Depression Markers in Young Depression Markers in Young Children‘s Play:Children‘s Play:

observations for/ from observations for/ from teachersteachers

Annemieke Mol Lous,Annemieke Mol Lous,and J. Marianne Riksen-Walravenand J. Marianne Riksen-Walraven

Amsterdam Institute of Education, The Netherlands.Amsterdam Institute of Education, The Netherlands.Department of Developmental Psychology Radboud Department of Developmental Psychology Radboud

University of NijmegenUniversity of Nijmegen

Depression and Play Depression and Play SEBCD 2007 SEBCD 2007

• Play observation as an assesment tool for depression in Play observation as an assesment tool for depression in young children?young children?

• Research: A comparison of 30 depressed and 60 Research: A comparison of 30 depressed and 60

nondepressed childrennondepressed children (Mol Lous, De Wit, De Bruyn, Rost, & Riksen-(Mol Lous, De Wit, De Bruyn, Rost, & Riksen-Walraven) Walraven)

• Future research: play behaviour and depression in Future research: play behaviour and depression in classrooms: evident for and from teachers?classrooms: evident for and from teachers?

Play and depression: a “contradictio in terminis”?Play and depression: a “contradictio in terminis”?

“The most specific symptom

of depressive disorders in kids

under age 6 is something called anhedonia –

essentially, appearing to have no fun

while at play," (J.L.Luby, 2003)

Assessing Childhood Depression: How?Assessing Childhood Depression: How?

• Children’s limited capacity to reflect and communicate Children’s limited capacity to reflect and communicate

about persistent depressive cognitions and feelingsabout persistent depressive cognitions and feelings (Harter & (Harter & Pike, 1984; Schwab-Stone, Faillon, Briggs, & Crowther, 1994; Verhulst & Pike, 1984; Schwab-Stone, Faillon, Briggs, & Crowther, 1994; Verhulst & Akkerhuis, 1989). Akkerhuis, 1989).

• Parents and teachers are often not sufficiently aware of a Parents and teachers are often not sufficiently aware of a

child's depressive cognitions and feelingschild's depressive cognitions and feelings (Edelbrock, Costello, (Edelbrock, Costello, Dulcan, Conover & Kalas, 1986; Harrington, 1993; Klein, 1991; Stevenson-Dulcan, Conover & Kalas, 1986; Harrington, 1993; Klein, 1991; Stevenson-Hinde & Shouldice, 1995). Hinde & Shouldice, 1995).

A play observation procedure for assessment of depression in A play observation procedure for assessment of depression in young children: why?young children: why?

• Play "represents a window to the child's mind" Play "represents a window to the child's mind" (Rubin, Fein & (Rubin, Fein & Vandenberg, 1983) Vandenberg, 1983)

• Symbolic play reflects children's emotional and behavioural Symbolic play reflects children's emotional and behavioural disorders disorders (Singer & Singer, 1976; Sutton-Smith, 1980; Warren, Oppenheim (Singer & Singer, 1976; Sutton-Smith, 1980; Warren, Oppenheim & Emde, 1996). & Emde, 1996).

• Disruptions of symbolic play have been found associated with Disruptions of symbolic play have been found associated with a variety of emotional problems in children a variety of emotional problems in children (Hartup, 1976; (Hartup, 1976; Hetherington, Cox & Cox, 1979; Nader & Pynoos 1991).Hetherington, Cox & Cox, 1979; Nader & Pynoos 1991).

• Play observation also seems a promising method to obtain Play observation also seems a promising method to obtain direct and indirect information about affective, motivational direct and indirect information about affective, motivational and other behavioural symptoms of the depressive syndrome. and other behavioural symptoms of the depressive syndrome.

What others found:What others found:

• Play inhibition and the reflection herein of the depressed Play inhibition and the reflection herein of the depressed children's loss of interestchildren's loss of interest (Nissen, 1971; Ushakov & Girich, 1972)(Nissen, 1971; Ushakov & Girich, 1972)

• ““Changes in the quality and quantity of play activity” of Changes in the quality and quantity of play activity” of depressed childrendepressed children (Kovacs, 1977, p. 157).(Kovacs, 1977, p. 157).

