THE EXTENDED PLAY-BASED DEVELOPMENTAL ASSESSMENT: …

THE EXTENDED PLAY-BASED DEVELOPMENTAL ASSESSMENT: CHILDREN

FIVE TO NINE YEARS OLD WITH TRAUMA HISTORY

Janet R. O’Donnell

A dissertation to fulfill the requirements for a

DOCTOR OF PSYCHOLOGY IN COUNSELING PSYCHOLOGY

at

NORTHWEST UNIVERSITY

2012

Signatures have been om itted fo r security reasons.

Approval Signatures:

Committee Chair (Jacqueline N. Gustafson, Ed.D.) Date

Committee Member (Sarah B. Drivdahl, Ph.D.) Date

Committee Member (K. Kim Lampson, Ph.D.) Date

Dean of College of Social and Behavioral Sciences (Matt Nelson, Ph.D.) Date

Abstract

Children who have experienced trauma and abuse require special provisions to

navigate successfully through the initial phase of therapy, in particular the assessment

process (Briere, Johnson, Bissada, Damon, Crouch, & Gill, 2006; Nader, 2008), which

suggests the use of a more child friendly, play-based model of assessment (Shelby & Berk,

2009; Cattanach, 2008; Gil, 2006; Greenspan & Greenspan, 2003). The Extended Play-Based

Development Assessment (EPBDA), developed by Eliana Gil (2011), is an integrated

assessment model that uses directive and nondirective play approaches, intended to recognize

the developmental levels of the different ages, and offers a step by step procedure for

standardized use. The purpose of this study was to explore the experiences of participants

using the EPBDA following a qualitative, collective case design. Data collection included

interviews, questionnaires, direct observation, therapist field notes, and audio/visual

materials. The participants included four children with a trauma history, between the ages of

five and nine years of age. Further, the study examined the experiences of the parents and

therapist. From the constructivism perspective, this study focused on the participant’s

viewpoint, the play room setting in which experiences were made, and the meanings behind

those experiences. Themes that emerged from this study included the experiences of

enjoyment, calmness, and enrichment. Conclusions drawn from this study are in close

alignment with the theoretical material that justifies play-based assessment as a practical

clinical method. The results of this study will contribute to the body of knowledge in play

therapy and the assessment of children with a trauma history; moreover, this study utilized a

practical model that a therapist can easily replicate in clinical practice and research.

Table of Contents

Acknowledgments................................................................................................................ i

List of Tables......................................................................................................................... ii

I. Introduction to the Study................................................................................................... 1

Background.................................................................................................................. 2

Information about the Study......................................................................................... 4

The Research Problem/Question.................................................................................. 6

Methodology................................................................................................................. 6

Assumptions and Limitations........................................................................................ 7

Significance.................................................................................................................. 8

Summary........................................................................................................................ 8

II. Literature Review............................................................................................................ 9

Introduction.................................................................................................................. 9

Theories in Child Development.................................................................................... 9

Jean Piaget.............................................................................................................. 10

Lev Vygotsky.......................................................................................................... 12

Trauma.......................................................................................................................... 15

Play Therapy.................................................................................................................. 16

Directive and Nondirective Play.............................................................................. 18

Summary......................................................................................................................... 21

III. Research Design and Methodology.................................................................................. 23

Introduction.................................................................................................................. 23

Rationale for Qualitative Research................................................................................ 23

Overview of Research.................................................................................................... 24

Credibility of Therapist................................................................................................. 24

Participants.................................................................................................................... 25

Procedures..................................................................................................................... 25

Video Recordings..................................................................................................... 26

Human Subjects Review Board................................................................................ 26

Materials.......................................................................................................................... 27

Setting............................................................................................................................ 27

Data Collection and Analysis......................................................................................... 28

Summary.........................................................................................................................29

IV. Data Analysis.................................................................................................................. 31

Introduction.................................................................................................................... 32

Snapshot of Children...................................................................................................... 32

Andrew...................................................................................................................... 32

Bobby........................................................................................................................ 32

Carlton...................................................................................................................... 33

Dawn......................................................................................................................... 33

Findings.............................................................................................................................. 33

Video Observation...................................................................................................... 33

Coding Behaviors.................................................................................................... 34

Overvi ew of Behaviors.......................................................................................... 35

