Scholarly Analysis

Child-Centered Play Therapy With Children Affected by Adverse Childhood Experiences: A Single-Case Design

Sara C. Haas Northern Arizona University

Dee C. Ray University of North Texas

We conducted single-case research with 2 participants to explore the influence of child-centered play therapy (CCPT) on children who had 4 or more adverse childhood experiences (ACEs) and analyzed data collected from the Strength and Difficulties Questionnaire on a weekly basis and the Trauma Symptoms Checklist for Young Children at pre- and posttest. Both participants demonstrated significant improvement in total difficulties and prosocial behaviors, revealing potential therapeutic benefits for the use of CCPT with children who have 4 or more ACEs. The discussion of study results includes implications for practice, suggestions for future research, and limitations.

Keywords: child-centered play therapy, adverse childhood experiences, single-case design

Adverse childhood experiences (ACEs) can be defined as traumatic and stressful experi- ences occurring in childhood (Felitti et al., 1998). Categories for ACEs include physical abuse, sexual abuse, emotional abuse, emo- tional neglect, physical neglect, mental illness, substance abuse, separation/divorce, domestic violence, incarceration, and living in foster care (Felitti et al., 1998; Wade et al., 2016). The commonality between all of the categories is a self-report of feeling maltreated or living in household dysfunction during childhood. The Centers for Disease Control and Prevention (CDC, 2019) noted that over 50% of adults in the United States have reported experiencing at least one ACE, and 15% have reported experi- encing four or more ACEs. Adverse experi- ences occurring in childhood have been found

to have a profound influence on the health and well-being of children and adults (Clarkson Freeman, 2014; Felitti et al., 1998; Wade et al., 2016). The resulting trauma that, over multiple events, leads to complex trauma is a common outcome and response to the experiencing of adverse experiences (Substance Abuse and Mental Health Services Administration [SAM- HSA], 2018). Although various mental health interventions have been proposed to address the symptoms resulting from ACEs and childhood trauma, there is still little evidence to support positive treatment outcomes for children who have experienced ACEs. Child-centered play therapy (CCPT) fosters connections and rela- tionships in a safe, therapeutic environment, lending to the potential of CCPT being an ef- fective intervention with children who have ex- perienced multiple ACEs.

Broad Spectrum of ACEs Outcomes

Adverse experiences occurring in childhood have been found to have a profound influence on the health and well-being of adults (Felitti et al., 1998; Wade et al., 2016). ACEs have long- term effects on physical and mental health, ad- dictive behaviors, criminal activities, and adult relationships. As a result of ACEs, adults may

This article was published Online First July 6, 2020. X Sara C. Haas, Department of Educational Psychology,

Northern Arizona University; X Dee C. Ray, Department of Counseling and Higher Education, University of North Texas.

Correspondence concerning this article should be ad- dressed to Sara C. Haas, Department of Educational Psy- chology, Northern Arizona University, 15451 North 28th Avenue, Phoenix, AZ 85053. E-mail: [email protected]

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International Journal of Play Therapy © 2020 Association for Play Therapy 2020, Vol. 29, No. 4, 223–236 ISSN: 1555-6824 http://dx.doi.org/10.1037/pla0000135

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have a higher risk for health symptoms that lead to death and a shortened life span, as well as fatigue and lack of energy that impact the per- ceived quality of life (Felitti et al., 1998). Sub- sequent mental health issues, such as posttrau- matic stress, depression, anxiety, hopelessness, stress, and even suicidal behavior, appear to be linked to a person’s ACEs. Generally, affective disorders, as well as depressive and anxiety disorders, in adulthood are likely to be corre- lated with adverse experiences in childhood (Spinhoven et al., 2010). Grasso, Dierkhising, Branson, Ford, and Lee (2016) found that if children had multiple types of ACEs during any time of childhood, early childhood, middle childhood, or adolescence, the participants were affected developmentally and had a persistent amount of stress into adolescence and adult- hood.

Additionally, ACEs appear to be linked to later substance abuse and criminal activity. Sub- stance abuse issues are highly correlated with an increased number of ACEs (Felitti et al., 1998), a consistent finding across cultures (Brockie, Dana-Sacco, Wallen, Wilcox, & Campbell, 2015; Giordano, Ohlsson, Kendler, Sundquist, & Sundquist, 2014). Regarding criminal activ- ity, researchers have linked juvenile offenders and an increased number of ACEs (Baglivio & Epps, 2016). Fox, Perez, Cass, Baglivio, and Epps (2015) found that the number of ACEs experienced by serious, violent, and chronic offenders was statistically significantly higher than the number of ACEs for offenders who had one violation, suggesting that the identification of ACEs could be one indicator in determining youth who are at a higher risk of becoming serious, violent, and chronic offenders.