• Overt behavioural symptoms of depression such as Overt behavioural symptoms of depression such as psychomotor agitation and retardation systematically psychomotor agitation and retardation systematically observed during standardized play proceduresobserved during standardized play procedures (Altman & Gotlib, (Altman & Gotlib, 1988; Field, Sandberg, Goldstein, Garcia, Vega-Lahr, Porter & Dowling, 1987; 1988; Field, Sandberg, Goldstein, Garcia, Vega-Lahr, Porter & Dowling, 1987; Kashani et al., 1997; Kazdin, 1990). Kashani et al., 1997; Kazdin, 1990).

• Lower frequency of symbolic or fantasy play in free play Lower frequency of symbolic or fantasy play in free play situations to differentiate depressed from both normal and situations to differentiate depressed from both normal and conduct disordered childrenconduct disordered children (Field et al.,1987)(Field et al.,1987)

Depression Markers in Young Depression Markers in Young Children ‘s PlayChildren ‘s Play

A Comparison between Depressed and A Comparison between Depressed and Nondepressed 3- to 6 Year-Olds in Nondepressed 3- to 6 Year-Olds in

various Play Situationsvarious Play Situations

Annemieke Mol Lous, Cees A.M. de Wit, Eric E.J. De Bruyn, and J. Annemieke Mol Lous, Cees A.M. de Wit, Eric E.J. De Bruyn, and J. Marianne Riksen-WalravenMarianne Riksen-Walraven

Method: ParticipantsMethod: Participants

• 3-6-Year Old children 3-6-Year Old children

• 30 depressed (17 + 13)30 depressed (17 + 13)

• 30 nondepressed clinical (18 + 12) 30 nondepressed clinical (18 + 12)

• 30 nondepressed nonclinical children (17+13) 30 nondepressed nonclinical children (17+13)

•• 20 day-care units of clinical institutions for young children 20 day-care units of clinical institutions for young children

with somatic, somatoform, psychiatric, and psychosocial with somatic, somatoform, psychiatric, and psychosocial problemsproblems

Method: Selection of the sampleMethod: Selection of the sample

• first selection by clinical staffs. (DSM-IV and the ICD-10 first selection by clinical staffs. (DSM-IV and the ICD-10 criteria for major depressive episode) criteria for major depressive episode)

• checklist data discussed with the first author in order to checklist data discussed with the first author in order to come upon a staff nomination of participants. come upon a staff nomination of participants.

• clinical files of the nominated children: judged by an clinical files of the nominated children: judged by an independent child psychiatristindependent child psychiatrist

The Play Procedure (1): Solitary free play.The Play Procedure (1): Solitary free play.

• Embedded in a larger interactive play situationEmbedded in a larger interactive play situation

• ““waiting room” with play objects (Lego “Belville” dolls and waiting room” with play objects (Lego “Belville” dolls and accessories). accessories).

• Hidden camera in waiting roomHidden camera in waiting room

• Observing play in the “strict” senseObserving play in the “strict” sense

The Play Procedure (2): Interactive Free PlayThe Play Procedure (2): Interactive Free Play

• play with the experimenter for 20 minutes. play with the experimenter for 20 minutes.

• diversity of play materials. diversity of play materials.

• choice of the play materials and activities left to the child. choice of the play materials and activities left to the child.

• experimenter followed the child’s initiatives. experimenter followed the child’s initiatives.