Categories and Themes.......................................................................................... 36

Child Questionnaire..................................................................................................... 37

Parent Questionnaire.................................................................................................... 39

Therapist Field Notes and Questionnaire................................................................. 41

Triangulation.................................................................................................................. 43

Summary........................................................................................................................ 43

V. Conclusion and Implications............................................................................................ 45

Introduction.................................................................................................................. 45

Conclusions of the Study.............................................................................................. 45

Calmness.................................................................................................................. 46

Enjoyment................................................................................................................ 47

Enrichment.............................................................................................................. 48

Implications of Clinical Practice.................................................................................. 48

Implications for Future Research................................................................................. 49

Limitations.................................................................................................................... 50

Retrospective Commentary.......................................................................................... 51

Summary...................................................................................................................... 52

References............................................................................................................................ 54

Appendix A. Brochure and Webpage Announcement......................................................... 62

Appendix B. Informed Consent and Clients Rights............................................................. 64

Appendix C. Child Background Information...................................................................... 66

Appendix D. EPBDA Directives and Procedures................................................................ 73

Appendix E. Play Room Materials...................................................................................... 78

Appendix F. Play Assessment Observation Form................................................................ 79

Appendix G. Research Questionnaires................................................................................. 83

Appendix H. Video Observation Rubric.............................................................................. 87

I

AcknowledgementsThere are several people who have helped me through my doctoral journey and I feel

extremely blessed to have so much support from so many people. First, I must thank Dr.

Gustafson, my dissertation chair, for sharing her time and expertise so graciously, and

expanding my research sensibilities. I am also very grateful for my committee members: Dr.

Drivdahl, who provided encouragement and guidance, and Dr. Lampson, who provided

support as a role model and an advocate on many occasions.

I am very thankful for Dr. Phil Templeton, my mentor and teacher. You believed in

me, prayed for me, and encouraged me beyond measure. I am thankful to Pastor Joe Fuiten

for his generous spirit and support, and many thanks to the staff at Cedar Park Counseling

Network and Cedar Park Church for their prayers and support throughout this journey. I

thank Dr. Cheryl Azlin and Dr. Peggy Murphy for their critical insight and therapeutic

expertise, and a very special thank you to Dr. Eliana Gil for her gracious permission to use

the Extended Play-Based Developmental Assessment in research.

To Kelly, my best friend, I appreciate your perpetual optimism, extraordinary

wisdom, and unfaltering faith...... you help me view the world with a kaleidoscope

perspective. Thanks Kelly for always being there. To Mary, whose friendship helped me stay

grounded in my faith, and never letting me feel as if I was “friendship abandoned” which so

often happens when in graduate school. Thank you Mary for your support and cheerleading.

Most importantly, I am grateful and blessed for my family, whose love and prayers

kept me motivated to stay focused on my work. And to Ken, my loving husband, I thank you

for your endless patience, strength, understanding, and encouragement to follow my dream.

Finally, I thank my Lord and Savior, Jesus Christ, for only through Him was I able to

persevere and accomplish my goals, and in Him goes all the glory.

II

List of Tables

Table 1. Video Observation.................................................................................................... 37

Table 2. Child Questionnaire.................................................................................................. 38

Table 3. Parent Questionnaire................................................................................................. 40

Table 4. Therapist Field Notes and Questionnaire................................................................ 42

Extended Play-Based Developm ental Assessm ent 1

Chapter 1

Introduction to the Study

Historically, psychiatrists understood the origin of most psychopathology to be

childhood trauma (Van der Kolk, 1987; Wolf, Reinhard, Cozolino, Caldwell, & Asamen,

2009). How an individual reacts to trauma essentially represents that individual’s

psychological resilience and ability to cope with the events that occurred (Cicchetti,

Rogosch, Lynch, & Holt, 1993; Perry & Szalavitz, 2006). Research in psychiatric inpatient

and outpatient populations report a frequency of more than 50% of childhood cases has

trauma from abuse (Hanson, Hesselbrock, Tworkowski, & Swan, 2002).

