end of therapy

20. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 20 Reduction of Unwillingness to Cooperate of inattentive children with oppositional defiant behaviour Assessment methods: CASCAP-D (Doepfner et al., 1999), survey time period: start and end of therapy

21. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 21 Reduction of Inattentiveness of inattentive children with oppositional defiant behaviour Assessment methods: CASCAP-D (Doepfner et al., 1999), survey time period: start and end of therapy

22. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 22 Improvement of Language Comprehension of inattentive children with oppositional defiant behaviour Assessment methods: CASCAP-D (Doepfner et al., 1999), survey time period: start and end of therapy

23. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 23 Clinical and Statistical Significance Reduction of symptoms after treatment with Theraplay M=Means based on CASCAP-D,  =change, s=Standard deviation 4-point scale: 1=not symptomatic; Symptom: 2=slightly...,3=impaired, 4= strongly impaired symptom Symptoms CLS N=21 oppositional defiant, inattentive children MCS N=105 oppositional defiant, inattentive children TT-B  TT-E M  M sprob.> F TT-B  TT-E M  M sprob.> F oppositional defiant 3.1  1.3 0.80.0001 3.3  1.4 0.80.0001 uncooperative 3.1  1.6 1.10.0001 3.0  1.5 1.00.0001 inattentive 3.1  2.0 0.90.0001 3.3  2.0 0.80.0001 receptive language disorder 2.6  2.0 1.10.0244 2.7  1.9 0.90.0001

24. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 24 The Lasting Effect of the Treatment with Theraplay on originally oppositional defiant, inattentive children 2 years after treatment with Theraplay A comparison with the ‘norm’ of clinically not symptomatic children

25. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 25 Lasting Effect of Reduced Oppositional Defiance of originally oppositional defiant, inattentive children Assessment methods: CASCAP-D (Doepfner et al., 1999), survey time period: start and end of therapy, 2 years based after treatment with Theraplay Means

26. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 26 Lasting Effect of Reduced Uncooperative Behavior of originally oppositional defiant, inattentive children Assessment methods: CASCAP-D (Doepfner et al., 1999) survey time period: start and end of therapy, 2 years based after treatment with Theraplay Means

27. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 27 Lasting Effect of Reduced Inattentiveness of originally oppositional defiant, inattentive children Assessment methods: CASCAP-D (Doepfner et al., 1999) survey time period: start and end of therapy, 2 years based on treatment with Theraplay Means

28. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 28 Duration of Therapy of originally oppositional defiant, inattentive children (Number of 30-minute therapeutic sessions) Means

29. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 29 The Effectiveness of Theraplay (part 2) on inattentive toddlers and preschool children, with shy interaction behaviour.

30. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 30 Characteristics of Shyness in the Therapeutic Interaction Reference: Doepfner et al, 1999 Clinical Assessment Scale for Child and Adolescent Psychopathology (CASCAP-D) The child seems to be very insecure, and seems to be uncomfortable during diagnosis or therapy. The child does not make eye-contact with the therapist. The child always answers in a quiet, stuttering voice. The primary caretaker (e.g. mother) describes: –The child avoids certain social situations. –The child is shy and very insecure. –The child avoids contact to peers. –The child is unable to assert himself in situations. –The child is unable to defend itself from peer’s demands and cannot assert its own demands or wishes.

31. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 31 Reduction of Shy Interaction Behaviour of shy, inattentive children Assessment methods: CASCAP-D (Doepfner et al., 1999), survey time period: start and end of therapy

32. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 32 Reduction of Unwillingness to Cooperate of shy, inattentive children Assessment methods: CASCAP-D (Doepfner et al., 1999), survey time period: start and end of therapy

33. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 33 Reduction of Inattentiveness of shy, inattentive children Assessment methods: CASCAP-D (Doepfner et al., 1999), survey time period: start and end of therapy

34. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 34 Improvement of Language Comprehension of shy, inattentive children Assessment methods: CASCAP-D (Doepfner et al., 1999), survey time period: start and end of therapy

35. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 35 Clinical and Statistical Significance Reduction of symptoms after treatment with Theraplay M=Means based on CASCAP-D,  =change, s=Standard deviation 4-point scale: 1=not symptomatic; Symptom: 2=slightly...,3=impaired, 4= strongly impaired Symptoms CLS N=18 shy, inattentive children MCS N=86 shy, inattentive children TT-B  TT-E M  M sprob.> F TT-B  TT-E M  M sprob.> F shy 2.3  1.2 0.70.0001 2.8  1.2 0.80.0001 uncooperative 1.9  1.3 0.8< 0.01 2.4  1.3 1.00.0001 inattentive 2.7  2.1 0.7< 0.01 3.1  1.9 0.90.0001 receptive language disorder 2.8  2.3 0.9< 0.03 2.6  1.7 1.00.0001

36. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 36 Duration of Therapy of originally shy, inattentive children (Number of 30-minutes therapeutic sessions) Means

37. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 37 The Lasting Effect of the Treatment with Theraplay on originally shy, inattentive children 2 years after treatment with Theraplay A Comparison with the ‘norm‘ of clinically not symptomatic children

38. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 38 The Lasting Effect of Reduced Shyness of originally shy, inattentive children Assessment methods: CASCAP-D (Doepfner et al., 1999), survey time period: start and end of therapy, 2 years based after treatment with Theraplay Means

39. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 39 The Lasting Effect of Reduced Uncooperative Behaviour of originally shy, inattentive children Assessment methods: CASCAP-D (Doepfner et al., 1999) survey time period: start and end of therapy, 2 years based after treatment with Theraplay Means

40. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 40 The Lasting Effect of Reduced Inattentiveness of originally shy, inattentive children Assessment methods: CASCAP-D (Doepfner et al., 1999) survey time period: start and end of therapy, 2 years based on treatment with Theraplay Means

41. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 41 The Effectiveness of Theraplay (part 3) on inattentive toddlers and preschool children, with an an autistic-like lack of social mutuality CLS-Sample: 9 of 13 inattentive toddlers and preschool children with an autistic-like lack of social mutuality are diagnosed with “early childhood autism“

42. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 42 A Lack of Social Mutuality in the therapeutic interaction Reference: Doepfner et al, 1999 Clinical Assessment Scale for Child and Adolescent Psychopathology (CASCAP-D) It is impossible for the therapist to create an adequate social interaction with the child within a therapy setting. The child avoids eye-contact with the therapist. The child does not show any reaction to others. Eye-contact, mimic, gesture and body language are seldom shown in social interaction. The emotional reaction towards others is limited. The child is unable to modulate his or her own behaviour in social situations. The child does not develop relationships with peers that have the same interests and activities. These characteristics are shown in all situations.

43. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 43 The Reduction of the Lack of Social Mutuality of originally autistic-like acting, inattentive children Assessment methods: CASCAP-D (Doepfner et al., 1999), survey time period: start and end of therapy

44. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 44 The Reduction of Unwillingness to Cooperate of originally autistic-like acting, inattentive children Assessment methods: CASCAP-D (Doepfner et al., 1999), survey time period: start and end of therapy

45. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 45 The Reduction of Inattentiveness of originally autistic-like acting, inattentive children Assessment methods: CASCAP-D (Doepfner et al., 1999), survey time period: start and end of therapy

46. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 46 The Improvement of Language Comprehension of originally autistic-like acting, inattentive children Assessment methods: CASCAP-D (Doepfner et al., 1999), survey time period: start and end of therapy

47. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 47 Clinical and Statistical Significance Reduction of symptoms after treatment with Theraplay M=Means based on CASCAP-D,  =change, s=Standard deviation 4-point scale: 1=not symptomatic; Symptom: 2=slightly...,3=impaired, 4= strongly impaired Symptoms CLS N=13 inattentive children with lack an social Mutuality MCS N=40 inattentive children with lack an social Mutuality TT-B  TT-E M  M sprob.> F TT-B  TT-E M  M sprob.> F lack of social mutuality 3.2  2.2 0.8<0.002 3.1  1.9 0.70.0001 uncooperative 3.5  1.8 0.90.0001 3.1  1.6 1.00.0001 inattentive 3.7  2.8 1.00.0076 3.6  2.2 0.90.0001 receptive language disorder 3.9  3.0 0.70.0008 3.2  1.1 1.30.0001

48. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 48 Duration of Therapy of inattentive children with a lack of social mutuality (Number of 30-minute therapeutic sessions without preparation and follow-up) Means

49. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 49 The Lasting Effect of the Treatment with Theraplay on originally inattentive children with an autistic-like lack of social mutuality 2 years after treatment with Theraplay A Comparison with the ‘norm‘ of clinically not symptomatic children

50. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 50 The Lasting Effect of the Reduced Lack of Social Mutuality of originally inattentive children with an autistic-like lack of social mutuality Assessment methods: CASCAP-D (Doepfner et al., 1999), survey time period: start and end of therapy, 2 years based after treatment with Theraplay Means

51. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 51 The Lasting Effect of the Reduced Uncooperative Behaviour of originally inattentive children with an autistic-like lack of social mutuality Assessment methods: CASCAP-D (Doepfner et al., 1999) survey time period: start and end of therapy, 2 years based after treatment with Theraplay Means

52. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 52 The Lasting Effect of Reduced Inattentiveness of originally inattentive children with an autistic-like lack of social mutuality Assessment methods: CASCAP-D (Doepfner et al., 1999) survey time period: start and end of therapy, 2 years based on treatment with Theraplay Means

53. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 53 The Lasting Effect of Improvement of Language Comprehension of originally inattentive children with an autistic-like lack of social mutuality Assessment methods: CASCAP-D (Doepfner et al., 1999), survey time period: start and end of therapy

54. Copyright 2004 Theraplay Insitut The Effectiveness of Theraplay on Attention Deficit Disorders 54 Theraplay Institut D-71229 Leonberg (Germany) Obere Burghalde 42 Questions about Theraplay: Ulrike Franke speech-language pathologist (SLP) reg. Play Therapist and Supervisor (RPT-S/APT) certified Theraplay Therapist and Trainer (CTT-T/TTI) Phone: +49-(0)6202-54051, Office: +49-(0)6221-88-2055, Fax: +49-(0)6202-54958 e-Mail: Franke.Theraplay@t-online.de Questions about the evaluation research: Herbert H.G. Wettig Clinical Psychologist Phone: +49-(0)7152-27062 Fax: +49-(0)7152-22602 e-Mail: Herbert.Wettig@t-online.de ® 1996 Theraplay is legally protected by 39518465 and 39518466Franke.Theraplay@t-online.deHerbert.Wettig@t-online.de