The Play Procedure (3): Play narrativesThe Play Procedure (3): Play narratives

• child with the experimenterchild with the experimenter

• dolls and props are presenteddolls and props are presented

• child chooses dolls that will represent the child and his/her familychild chooses dolls that will represent the child and his/her family

• four different standardized story beginningsfour different standardized story beginnings– the doll which was chosen by the child to represent him or herself, the doll which was chosen by the child to represent him or herself,

was the central figure. was the central figure. – The themes were ordinary activities in daily life: The themes were ordinary activities in daily life:

• waking up in the morning, waking up in the morning, • going to school or kindergarten, going to school or kindergarten, • coming home from school, and going to bed in the evening. coming home from school, and going to bed in the evening. • All themes to be played in sad, happy and neutral moodAll themes to be played in sad, happy and neutral mood

Table 1 Table 1 Order of Presentation of Play Situation SequencesOrder of Presentation of Play Situation Sequences

• __________________________________________________________________________________________________________________• SequenceSequence Order of presentationOrder of presentation• 11 22 33 44 55• ____________________________________________________________________________________________________________________• AA SFPSFP PNPN PNsPNs PNh*PNh* IFPIFP• BB IFP*IFP* SFPSFP PNPN PNsPNs PNhPNh• CC PNPN PNsPNs PNh*PNh* IFPIFP SFPSFP• DD SFPSFP PNPN PNhPNh PNsPNs IFPIFP• EE IFP*IFP* SFPSFP PNPN PNhPNh PNsPNs• FF PNPN PNhPNh PNs*PNs* IFPIFP SFPSFP• ____________________________________________________________________________________________________________________• SFP = solitary free play;SFP = solitary free play;• IFP = interactive free play; IFP = interactive free play; • PN = play narratives without mood-presentation;PN = play narratives without mood-presentation;• PNs = play narratives with sad mood-presentation; PNs = play narratives with sad mood-presentation; • PNh = play narratives with happy mood-presentation; PNh = play narratives with happy mood-presentation; • * = break.* = break.•

Observed Categories of play behaviourObserved Categories of play behaviour

Manipulative play (Man)Manipulative play (Man)

Repeating actions for the sake of pleasure,Repeating actions for the sake of pleasure,

such as repeatedly lifting up an arm or legsuch as repeatedly lifting up an arm or leg

of a doll of a doll

Symbolic play (Sym)Symbolic play (Sym)

Making objects, actions and/or persons represent other Making objects, actions and/or persons represent other absent objects, actions and/or personsabsent objects, actions and/or persons

Observed categories of nonplay behaviour (1)Observed categories of nonplay behaviour (1)

Exploration (Expl)Exploration (Expl)Looking at, touching and/or manipulating the play-object or Looking at, touching and/or manipulating the play-object or parts of them, evidently in order to find out how it worksparts of them, evidently in order to find out how it works

Experimenter oriented behavior (Exp)Experimenter oriented behavior (Exp)The subject is actively engaging with the experimenter.The subject is actively engaging with the experimenter.

Environment oriented behaviour (Env)Environment oriented behaviour (Env)Looking at, touching or manipulating (objects in) the Looking at, touching or manipulating (objects in) the environment.environment.

Self oriented behaviour (Self)Self oriented behaviour (Self)The subject is only interested in/or busy with him/herselfThe subject is only interested in/or busy with him/herself

Observed categories of nonplay behaviour (2)Observed categories of nonplay behaviour (2)

• Handling (Hand)Handling (Hand)

• Handling without any specific intention.Handling without any specific intention.

• Looking (Look)Looking (Look)

• Looking or staring in a non-explorative way.Looking or staring in a non-explorative way.

Mean Amounts of Play Behaviour for the Three Groups in Mean Amounts of Play Behaviour for the Three Groups in Three Play SituationsThree Play Situations

Play *Play * DD 118.81118.81 51.451.4

group group NDCNDC 196.2196.2 29.2 29.2 NDNC 228.3 NDNC 228.3 41.741.7

• D=depressedD=depressed

• NDC=non-depressed clinicalNDC=non-depressed clinical

• NDNC=non-depressed non-clinicalNDNC=non-depressed non-clinical

Manipulative(man) and symbolic (sym) play by group Manipulative(man) and symbolic (sym) play by group