The National Child Traumatic Stress Network (2010) defines trauma in two

categories: acute (e.g. as in natural disasters, witnessing a violent act or a serious accident,

sudden death of a loved one, or physical and sexual abuse) and chronic (e.g. as in ongoing

experiences of domestic violence, physical and sexual abuse, or war). Statistics collected

from the Data Archive on Child Abuse and Neglect (Administration for Children and

Families, 2011) reported in 2009 that over 78.3% of Child Protective Service cases were

considered child neglect, 17.8% physical abuse, 9.5 % sexual abuse, and 7.6% psychological

maltreatment. Over 3.3 million cases were referred to CPS, with % of these cases dismissed

on unsubstantiated evidence. Approximately 1,770 children died from abuse; 80% of these

children were 4 years and younger.

Traumatic events can have long-term negative consequences on a child’s behavioral,

physical, cognitive, and emotional development (Goodyear-Brown, 2010; Van der Kolk,

2005; Wolf et al., 2009). A child’s reaction to trauma is influenced by age, developmental

ability, personality, parental support, environmental structure, and whether the trauma

experience was acute or chronic (Briere & Scott, 2006; Cohen, Mannarino, & Deblinger,


2006; Nader, 2008). Considering the potentially adverse effects of childhood trauma,

developmentally appropriate assessments are needed for these children as they embark in

therapeutic recovery (Findley, 2004; Findling, Bratton, & Henson, 2006).

Children who have experienced trauma require the assessment of symptoms, needs,

and overall functioning in order for practitioners to create developmentally and age

appropriate recommendations for treatment (Briere, Johnson, Bissada, Damon, Crouch, &

Gil, 2001; Greenspan & Greenspan, 2003). Therefore, it is essential that the clinician

evaluate the problematic domains (cognitive problems, relationship problems, affective

problems, family problems, and somatic problems) in the assessment process (Cohen,

Deblinger, & Mannarino, 2006; Gil, 2006; Shelby & Felix, 2006). In addition, Greenspan

and Greenspan (2003) suggested a systematic approach in observation of physical

development, mood, relational capacity, affect, and use of space (e.g. play room and toys) (p.

35).

Background. Standardized measures utilizing objective endorsements via parent or

teacher endorsements, such as The Child Behavioral Checklist ([CBCL] Achenbach &

Rescorla, 2001) and UCLA PTSD Index for DSM-IV (Pynoos, Rodriquez, Steinberg, Stuber,

& Fredrick, 1998), reliably report information regarding observable symptoms; however,

many instruments professed to be effective in assessing young children lack the sufficient

information of a child’s self-report (Drake, Bush, & van Gorp, 2001; Westby, 2000).

Some researchers report the most important assessment of a child’s internal distress is

the child’s self report (Nader, 2008; Rey, Schrader, & Morris-Yates, 1992). Popular

standardized assessments for collecting a child self report include the Trauma Symptom

Checklist for Children ([TSCC] Briere, 1995) and the Screen for Child Anxiety Related

Emotional Disorders ([SCARED] Birmaher, Khetarpal, Brent, Cully, Balach, & Kaufman,


1997), which assesses a broad range of trauma-related symptomology such as anxiety,

depression, dissociation, rage/anger, and sexual behavior concerns. Inasmuch as these

assessments are beneficial in measuring various levels of trauma, they require a child to

articulate to some degree the insight of self.

One difficulty in assessing children is that those younger than ten years of age are still

in the process of developing the capacity for abstract thought; consequently, these young

children lack the ability to exhibit meaningful verbal expression and understand complex

issues, reasoning, and feelings (Salmon & Bryant, 2002). Due to these challenges in

assessing young children alternative methods have been sought after by therapists, such as

with play-based assessments. As adults communicate naturally through words, children

express themselves naturally through the tangible world of play and movement (Axline,

1947, 1969; Landreth, 2002; Piaget, 1962). There is a significant quality in a play-based

assessment for gathering a child’s self report, especially in situations of maladaptive

symptoms which children often experience following trauma and /or abuse (Findling,

Bratton, & Henson, 2006; Gil, 2006; Schafer, Gitlin & Sandgrund, 1994; Westby, 2000).

Play therapy intervention is based on the understanding of child development and is

often used to assist children with developmental and emotional difficulties (Axline, 1947,

1969; van der Kolk, 2005). For children, play is often the vehicle of communication.