ACEs Outcomes During Childhood

Although research has been conducted on the effects of ACEs in adulthood, there are substan- tially fewer studies exploring the effects of ACEs during childhood. Burke, Hellman, Scott, Weems, and Carrion (2011) found that children who experienced four or more ACEs had a significantly higher probability of having learn- ing and behavior problems. Utilizing the Na- tional Survey of Child and Adolescent Well- Being (NSCAW) and the Child Behavior Checklist (CBCL; Achenbach, 1991), Clarkson Freeman (2014) examined the prevalence and

relationship between ACEs and internalizing, externalizing, and total problems for 2,830 chil- dren 6 years of age and younger. Overall, chil- dren who had four or more ACEs were more likely to exhibit problematic behaviors than children who did not experience ACEs (Clark- son Freeman, 2014). Escueta, Whetten, Oster- mann, O’Donnell, and the Positive Outcomes for Orphans Research Team (2014) examined the psychosocial well-being and cognitive de- velopment of orphaned and abandoned children who experienced ACEs in five low-income countries. They found that exposure to poten- tially traumatic events was determined to be a predictor of emotional difficulties. Child re- search on ACEs reveals a dose– effect response whereby the more ACEs reported, the higher the number and intensity of negative outcomes (Grasso et al., 2016; Jimenez, Wade, Lin, Mor- row, & Reichman, 2016; Thurston, Bell, & Induni, 2018). Although research on ACEs while participants are still in childhood is lim- ited, there is evidence to suggest that children exhibit the deleterious consequences of ACEs during and immediately following adverse events.

The CCPT and ACE Connection

As children grow and develop, influences from caregivers have the potential to disconnect them from their natural organismic valuing pro- cess. Although the organismic valuing process still remains, children begin to rely more on external messages from caregivers and become less attuned to their organismic valuing process, placing greater emphasis on what others value (Turner, 2012). Children’s self-structure changes to integrate the way they view them- selves and their actual experiences (Wilkins, 2010). Children strive to be protected, nurtured, and cared for by others. Because of the need to be positively regarded by others, children rely on an external locus of control and create con- ditions of worth. Conditions of worth are mes- sages created to earn love or acceptance from others by conforming to demands, expectations, and positive evaluations from others (Wilkins, 2010). Children may begin to have beliefs of only being accepted when their conditions of worth are met. Children experience incongruity because they no longer take in all experiences through their organismic valuing process; in-

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stead, experiences are taken in through the filter of a rigid self-perception influenced by the val- ues of others (Wilkins, 2010).

Because of the nature of the conditions pro- vided to children who have experienced ACEs, they may develop extremely negative and abu- sive self-regard, which can become the focus of their self-concepts and influence their decisions and attitudes toward themselves (Power, 2012). Children who experience ongoing adverse and traumatic experiences likely live in a world of fear (Hawkins, 2014). Whereas typical self- structures are fluid and allow for new experi- ences to help shape the way children view ex- periences (Rogers, 1957), the self-structures of children who have ongoing adverse or traumatic experiences are rigid (Wilkins, 2010). The ri- gidity of self-structure occurs because their con- ditions of worth continue to contribute to their negative self-regard. Children’s understanding of the world and reality might be altered and viewed through a more negative lens. Ongoing confirmation of negativity serves the purpose of maintaining the rigidity of the self-structure. The utilization of negative behaviors ensures that others will treat them in ways matching their current self-concept (Clarkson Freeman, 2014).

Children who have experienced multiple or ongoing ACEs are likely to need experiences that contradict the traumatic experiences that have influenced their rigid self-structures. CCPT is an intervention that promotes the rela- tionship between therapist and child as the pri- mary healing agent in therapy (Landreth, 2012). Child-centered play therapists hold the belief that children innately have the capacity within them to work through and make sense of mal- adaptive behaviors when provided with the nec- essary environment (Landreth, 2012). CCPT therapists provide the core conditions of person- centered theory— congruence, empathic under- standing, and unconditional positive regard (UPR)—to create a therapeutic relationship with children (Landreth, 2012). As a child slowly perceives and integrates the therapist attitudinal conditions, the child is able to form a new self-structure. When counselors are free of expectations while unconditionally positively regarding clients, children are able to grow and develop (Rogers, 1957). Although the self- actualizing tendency may have been halted through adverse events, it is still a dynamic

force inside of a child. By experiencing UPR and empathic understanding, a child can begin to integrate new experiences and establish a more fluid self-structure (Ray, 2011). The flu- idity of self-structure will provide the child with the ability to accept more positive experiences without rejecting them fully. In essence, CCPT offers an alternative positive childhood experi- ence to counteract the negative impact of con- ditions and disrupted relationships experienced during adverse events. Additionally, CCPT in- volves the facilitation of parent consultation in order to address the environmental facilitation of relationships and stability for the child.