MM SD SD

ManMan

DD 31.731.7 22.8 22.8

play *play * NDCNDC 30.730.7 23.3 23.3

groupgroup NDNCNDNC 23.623.6 27.6 27.6

Sym Sym D D 87.11 87.11 45.9 45.9

NDCNDC 165.6165.6 37.637.6

NDNCNDNC 204.8 204.8 49.449.4

Play by situation: Manipulative Play (man) Play by situation: Manipulative Play (man)

SFP=Solitary Free Play, IFP=Interactive Free Play , PN=Play SFP=Solitary Free Play, IFP=Interactive Free Play , PN=Play NarrativesNarrativesPlay * Man SFP D 14.9 19.1

sit. * NDC 17.8 21.9 group NDNC 17.3 22.1

IFP D 8.0 9.8NDC 7.8 11.7

NDNC 3.4 4.9

PN D 8.9 7.7NDC 5.1 6.7

NDNC 3.06.1

Play by situation: symbolic play (sym)Play by situation: symbolic play (sym)

• Sym SFPSym SFP D D 13.313.31 1 24.024.0 NDCNDC 30.030.0

25.425.4• NDNCNDNC 53.853.8 31.531.5• IFPIFP D D 34.734.711 19.019.0• NDCNDC 51.151.1 20.820.8• NDNCNDNC 59.559.5 23.023.0• PNPN D D 39.239.211 18.918.9• NDCNDC 84.584.5 13.413.4• NDNCNDNC 91.591.5 11.011.0

Mean Amounts of Play after Presentation of a Positive, Neutral, Mean Amounts of Play after Presentation of a Positive, Neutral, and Negative Mood during Play Narrativesand Negative Mood during Play Narratives

• ________________________________________________________________________________• MoodMood GroupGroup MM SDSD • ________________________________________________________________________________• PosPos DD 63.3063.301,21,2 25.3125.31• NDCNDC 93.7693.76 9.949.94• NDNCNDNC 94.0194.01 10.9110.91• NeutNeut DD 54.6654.661,21,2 24.1624.16• NDCNDC 87.4987.49 11.8511.85• NDNCNDNC 92.5292.52 8.838.83• NegNeg DD 26.0126.011,21,2 20.120.1• NDCNDC 87.3287.32 19.3219.32• NDNCNDNC 96.7996.79 9.029.02• ____________________________________________________________________________________• NoteNote. D = Depressed (N=30); NDC = NonDepressed Clinical (N=30); NDNC = . D = Depressed (N=30); NDC = NonDepressed Clinical (N=30); NDNC =

NonDepressed NonClinical (N=30); Neut = neutral mood presentation; Pos = NonDepressed NonClinical (N=30); Neut = neutral mood presentation; Pos = positive mood presentation; Neg = negative mood presentation.positive mood presentation; Neg = negative mood presentation. 1 = D vs NDC: p = <.000; 2 = D vs NDNC: p = <.000.1 = D vs NDC: p = <.000; 2 = D vs NDNC: p = <.000.

Results:Results:

• (1) depressed children less (symbolic) play in both control (1) depressed children less (symbolic) play in both control groups, across all play situationsgroups, across all play situations

• (2) the differences in play among the depressed and the (2) the differences in play among the depressed and the nondepressed children are largest in the play narratives nondepressed children are largest in the play narratives situation, situation,

• (3) the depressed children show more behavioural changes (3) the depressed children show more behavioural changes than the nondepressed children in both control groupsthan the nondepressed children in both control groups

• (4) mood presentation during the play narratives differentially (4) mood presentation during the play narratives differentially

affects the play behaviour of depressed and nondepressed affects the play behaviour of depressed and nondepressed children; the largest differences in play between depressed children; the largest differences in play between depressed and nondepressed children emerge when a negative mood is and nondepressed children emerge when a negative mood is presented. presented.

Discussion: But what might cause these apparent regulatory Discussion: But what might cause these apparent regulatory problems in depressed children? problems in depressed children?

• Interpersonal experience, particularly in parent-infant interactions, Interpersonal experience, particularly in parent-infant interactions, plays an important role in the development of affect regulation. plays an important role in the development of affect regulation.