Through the use of play materials, directly or symbolically, children act out feelings,

thoughts, and experiences in a meaningful expression beyond their limited use of words

(Landreth, 2001; Piaget, 1924). Play bridges the gap between a child’s experience and

understanding, thereby providing the means for insight, learning, problem solving, coping

and mastery of skills (Axline, 1969; Landreth, 2001; Schaefer, Gitlin & Sandgrund, 1994).


In essence, the language of play between the child and therapist can assist the therapist in

assessing a child’s behavior.

Additionally, by the time a child who has experienced a traumatic event reaches a

therapy room, more than likely he/she has been involved with one, if not all, of the

following: questioning by parents/caregivers, interviews by state officials, medical

examinations by health providers, and evaluations by a school psychologist (Everstine &

Everstine, 1993; Gil, 2006; Greenspan & Greenspan, 2003). These experiences often

compound the current stressors in a child’s life, resulting in feelings of fear and distrust,

escalating defenses toward unfamiliar surroundings and people (Cattanach, 2008). Children

need to find their surroundings secure and comfortable and may benefit from more time spent

in a new environment in order to adapt and become familiar with the assessment process and

the therapist (Axline, 1947, 1969; Goodyear-Brown, 2010). Development of this adaption

may require more than the average number of sessions normally accepted by insurances or

clinical practices.

Information about the study. Based on the literature, children who have

experienced trauma and abuse require specific provisions to navigate successfully through

the initial phase of therapy, in particular the assessment process. This finding supports the

use of a more child friendly, play-based model of assessment (Cattanach, 2008; Gil, 2006;

Greenspan & Greenspan, 2003; Shelby & Berk, 2009). The Extended Play-Based

Development Assessment (EPBDA), developed by Eliana Gil (2011), is an integrated

assessment model that uses directive and non-directive play approaches, intended to discern

the developmental levels of the different ages, and offers a step by step protocol for

standardized use.

Eliana Gil (2011) stated in the EPBDA:


The original purpose of the Extended Play-Based Developmental Assessment is to

give children more ample opportunities to become comfortable with the therapist and

the setting, to encourage children to develop feelings of trust and safety, and to invite

them to externalize their thoughts and feelings in child-friendly ways. (p.1)

The EPBDA model is designed to be used alongside other assessment measurements,

such as the Child Behavioral Checklist (Achenbach & Rescorla, 2001), the Parent Stress

Index (Abidin, 1990), and The Trauma Symptom Checklist for Young Children (Briere,

2005), to ensure sufficient information is collected for treatment planning.

There is support for play therapy as an effective treatment for a variety of problems,

such as anxiety, depression, grief, rage, and/or fears (Axline, 1947; Klein, 1955; Landreth,

2002; Le Vieux, 1994). The assessment phase is the initial part of treatment, and in that the

therapist would assess the level of need for integrating the appropriate play therapy approach

as part of the treatment (Ray, Bratton, Rhine, & Jones, 2001; Schafer, Gitlin, & Sandgrund,

1994). Integrating non-directive with directive play extends the amount of time to the initial

phase of the assessment process, from an average of 1-2 sessions to 8-10 sessions (Gil,

2011). Extending the assessment with a preliminary non-directive play phase encourages the

development of safety in the therapy room and security within the relationship between the

therapist and the child (Gil, 1991; Goodyear-Brown, 2010; Shelby & Felix, 2006).

Following a non-directive phase is the directive play phase, concluding the assessment of the

different domains of functioning (Rasmussen & Cunningham, 1995; Shelby & Felix, 2006).

Quite possibly in using the EPBDA model, and the integration of a directive and non

directive play approach in assessment, a child’s apprehension can be diffused, as the child

adjust to the environment and open expression of thoughts and emotions occur through the

play modality. Play becomes the representation of the child’s self-report and ultimately


identifies internal distress (Gil, 2006; Van der Kolk, 2005). The goal of gaining insight into

a child’s development and presenting problems can be achieved without further exacerbation

of the child’s anxiety; and in so doing, the domains of functioning which are critical to

development of treatment plans can be ascertained.

The research problem/question. The purpose of this study was to explore the

experiences of the child, the parent/caregiver, and the therapist in the use of the assessment

model, The Extended Play-Based Developmental Assessment, developed by Eliana Gil

(2011). The research question was: What are the experiences of the participants (child,

parent, and therapist) as they partake in the EPBDA model? The guiding questions in this

study were:

1. How did the child respond to the use of the EPBDA model?

2. What was the experience from the parent perspective?

3. How did the therapist describe the assessment experience using the EPBDA

model?