Although CCPT research has not been con- ducted on ACEs as a singular construct, histor- ical and recent research on CCPT supports the use of intervention with children with individ- ual ACEs. Intervention research has been con- ducted on the individual ACEs of sexual abuse, witnessing domestic violence, and refugee trau- ma. Kot, Landreth, and Giordano (1998) uti- lized intensive CCPT with children who wit- nessed domestic violence. The experimental group demonstrated a statistically significant in- crease in self-concept and a statistically signif- icant reduction of externalizing and total behav- iors. Scott, Burlingame, Starling, Porter, and Lilly (2003) conducted 7 to 13 CCPT sessions with 26 participants aged 3 to 9 years old who were sexually abused and found that whereas the child self-report results showed progress, the parent reports did not show significant changes. Scott et al. hypothesized that children began to feel different before external changes were observable by parents. Schottelkorb, Dou- mas, and Garcia (2012) compared the effective- ness of CCPT to trauma-focused cognitive– behavioral therapy (TF-CBT), finding that CCPT had a statistically significant impact with children who suffered from refugee trauma. CCPT research was also conducted with chil- dren living in poverty. Although poverty is not considered an ACE, Wade et al. (2016) demon- strated that living in poverty was correlated with experiencing ACEs. Bratton et al. (2013) exam- ined the effectiveness of CCPT with 54 children enrolled at a low-income preschool and found that the CCPT group had a statistically signifi- cant decrease of disruptive behaviors, aggres- sion, and attention problems. Bratton et al. dem- onstrated the effectiveness of using CCPT to reduce the problem behaviors of children in

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lower-socioeconomic-status preschools. CCPT has been shown to be effective with selected individual ACEs, lending to the hypothesis that CCPT may be effective with children who have experienced multiple ACEs.

Purpose of Study

The purpose of this study was to investigate the impact of CCPT on children who have ex- perienced four or more ACEs. Specifically, we examined the effect of CCPT on the child’s emotional symptoms, interpersonal relation- ships, and problem behaviors. A single-case design was implemented, and data were col- lected throughout baseline, intervention, and follow-up phases for two children participating in CCPT. The guiding research question for this study was as follows: What is the impact of CCPT on the emotional symptoms, conduct problems, hyperactivity and inattention, peer relationship problems, prosocial behavior, and posttraumatic stress of children who experi- enced four or more ACEs?

Method

Participants

Research participants included two children recruited from a university-based counseling clinic that serves community clients located in the southwestern United States. The clinic is an instructional and training-based clinic that serves clients across the life span. The majority of clients (60%) are children under the age of 12. Child clients served through the clinic typ- ically come from families of low socioeco- nomic status and low educational attainment. Participants met the following inclusion crite- ria: (a) between the ages of 4 and 9 years old, (b) score of 4 or higher on the Adverse Child- hood Experiences Checklist, and (c) not partic- ipating in other forms of counseling over the course of the study. Four participants were ini- tially identified for participation. However, two of the participants, who were also siblings, were dropped from the study because of home dis- ruption during the course of the study, resulting in the completion of the study by two partici- pants. The individual information for each par- ticipant is provided in the following sections.

Pseudonyms were used to maintain confidenti- ality.

Participant 1

Justin is an 8-year-old White American male who resides with his biological mother, sister, and maternal grandmother. Background infor- mation was reported by Justin’s mother. Justin qualified for the study because of his exposure to eight categories of ACEs: emotional abuse, emotional neglect, physical neglect, domestic violence, household substance abuse, household mental illness, parental separation, and incar- cerated household member.

Prior to the divorce between Justin’s mother and father, Justin’s mother reported that Justin witnessed the perpetration of domestic violence upon his mother by his father. Justin’s father was incarcerated multiple times for drugs and violence against Justin’s mother and her prop- erty. Justin’s father had a history of depression and was openly suicidal in Justin’s presence. Justin also verbalized negative thoughts about his self-worth and felt responsible for mediating between his parents. At intake for participation in the current study, Justin’s mother reported that Justin verbalized wanting to live with his father despite his fears and often blamed his mother for his father’s behavior. Justin’s mother reported that Justin had difficulty regulating emotions and cried and screamed at school. She was often asked to pick him up from school because of his difficulty.

Participant 2

Megan is a 9-year-old White American fe- male who resides with her biological father, stepmother, and multiple siblings who are step- siblings or half-biological siblings. Background information was reported by Megan’s father and stepmother. Megan qualified for the study be- cause of her exposure to eight categories of ACEs: sexual abuse, emotional neglect, physi- cal neglect, domestic violence, household sub- stance abuse, household mental illness, parental separation, and incarcerated household mem- ber.

Megan’s biological mother and father were separated when she was an infant. Her biolog- ical mother accused her father of sexually abus- ing Megan, resulting in invasive medical exam- inations. However, there were no findings that

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Megan’s biological father was physically abu- sive. Megan’s father and stepmother reported that as a young child, Megan witnessed her mother being physically abused by her mother’s boyfriend. During custodial visits with her mother, Megan was often unsupervised and found with dirty clothes and diapers when picked up by her father. Megan’s biological mother died from a drug overdose when Megan was 3 years old. At intake for the present study, Megan’s father reported that Megan frequently expressed low self-worth and a lack of belong- ing in her family.