• The inhibition of symbolic play and the behavioural fragmentation The inhibition of symbolic play and the behavioural fragmentation of the depressed children in our study remind of children with of the depressed children in our study remind of children with disorganised attachments, who are characterized by behavioural disorganised attachments, who are characterized by behavioural disorganisation and disengaged states in stressful interpersonal disorganisation and disengaged states in stressful interpersonal situations situations (Main & Solomon, 1990; Lyons-Ruth & Jacobvitz, 1999). (Main & Solomon, 1990; Lyons-Ruth & Jacobvitz, 1999).

• Disorganised attachment more often linked with externalising than Disorganised attachment more often linked with externalising than with internalising disorders with internalising disorders (Lyons-Ruth & Jacobvitz, 1999; Van IJzendoorn, Schuengel, & (Lyons-Ruth & Jacobvitz, 1999; Van IJzendoorn, Schuengel, & Bakermans-Kranenburg, 1999)Bakermans-Kranenburg, 1999)

• Disorganised attachment has been found associated with Disorganised attachment has been found associated with internalising problems in several studies internalising problems in several studies (Carlson, 1998; Moss, Rousseau, Parent, St-(Carlson, 1998; Moss, Rousseau, Parent, St-

Laurent, & Saintong, 1998)Laurent, & Saintong, 1998) and might theoretically cause such fragmented and might theoretically cause such fragmented play behaviour as observed in our depressed pre-schoolers. play behaviour as observed in our depressed pre-schoolers.

Discussion: Discussion: Affect regulation & play of depressed young Affect regulation & play of depressed young childrenchildren

• Significant and strong negative effect of mood presentation Significant and strong negative effect of mood presentation on the play of depressed children. on the play of depressed children.

• A clear drop in the amount of play in depressed children A clear drop in the amount of play in depressed children when a negative mood was presented in the play narratives when a negative mood was presented in the play narratives situationsituation

• Regulatory problems that characterize depressed children Regulatory problems that characterize depressed children (Cicchetti & Toth, 1998; Field 1992; Garber, Braaflandt, & (Cicchetti & Toth, 1998; Field 1992; Garber, Braaflandt, & Weiss, 1995; Kovacs, 1997; Sheeber et al., 2000) have an Weiss, 1995; Kovacs, 1997; Sheeber et al., 2000) have an inhibiting effect on these children’s symbolic play. This type inhibiting effect on these children’s symbolic play. This type of play probably triggers thoughts and emotions that are of play probably triggers thoughts and emotions that are difficult to control for depressed children, given their affect difficult to control for depressed children, given their affect regulation problems. regulation problems.

No play = no joy?No play = no joy?

Recent neurobiological research Recent neurobiological research (Fox, 1994)(Fox, 1994) : :• Frightening and traumatic experiences of disorganised Frightening and traumatic experiences of disorganised

children with their parents negatively affect the children with their parents negatively affect the development of the major regulatory system in the brain, development of the major regulatory system in the brain, i.e., the orbital prefrontolimbic system. The impaired i.e., the orbital prefrontolimbic system. The impaired functioning of this system, in turn, contributes to the functioning of this system, in turn, contributes to the inability to cope with novel and stressful circumstances. It inability to cope with novel and stressful circumstances. It might, for example, preclude children to engage in dyadic might, for example, preclude children to engage in dyadic play states that create high levels of arousal play states that create high levels of arousal (Schore, 2001)(Schore, 2001)

Future ChallengesFuture Challenges

• Play narratives: differentiating between emotional problems?Play narratives: differentiating between emotional problems?

• Early detection: Can play observation be used by teachers?Early detection: Can play observation be used by teachers?

• Early intervention: Can we use play therapy or intervention to help Early intervention: Can we use play therapy or intervention to help children cope and prevent?children cope and prevent?

• Treatment: can we use play therapy with depressed children?Treatment: can we use play therapy with depressed children?

• Attachment- affectregulation-depression? Attachment- affectregulation-depression?

??