The supporting question was: What was and was not helpful with this assessment approach?

Methodology. From the constructivism perspective, this study focused on the

participant’s viewpoint, the play room setting in which experiences were made, and the

meanings behind those experiences (Creswell, 2005; Denzin & Lincoln, 2000). A

qualitative, collective case study design was utilized to gain an in-depth understanding of the

experiences and meaning of the participants experiences. The collective case study design

was tied to the ethnographic tradition, and can be explained as the process of describing and

interpreting behavior (Crane, 2005; Creswell, 2005; Levin, 1992), specifically the

experiences in using the EPBDA model.


Assumptions and limitations. There are several assumptions to consider relating to

this study. One assumption was in the integrity of the participating children and parents, and

the reporting of experiences in the study. Research findings would be significantly

influenced by the participant’s reservation to report or express their reactions honestly. A

second assumption was in the researcher’s ability to understand and make meaning from the

participant’s statements and behaviors. Further assumptions to consider for this study

include (a) parent willingness to complete the interview process, post questionnaires, and

accompanying their children to sessions, (b) children’s willingness to participate in

assessment protocols, (c) participants were willing to not be involved in any other mental

health therapy during the study, and (d) participants were willing to complete research

assessment process.

Regarding limitations for this study, first there is the limitation of a small sample size.

Due to time constraints of the researcher, the sample size was limited based on availability of

participants within the window of time that the study was conducted. Further, the study was

limited to children between the ages of five and nine years old, with a history of trauma, who

live in Snohomish or King County of Washington. Case studies are often considered a

concern in qualitative research due to the limitation in their generalizability; therefore,

conducting additional studies using the EPBDA model in various clinical settings is

suggested. A second limitation is the dual-role of the researcher/participant, and the

potentiality of a theoretical presupposition that may have influenced the findings. In order to

strengthen the reliability of this study, the following procedures were applied (a) multiple

sources of data collection; (b) use of a second rater to code and assimilate data; and (c)

triangulation method of data analysis.


Significance. Current empirical research paradigms appear to have a void in studies

that thoroughly investigate clients’ experiences with assessments for trauma in children

(Leblan & Ritchie, 2001; Ray et al, 2001; White & Allers, 1994). In efforts to improve the

credibility of play-based therapy and assessment research, it has been suggested that studies

by graduate students be conducted in collaboration with practicing clinicians who are

currently developing new treatments and interventions (Ray & Schottelkorb, 2010; Snow,

Wolff, Hudspeth, & Etheridge, 2009; Urquiza, 2010).

Summary. The purpose of this study was to explore the experiences of the child, the

parent/caregiver, and the therapist in the use of the assessment model EPBDA model.

Through the exploration of participant’s experiences, the intention was to add to current

research and encourage further study of the EPBDA, as there is a need for play-based

assessment protocols when working with children who have experienced trauma. The

theoretical and conceptual framework for this study is presented in the following chapter, as

is the background of child development, the effects of trauma to the child psyche, and the

basis for use of play therapy in the assessment of children.


Chapter 2

Literature Review

Introduction.

“Play bridges the gap between concrete experience and abstract thought,

allowing children to learn to live in our symbolic world of meanings and values.”

(Piaget, 1962)

This chapter features the concepts of child development, trauma, and play therapy in

greater depth, based on the available research in the topic. The specific topics in review

include: (a) theories in child development; (b) background in trauma, to include definition;

(c) history of play therapy; and (d) directive and nondirective play concepts. In general, the

modern concept of play therapy emphasizes the therapist’s role as a facilitator of thematic

communication through both nonverbal and verbal means. The therapist must both seek to

understand the psychological needs of the child and try to reflect the meaning of the child’s

thoughts and emotions back to the child, to enhance the cyclical learning process. This

therapeutic method has a long history of success, particularly in its application since Piaget’s

contributions.