Instruments

Adverse Childhood Experiences Checklist. The original Adverse Childhood Experiences (ACE) Checklist (Felitti et al., 1998) is a 10- item checklist that assesses adults for the past experiences of ACEs. The total number of ACEs checked provides participants with their ACE numbers. Felitti et al. (1998) introduced the original ACEs adult checklist, which in- cluded items related to physical abuse, sexual abuse, emotional abuse, emotional neglect, physical neglect, mental illness, substance abuse, separation/divorce, domestic violence, and incarceration. Wade et al. (2016) modified the adult checklist to incorporate extended ACEs, including witnessing violence, felt dis- crimination, lack of neighborhood safety, feel- ing bullied, and living in foster care. The orig- inal checklists were designed for adults to answer about their childhoods. For the purposes of the present study, the ACE Checklist was modified for language in order to use present- tense language for parents to complete items regarding their children. For example, the orig- inal ACE Checklist (Felitti et al., 1998) asked, “Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?” The question was rewritten to state, “Has your child lived with anyone who is/was a problem drinker or alcoholic or had a problem with street drugs or prescription drugs?” The ACE Check- list (Cronholm et al., 2015) included the origi- nal 10 ACEs (Felitti et al., 1998) and foster care as identified by Wade et al. (2016).

Strengths and Difficulties Questionnaire. The Strengths and Difficulties Questionnaire (SDQ; Goodman, 2001) is a 25-item assessment completed by parents/caregivers and used to

identify the behavioral problems and interper- sonal strengths of children 4 to 17 years of age. The SDQ Total Difficulties score is a composite of four subscales: Emotional Symptoms, Con- duct Problems, Hyperactivity and Attentional Difficulties, and Peer Relationship Problems. The Total Difficulties score can range from 0 to 40. An additional fifth subscale indicates Proso- cial Behavior. Higher Total Difficulties scores have been correlated to greater psychopathol- ogy (Goodman & Goodman, 2009). Goodman (2001) reported internal consistency reliability coefficients for the scales ranging from .41 to .87, with .82 for the total parent score. The reported mean test–retest reliability for the SDQ is r � .72, and the mean internal consistency is � � .71 (National Center for Child Traumatic Stress [NCTSN], 2018). For the current study, the SDQ total score was used as the weekly measurement of behaviors for the participants.

The Trauma Symptom Checklist for Young Children. The Trauma Symptoms Checklist for Young Children (TSCYC; Briere, 2005) is an assessment used to evaluate post- traumatic stress and consists of 90 questions and the following eight subscales: Anxiety, Depres- sion, Anger/Aggression, Posttraumatic Stress— Intrusion, Posttraumatic Stress—Avoidance, Posttraumatic Stress—Arousal, Dissociation, and Sexual Concerns. The subscales result in an overall Posttraumatic Stress score (Briere, 2005). Internal-consistency alphas were re- ported as ranging from .73 to .86. The test– retest reliability for the TSCYC correlation co- efficients ranged from .68 to .96, with a median of r � .88 (Briere, 2005). For the purposes of the current study, the TSCYC total score was used as a descriptive measurement of change from pre- to posttest across the duration of the study.

Procedure

Following approval by the University of North Texas Institutional Review Board (IRB), we examined the intake documentation of chil- dren ages 4 to 9 who presented to the clinic for services. Upon determination of the children having a strong probability of having experi- enced ACEs based on intake caretaker report, we contacted the caregivers to provide an over- view of the study and inquire about interest in participation. If parents indicated interest, we

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set up parent interviews in which we gained background information, gained consent to par- ticipate, and determined eligibility through the use of the ACE Checklist–modified. Of 6 chil- dren identified as potential participants, 4 met the criterion of reporting four or more ACEs. For those four children, parents/guardians com- pleted the initial TSCYC and SDQ. Parents continued to complete the SDQ weekly for a minimum of 3 weeks to establish a baseline, during which time the participants received no treatment. Over the course of the study, two of the participants were removed from the study as a result of a disruption in the home environ- ment. For both participants completing the study, a consistent baseline was established at 6 weeks. Once a consistent baseline was estab- lished, the treatment phase began.

During the treatment phase, participants par- ticipated in 24 play therapy sessions held bi- weekly for 45 min each. Occasionally, partici- pants only engaged in one play therapy session because of participant or play therapist illness. The participants did not engage in play therapy for 2 weeks because of holiday vacations. Par- ents continued to complete the SDQ weekly. At the 12-session midpoint and following the 24th session, parents/guardians completed the TSCYC. After completion of the 24th session, final interviews were conducted with the care- givers to gather information about caregivers’ and children’s experiences of CCPT. Following the 24th session, the SDQ was completed weekly for 4 weeks during the follow-up phase, during which parents/guardians and children did not receive services.

CCPT Intervention

The CCPT intervention was facilitated by an advanced doctoral student in a counselor edu- cation doctoral program accredited by the Council for Accreditation of Counseling and Related Educational Programs (CACREP) who completed 2.5 years of doctoral work in coun- seling, had 23 hr of graduate-level coursework in play therapy, had and 5 years of experience utilizing CCPT. Additionally, the counselor was a licensed professional counselor intern and cer- tified school counselor, and she participated in weekly supervision of play therapy with a doc- toral-level faculty member who is a licensed

professional counselor supervisor and a regis- tered play therapist supervisor.

Each child was scheduled to receive 45 min of individual CCPT twice a week for 12 weeks. In order to ensure treatment adherence, a rater trained in the Child-Centered Play Therapy- Research Integrity Checklist (CCPT-RIC; Ray, Purswell, Haas, & Aldrete, 2017) rated 15 min of each session using the CCPT-RIC. Fidelity adherence was 96%, exceeding recommenda- tions by Ray et al. (2017).