Theories in child development. Among the foundational theories of child

development, Jean Piaget and Lev Vygotsky stand out for providing the basic theoretical

models that persist in some form in most of today’s literature on child development (Becker

& Varelas, 2001; De Vries, 1997; Fredericks, 1974; Gillen, 2000). While Piaget provided a

generalizable model of development stages that children experience, which helps

practitioners apply practical approaches to working with children identified as falling within

a given stage of development, Vygotsky more specifically formulated a theory of children’s

playing (Gillen, 2000). A comparison of the two theories shows that both may operate


simultaneously in a given observation. Piaget’s theory specifies the basic parameters of the

child’s psychological functioning, with the emphasis on the learning process, while

Vygotsky’s theory focuses on the child’s use of language during play, which takes on distinct

forms as the child passes through each of Piaget’s stages of development.

Jean Piaget. Jean Piaget’s theory includes four stages of cognitive development,

according to which children become actively involved in constructing their own cognitive

worlds by the use of schemas, actions, and mental representations to organize knowledge

(Piaget, 1962; Piaget & Inhelder, 1969). This refers to the sensori-motor period, which

covers the first two years of life; the pre-operational stage, which lasts through approximately

the age of six years; the concrete operational stage, which subsequently lasts through the age

of 12 years; and finally the formal operational stage, which takes the child through the

remainder of the actual childhood period and into adulthood (Piaget, 1962).

In Piaget’s (1962) first stage of cognitive development, which lasts through the age of

two years, the child is learning sensori-motor habits, so behavior develops insofar as

particular choices of sensory experience result in the perceived effect of that experience. The

child thus exercises a maximum range of sensory opportunities, which explains in part why

children appear to be willing to taste everything, rather than merely feeling it with their hands

and observing it with their eyes. Eventually, by this means, the child develops a sense of the

permanence of objects. This refers to the expectation that objects known within the child’s

sensory experience persist, even when the child loses sight of them.

In Piaget’s (1962) second stage of cognitive development, which lasts from two to six

years of age, the child experiences pre-operational development. Piaget explained that the

child becomes strongly egocentric in this phase, which is an aspect of the child’s need to

develop a sense of autonomy from the parent, although it falls short of reaching a level of a


fully independent identity. During this stage of development, children adhere to a singular

point of view respecting each experience, rather than being open to alternative perspectives.

When approached by other children with conflicting points of view, they reject them, if they

have already expressed their own point of view on the phenomenon at hand. Nevertheless,

this intransigence is temporary, for the presentation of an alternative point of view by a

parent usually becomes a new source of information for the child shortly thereafter.

Therefore, at first, a child is likely to oppose the new perspective vehemently, only later to

adopt it as though there was never any opposition at all.

In Piaget’s (1962) third stage of cognitive development, which lasts from six to about

12 years of age, the child in experiencing concrete operational behavior. This refers most

specifically to the ability to perform actions that originate in thought, such as pouring water

accurately, drawing pictures that demonstrate detail, operating mechanisms of various kinds,

and experimenting with the inner workings of objects to try to understand them better. At

this stage of development, the child now has the ability to accept or accommodate alternative

modes of understanding about the world, rather than adhering stubbornly to only one.

Meanwhile, the child has also acquired a sense of equivalency among configurations of

concepts, such as volume, mass, and length, about which the child more easily predicts what

the alternative configurations of the noted dimensionality may be. Therefore, at the concrete

operational stage of development, the child has become mentally functional in a way that is

reminiscent of that of an adult, in the area of comprehending physical dimensionality. The

child can therefore perform many work functions that are infeasible for younger children, so

specific skills are now within reach of the child’s learning.

In Piaget’s (1962) fourth and final stage of cognitive development, which lasts from

about 12 years of age through the end of childhood, the child experiences formal operational


development, which means that the child’s thought processes now extend beyond the realm

of the concrete and into the realm of the abstract. This signifies the beginning of the child’s

apprehension of logical processes. Thus, in a manner of speaking, the child no longer needs

to see the object to imagine its possibilities, but may now imagine the object and do the

same. This is the stage at which full creativity at last becomes possible. Children at this age

can consequently learn abstractions of all sorts, including mathematical models. Therefore,

within this stage, the child becomes an adult in most manifest ways and can function

alongside adults on adult projects of various kinds.

Likewise, Piaget believed that children need to experience personal involvement in

their own learning to the point of healthy experimentation and application of active thinking

to reflect upon their learning (Piaget, 1972). According to Piaget (1924), children below the

age of 12 years have yet to develop the ability to engage effectively in abstract reasoning.

Therefore, they engage in very limited communication through verbal language. By

reference to this understanding, children then have only a restricted potential for language

processing and may be unable to express their thoughts and feelings accurately. Play uses the

resources of schematic and mental symbols, which bridge the gap between concrete

expression and abstract thought. By this means, children may use toys as language symbols

to allow freer expression of feelings and ideas (Axline, 1947, 1964; Landreth, 2001; Piaget,

1969).

Lev Vygotsky. Lev Vygotsky’s sociocultural theory depicts children as social

creatures and suggests that higher-order cognitive development (i.e., comprehending abstract

thoughts) occurs primarily through social interaction, in view of the fact that language and

thought are mutually discrete functions that eventually merge in terms of relational exchange

(Bodrova & Leong, 2007). In the communal environment, children use symbols and


concepts to think. In a form of language that befits their overall cognitive development,

children are thus capable of imagining, manipulating ideas, creating new ideas, and sharing

those new ideas. Through this language exchange, children are able to appropriate the

meaning of mental concepts; thus, in essence, they shift meaning through talking, which

leads to an enrichment of their understanding (Fredericks, 1974; cf. Piaget, 1924).

Within the context of language acquisition, Vygotsky also proposed a theory of how

children develop through the mechanism of play (Santrock, 2004). Specifically, Vygotsky

believed that play facilitates the child’s evolving apprehension of the nature of objects,

through sequential appreciation of permanence, concreteness, and abstraction (Santrock,

2004). This follows essentially the same developmental order of events as depicted in

Piaget’s model. Importantly, Vygotsky believed that human beings must ultimately develop

highly complex mental aptitudes to function effectively in human society (e.g., all human

beings must develop an appreciation of the abstract notion of risk in making decisions

involving multiple parameters simultaneously), but this development encounters a great deal

of resistance without the help of the mechanism of play. For Vygotsky, therefore, play

constitutes an essential facet of human development as a whole, rather than merely an

optional facet of recreation. It exists among human beings fundamentally to provoke abstract

thinking.

Further reinforcing the connection between Vygotsky’s psychology of play and

Piaget’s developmental stages is Vygotsky’s illustration of the child who sees someone

riding a horse and wishes to do so himself. Vygotsky (1978) explained that a child under the

age of three (i.e., in Piaget’s first developmental stage) has yet to develop the ability to form

mental abstractions. Consequently, the child may cry in protest, demanding a social response

that is impossible to provide. In contrast, a child aged three or beyond (i.e., in Piaget’s


second developmental stage) can now imagine riding the horse and may simulate the action

in play. This reflects a significant change in the child’s psychological functioning, by which

the impossible now becomes possible on a different plane of thought, that of the imagination.

The child’s normal solution is to adopt an artifact that only resembles a horse insofar as the

child is capable of wielding it in approximately the same way as one wields a horse, and then

simply pretend to ride the horse. Vygotsky (1978) explained that the chosen option, known

psychologically as a pivot, serves to enable the child to connect real action (play) with

desired action (riding a horse), by means of a mostly arbitrary but deeply meaningful

concrete solution.

Vygotsky (1978) argued further that the necessity for pivots, which serve as concrete

media enabling the child’s imagination to function fully in play, decreases as the child

develops a stronger ability to internalize the abstraction that it represents. Ultimately,

imagination loses its dependence on concrete objects, and common activities that replace

play become more abstract themselves, such as in the form of structured board games,

creative art, or creative writing. This transition occurs during Piaget’s third developmental

stage (between the ages of six and 12), after which the child’s interest in play that involves

concrete substitutes for known objects subsides, while a new interest in play that occurs at

one or two levels of abstraction afield of the objectively identifiable form of play emerges.

For example, a young child in Piaget’s second level of development may pretend to

drive a car, by walking around with a kitchen plate as the steering wheel, while making

noises that seem to resemble the familiar aspects of the experience of being in a car (Piaget &

Inhelder, 1969). A few years later, simulating a car may no longer be entertaining, but

simulating space flight may emerge as a new interest. The kitchen plate no longer suffices,

because the tax on the imagination exceeds such simplicity. However, the availability of


monkey bars on a playground may provide just enough of a concrete pivot to simulate this

more abstract concept. Later, it may suffice to write stories or draw pictures to achieve the

same satisfaction from working out an abstraction in accordance with the developing

imagination (Gillen, 2000).