For the play therapy sessions, the playroom was equipped according to Ray’s (2011) Child- Centered Play Therapy Manual. Each room used was equipped with a video camera to pro- vide the opportunity to check for fidelity. The rooms varied in size but were equipped with toys and materials recommended by Landreth (2012).

Parent Consultation

Typically, regular and consistent parent con- sultations are a part of CCPT implementation. In order to ensure consistency with CCPT, par- ent consultations were conducted for 30 min biweekly, in addition to the CCPT sessions. Parent consultations were conducted following every four play therapy sessions and were held at a separate time from the play sessions. Schot- telkorb, Swan, and Ogawa (2015) created a child-centered parent consultation model that was used to maintain consistency for the thera- pist. The five components of the parent consul- tation model are (a) creating and maintaining the therapeutic relationship with parents, (b) demonstrating an awareness and understanding by listening and responding, (c) honoring par- ents as the experts on their children, (d) provid- ing pertinent knowledge, and (e) teaching ther- apeutic skills. Parent consultations followed the five components of the model in order to pro- vide parents with information about their child and the therapeutic process while teaching skills deemed necessary to help facilitate the child– parent relationship. Schottelkorb et al. (2015) suggested a session format in order to ensure the five components are met. The first parent con- sultation session focused on the building of the relationship and gathering a deeper understand- ing of the child. Each subsequent session con- tinued with building the relationship, gaining and providing an understanding of the child,

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and teaching therapeutic techniques relevant to each individual. Final parent consultation ses- sions consisted of the parents and therapist re- porting progress and changes witnessed throughout the process (Schottelkorb et al., 2015).

Data Analysis

Using weekly data gathered from the SDQ, we used visual data analysis to examine predict- able baseline patterns, data within each phase, data between each phase, and integration of data between all phases (Ray, 2015). Following the standards from the What Works Clearinghouse on single-case-design studies (Kratochwill et al., 2013), we analyzed and reported the follow- ing: (a) the level of each phase, which is the mean of each phase; (b) the trend, which is the slope of data between each phase; (c) the vari- ability, which is the difference between the trend and individual data points; (d) the imme- diacy of effect, which measures how quickly there was an effect with the intervention; (e) the consideration of overlap, which compares how much one phase overlaps with another one; and (f) the consistency of data patterns across the phases (Ray, 2015). In order to find the strength of the relationship between variables, we calcu- lated effect size using nonoverlap of all pairs (NAP; Parker & Vannest, 2009) and interpreted according to the following criteria: 0 –.65, weak effect size; .66 –.92, medium effect size; and .93–1.0 strong effect size (Parker & Vannest, 2009). Data from the TSCYC were used de- scriptively to provide further information on change over the duration of the study.

Results

Participant 1: Justin

Justin participated in 6 weeks of a noninter- vention baseline phase, 13 weeks of an inter- vention phase where he participated in 24 play therapy sessions, and 4 weeks of a noninterven- tion follow-up phase. Table 1 provides the means and standard deviations for each subscale in each phase of the study. For five subscales, Emotional Symptoms, Conduct Problems, Hy- peractivity and Attentional Difficulties, Peer Relationship Problems, and Total Difficulties, the means continually decreased across all phases of the study, demonstrating improve- ment. The means of Prosocial Behavior in- creased across all phases, demonstrating im- provement. Figure 1 provides a graphical representation of all data. In addition to visual analysis, we calculated the NAP for Total Dif- ficulties. Because data for individual scales can be found in Table 1, we limited our narrative results to the Total Difficulties score on the SDQ and the TSCYC.

Total Difficulties score. Level analysis of the graph indicated a decrease from a mean of 26.5 in the baseline phase to 11.69 in the treat- ment phase, followed by another decrease to 3 in the follow-up phase. Trend analysis revealed a downward trend across the baseline and treat- ment phases of the study, with a large correla- tion (R2 � .78), indicating a large relationship between the play therapy phase and Justin’s decrease in overall difficulties. Analysis of vari- ability between conditions revealed large vari- ability between phases, with standard deviations (SD) of 1.22 in the baseline phase, 7.66 in the

Table 1 Means and Standard Deviations for Justin’s SDQ Scores

Subscale

Baseline Intervention Follow-up

M SD M SD M SD

Emotional Symptoms 7.83 .75 2 3.32 .25 .5 Conduct Problems 4.33 .52 1.77 1.17 .5 .58 Hyperactivity and Attentional Difficulties 9.67 .52 5.78 1.89 2.25 1.26 Peer Relationship Problems 4.5 .84 2.08 1.66 0 0 Prosocial Behavior 5.44 .79 7.23 1.48 9.5 1 Total Difficulties 26.5 1.22 11.69 7.60 3 .82

Note. SDQ � Strengths and Difficulties Questionnaire.

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intervention phase, and .82 in the follow-up phase. The decrease was not immediate because the data did not visibly decrease until the third data point of the intervention phase. Addition- ally, there were overlapping data between these two phases. The mean of the last three data points in the baseline (M � 27.33) was similar to the mean of the first two data points in the intervention phase (M � 28). In addition to visual analysis, we calculated the NAP statistic to examine the degree of the treatment’s effec- tiveness. The NAP effect size comparing the data from the baseline phase and the data from the intervention phase was a medium effect size of .87, whereas the effect-size calculation of the data from the baseline phase compared with the data from the follow-up phase was a strong effect size of 1 (Parker & Vannest, 2009).

Posttraumatic Stress score. The TSCYC was completed by Justin’s mother prior to the baseline, at the 12th intervention session, and at the 24th session. The Posttraumatic Stress T scores were 98 prior to the intervention, 48 at the 12th session of the treatment phase, and 46 at the 24th session. The Posttraumatic Stress scores decreased over the time of the study, with substantial improvement reported after 12 sessions.

Follow-up parent interview. Upon com- pletion of the intervention phase, Justin’s mother participated in a follow-up interview. She reported that Justin demonstrated less anger and was more carefree than when the study

began. He was no longer displaying sadness at school or home, and he was verbalizing his feelings and opinions. He no longer erupted in tears and anger; instead, he spoke up and shared what he was thinking and feeling. Justin’s melt- downs at school stopped, and his teachers re- ported that he was no longer displaying problem behaviors. Justin’s mother reported that he was helpful and kind at home and more readily used his manners. In regard to peer relationships, she reported that Justin had better relationships with peers and that he was able to problem solve when he was upset. Justin’s mother reported positive changes to their parent– child relation- ship. She previously felt that Justin hated her and blamed her for the divorce, yet at the final interview, she reported feeling reconnected to him. Additionally, Justin’s mother reported that he had demonstrated nurturing behaviors to- ward her. Overall, she reported that Justin looked forward to coming to play therapy dur- ing the intervention phase.

Participant 2: Megan

Megan participated in 6 weeks of a noninter- vention baseline phase, 12 weeks of an inter- vention phase where she participated in 24 play therapy sessions, and 4 weeks of a noninterven- tion follow-up phase. Table 2 provides the means and standard deviations for each subscale in each phase of the study. For two subscales, Emotional Symptoms and Hyperactivity and

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Figure 1. Justin’s Strengths and Difficulties Questionnaire (SDQ) scores during baseline, intervention, and follow-up phases.

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Attentional Difficulties, the means continually decreased across all phases of the study, dem- onstrating improvement. For Conduct Prob- lems, the means remained the same during the baseline and intervention phases and decreased during the follow-up phase. For Peer Relation- ship Problems and Total Difficulties, the means increased between the baseline and intervention phases and decreased during the follow-up phase. The means of Prosocial Behavior de- creased between the baseline and intervention phases and increased during the follow-up phase. Figure 2 provides a graphical represen- tation of all data.

Total Difficulties score. Level analysis of the graph indicated an increase from a mean of 15.5 in the baseline phase to 16.18 in the treat- ment phase, followed by a decrease to 9.25 in the follow-up phase. Trend analysis revealed a

consistent trend across the baseline and treat- ment phases of the study, with a small corre- lation (R2 � .03), indicating a weak relation- ship between the play therapy phase and Megan’s decrease in overall difficulties. Analysis of variability between conditions re- vealed variability between phases, with stan- dard deviations of 1.64 in the baseline phase, 3.59 in the intervention phase, and 1.71 in the follow-up phase. The decrease was not imme- diate because the data did not visibly decrease until the 17th data point of the intervention phase. Additionally, there were overlapping data between these two phases. The mean of the last three data points in the baseline (M � 15.67) was smaller than the mean of the first three data points in the intervention phase (M � 19). In addition to visual analysis, we calculated the NAP statistic to examine the

Table 2 Means and Standard Deviations for Megan’s SDQ Scores

Subscale

Baseline Intervention Follow-up

M SD M SD M SD

Emotional Symptoms .83 .41 .75 .86 0 0 Conduct Problems 4.83 .75 4.83 1.33 2.25 .96 Hyperactivity and Attentional Difficulties 8.83 .98 8.25 2.01 5.25 .5 Peer Relationship Problems 1 .63 2.5 1 1.75 .95 Prosocial Behavior 8.5 .55 7.83 1.93 9.5 .58 Total Difficulties 15.5 1.64 16.18 3.59 9.25 1.71

Note. SDQ � Strengths and Difficulties Questionnaire.

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Baseline Interven�on Follow-Up

Figure 2. Megan’s Strengths and Difficulties Questionnaire (SDQ) scores during baseline, intervention, and follow-up phases.

231CCPT WITH CHILDREN AFFECTED BY ACES

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degree of the treatment’s effectiveness. The NAP effect size comparing the data from the baseline phase and the data from the interven- tion phase was a weak effect size of �.35 in the negative direction, whereas the effect-size calculation of the data from the baseline phase compared with the data from the fol- low-up phase was a large effect size of 1, indicating that a substantial amount of im- provement was revealed toward the end of the intervention and following the intervention.

Posttraumatic Stress score. The TSCYC was completed by Megan’s stepmother prior to the baseline, at the 12fth intervention session, and at the 24th session. The Posttraumatic Stress T scores were 78 prior to the intervention, 76 at the 12th session of the treatment phase, and 50 at the 24h session. The Post-Traumatic Stress scores decreased over the time of the study, with the most substantial improvement occurring from the play therapy phase to fol- low-up.

Follow-up parent interview. Upon com- pletion of the intervention phase, Megan’s fa- ther and stepmother participated in a follow-up interview. They reported that following partic- ipation in CCPT, Megan appeared happier, bounced backed more quickly from disappoint- ments when things did not go as planned, dis- cussed her feelings with them, and accepted responsibilities for mistakes. They reported that Megan had a greater attention span and a better ability to stay focused at home and at school. Megan was less impulsive, and she started thinking before acting. Megan became more selective with her peer choices; therefore, she had better relationships with friends. Megan discontinued physically reacting when she was upset, and she demonstrated remorse when she was upset. They reported that Megan had be- come more affectionate with her stepmother, whereas prior to the study, she was only affec- tionate with her father. They reported having a deeper, stronger relationship and connection with Megan. Although they reported in the final interview that they initially had mixed feelings about seeking counseling, they reported that it was a positive experience. They reported that once Megan began feeling heard in the thera- peutic relationship, she tried calmer ways of receiving attention at home. Through parent consultations, they discovered Megan’s desire for relationships and physical touch and discon-

tinued removing relational activities as conse- quences. Megan’s father reported seeing grad- ual changes throughout the study; however, her stepmother reported that she was unaware of the gradual changes but recognized the drastic changes toward the end.

Discussion

The purpose of this study was to examine the effectiveness of facilitating CCPT with children who had four or more ACEs. Both of the par- ticipants in the study had eight ACEs, which was well over the criteria requirements for the study. Both participants demonstrated clinical levels in some or all of the subscales from the SDQ as well as high levels of posttraumatic stress at the initiation of the study. Throughout the duration of the study, both participants sig- nificantly decreased in all areas of concern and were not clinical in any area at the end of the follow-up phase. Although the improvements occurred at different times of the intervention phase, both children had lasting change once the initial change was reported. Through the play therapy experience, both participants were able to begin self-actualizing, which allowed them to build self-acceptance and self-confidence. Jus- tin demonstrated a rapid decrease in symptom- ology across subscales within the intervention phase, and this continued throughout the fol- low-up phase. Megan’s decrease in symptomol- ogy for clinically scored subscales occurred fur- ther into the intervention phase and continued throughout the follow-up phase. Although both participants decreased problematic behaviors and increased prosocial behaviors, the time in which the changes occurred was different for the participants.

Process of CCPT for Children With ACEs

Manifestation of change and growth is a slow process (Landreth, 2012). Children who lived through difficult situations typically present with intensified emotions, mostly negative and no longer tied to the reality of the moment but filtered through past experiences. When they enter therapy, their emotions are heightened, indiscriminate, and easily aroused (Moustakas, 1953). Through qualitative research, Moustakas (1953) identified four stages of change during the therapeutic process that lead to improved

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functioning. As children receive faith, accep- tance, and respect, relationships between thera- pists and children are strengthened, and children begin to move through the stages (Moustakas, 1953). Although there are significant shifts, par- ents and caregivers may not be immediately aware of the changes outside of the playroom.

When the conditions that created the malad- justment are still present, healing may take lon- ger (Axline, 1947). Therapeutic relationships provide the environment for healing, but when children are still subjected to the relationships that facilitated their conditions of worth, discov- ering their self-worth may take longer (Axline, 1947). Therefore, if children still reside in the environment where the ACEs occurred, their maladjusted behaviors may remain persistent compared with the potential for change in a stable, nurturing environment.

In Justin’s case, he still had contact with his father, but he no longer resided in the same house. Therefore, the majority of the ACEs were occurring less frequently or were less pres- ent. Justin was not exposed as often to the ongoing adverse conditions he had previously experienced. Justin’s progress was identified by his mother quickly after the intervention phase began. Because many of the adverse experi- ences were less present, when Justin received the core conditions, his self-structure was able to adapt more quickly. His movement toward self-actualization, as evidenced through a desire to connect to others, became apparent to his mother, and she observed his self-confidence change and grow.

In Megan’s case, she continued to live in an environment where some of the adverse expe- riences were still present. Throughout the first half of the study, Megan experienced being yelled at and ignored by her caregivers. Megan verbalized her feelings of being unwanted by her family. Therefore, the healing nature of the therapeutic relationship took longer than if those factors had been removed. As Megan strived to self-actualize during her play ses- sions, she was met with messages of being unwanted at home. Therefore, her self-structure remained rigid for a large portion of the session. As Megan’s self-structure became more flexi- ble, in spite of her environment, she began to demonstrate care and kindness toward her fam- ily. Megan’s healing relationship with her step- mother led to alleviating some of the ACEs that

were still occurring, which allowed her to con- tinue to self-actualize. Megan’s efforts to con- nect with her stepmother appeared to initiate her stepmother’s ability to reciprocate affection and acceptance.

Implications for Practice

The results of this single-case research de- sign have implications for clinicians who are working with children who have experienced multiple ACEs. CCPT is a promising inter- vention modality for working with children who have experienced multiple or ongoing ACEs. Children who have experienced mul- tiple or ongoing ACEs might have sporadic healing experiences (Power, 2012). Children may appear to be healing when negative be- haviors reoccur. Although their healing may not be a linear process, children are working through their difficulties in their own ways (Landreth, 2012). In addition, this study sup- ported the practice of working with parents through consultation as a way to affect the child’s systemic environment and encourage therapeutic progress. Yet, it also appeared that when parents were resistant to change, CCPT was effective in helping the child de- velop resources to provide for the parents’ needs, as in the case of Megan and her step- mother, thereby affecting the parent– child re- lationship in a positive way.

Children who have experienced ACEs may still be exposed to the same ACEs while in play therapy. Children who have endured on- going or multiple ACEs have had a difficult childhood prior to entering play therapy, and the nature of adversities differs based on in- dividuals (Clarkson Freeman, 2014). Because of the varying nature of the experiences, it is difficult to predict how children will present during play therapy. Sessions with children exposed to ACEs may differ greatly. Overall, CCPT appears to be a promising intervention for children who have experienced multiple or ongoing ACEs. The results of the current study indicate that when implementing CCPT, the number of sessions with children might vary, and healing might occur quickly or gradually. Although parents may not report sudden changes, small changes may be occur- ring.

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Implications for Research

This pilot study provided information for fu- ture research with children who have experi- enced multiple ACEs. Following this study, an- other single-case research design is suggested with a multiple-baseline design with three or more participants. By re-creating this study, us- ing the guidelines from the What Works Clear- inghouse (Kratochwill et al., 2013), researchers can assist in building the evidence-based liter- ature for children who have experienced ACEs.

In addition to evidence-based single-case re- search designs, correlational research is war- ranted in order to explore the impact of ACEs on children during childhood. Although there are a few studies examining the correlations between ACEs and children’s behaviors, more focus on children’s caregiver relationships, self- concept, and emotional states would serve to increase researchers’ understanding of assess- ment measures and the holistic effects of ACEs. Parent variables and the impact they have on therapeutic progress, as well as the number and types of ACEs children experience, are other necessary areas for inquiry. In particular, re- searchers might look at parents’ perceived stress, attachment, and mental health concerns. The types and numbers of parent ACEs could also be correlated with the types and numbers of the children’s ACEs.

To explore the generalizable effect of CCPT, we recommend randomized controlled trials in order to test the impact of CCPT for children who have experienced ACEs. Comparisons be- tween children who have experienced multiple ACEs receiving the CCPT intervention and children who receive no treatment or alternative treatments will provide researchers a further understanding of the effects of CCPT with chil- dren who have experienced ACEs.

One observation regarding the current study is the difficulty caregivers exhibited in commit- ting to and arranging for consistent intervention. On a therapeutic note, we recommend that play therapists provide extra, reasonable supports when possible in order to maintain the child’s participation in treatment, such as convenient session times, transportation support, and flex- ibility with parent consultations. On a research note, we recommend that researchers recruit more participants than needed. Because of the nature of ACEs, attrition is likely to occur at a

higher rate than with other studies. In addition to attrition, recruitment is difficult with this population because of the nature of the ques- tions used to determine eligibility. Identification of children who have experienced ACEs is lim- ited by the parent/caregiver’s willingness to provide information that is sensitive and may possibly have legal repercussions.

Limitations

Because this study is the first to explore the impact of CCPT on children who have experi- enced multiple ACEs, there were limitations to this pilot research. The single-case design has minimal external validity, which limits the abil- ity to generalize the findings to the general population. Although both participants demon- strated changes within the study, it is difficult to generalize these findings to all children who have experienced ACEs because of the individ- ual nature of single-case designs. Disruptions in the home environment may have affected the way in which participants were rated by their parents. Having one rater per participant may have inhibited the researchers from gaining a deeper understanding of the effectiveness of CCPT. In order to have gained more insight, the researchers could have utilized more raters per child or incorporated an observation measure.

Because of the use of caregivers’ reports re- garding the occurrence of ACEs rather than the self-reports of the children who had experienced them, not all of the ACEs may have been re- ported. Reports were based on the parents’ views of the child’s experiences, and as a result of changes in home environments, parents may not have had a full understanding of the depth of the ACEs. When answering the questions, par- ents may not have fully grasped how their chil- dren were experiencing the environments.

Conclusion

ACEs have been shown to have negative effects throughout the life span beginning in childhood following the adverse events (Agar- wal, 2015). This study demonstrated a positive impact of the use of CCPT with two children who had experienced four or more ACEs. Al- though each child’s healing occurred at differ- ent points, both children demonstrated signifi- cant changes in symptomology. The process of

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CCPT with participants who experienced ACEs appeared to support previous research related to stages of play therapy, moving from diffused negative reactions in the playroom to an inte- grated expression of self with positive emo- tions. The relationship between child and play therapist seemed to provide a reparative expe- rience for children whose primary relationships have been made vulnerable by ACEs. Although more research is necessary, CCPT seems to demonstrate promise as an intervention for chil- dren who have experienced multiple or ongoing ACEs.

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Received March 8, 2020 Revision received May 15, 2020

Accepted May 20, 2020 �

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