Trauma. Language and communication constitute a superbly human developmental

achievement, but this is vulnerable to significant stunting in the presence of abuse and trauma

(Briere & Scott, 2006). Studies of language in maltreated children show critical delays in

language development, especially in the verbal expression of children’s internal feelings

(Mills, 1995). This reflects the basic theory of Vygotsky, in that it emphasizes the role of

language complexity in psychological development (Bodrova & Leong, 2007). That is,

Vygotsky’s belief in the central importance of self-talk during play suggests that children

who find themselves unable to play will hence fail to engage in self-talk, which in turn

suggests that their entire psychological development will lag (1978). Before assessing the

presence or impact of trauma, however, it is essential to understand what constitutes a

reasonable definition of trauma from abuse or maltreatment.

References to trauma are subject to overuse in the current age, in contexts that often

simply imply stress in experiences that otherwise fall short of constituting legitimate traumas

(e.g., testing, public speaking, or driving in traffic; cf. Brody & Baum, 2007). The Diagnostic

and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association,

2000) defines a traumatic event as one that involves actual or threatened death, serious

injury, or harm to one’s physical integrity, witnessing thereof, or knowledge of an

unexpected death, serious harm, or threat of a loved one (Wingenfeld, 2002).

Van der Kolk (1987) explained that the critical issue in defining trauma and methods

of resolving it has to do with the debilitating nature of the loss of control in the event at issue,


which individuals experience, especially young children. The lack of a personal sense of

control over the event in question is the central determinant of its traumatic impact on the

individual (Wingenfeld, 2002). Because very young children are entirely dependent

psychologically on their parents, unexpected events that signal the abrupt loss of parental

protection can be potentially traumatic (Suedfeld, 1997). The effects of traumatic events can

linger long after the traumatizing event has passed and then recur, ebbing and flowing in

manifestation over time (Wingenfeld, 2002). Such effects may manifest themselves in

symptomatic behaviors associated with posttraumatic stress disorder (PTSD), although the

full criteria of PTSD may never reach a point of clear qualification (Gil, 2006; Walsh,

Fortier, & DiLillo, 2009; Wolf, Reinhard, Cozolino, Caldwell, & Asamen, 2009).

Children have unique ways of understanding trauma, both among themselves and in

comparison to adults (Cohen, Mannarino, & Deblinger, 2006). These distinctions involve

how they create meaning from the events in relation to themselves, how they access support

systems, and how they cope with psychological and physiological stress associated with the

traumatic or abusive event (Cohen et a l, 2006). Because a child’s particular mode of

responding depends on the child’s own personality, familial situation, and coping

mechanisms, it is necessary for the therapist to develop assessments and treatments to fit

each child’s uniquely identifiable needs and circumstances (Cicchetti, Rogosch, Lynch, &

Holt, 1993; Cohen et al., 2006; Gil, 2006). Taking a phenomenological approach to bringing

about this understanding between the therapist and the child often depends on the mere

mechanisms available in play therapy (Gil, 1991).

Play therapy. The etiology of play in therapy began in 1909 with psychoanalytic

theory, as documented by Sigmund Freud in the illustration of Little Hans (Gil, 1991,

O’Connor, 2000; Schaefer & O’Connor, 1983). In this illustration, Freud observed a young


boy at play and gave advice to the boy’s father based on his observations of precisely how

the child behaved in play (Landreth, 2002). A decade later, Anna Freud began implementing

play with children in her own approach to psychotherapy, as an avenue for unlocking the

unconscious motivation behind the manifest imagination, especially through drawing and

painting. However, Anna Freud considered play to serve more in the manner of a tool for

developing the relational bond between the child and the therapist, than in that of a medium

for activating the process of transference, for which the interpretation of play is paramount

(Freud, 1946). Anna Freud’s assumptions in this regard obeyed the central model of

Freudian psychology, namely, the tripartite division of the id, ego, and superego (Schafer,

1980). In theory, these dynamics manifest a significantly different structure in children, as

the id is at its greatest relative power respecting the other two, while the superego lags

behind in development (Freud, 1946). Therefore, watching children at play theoretically

demonstrates the relative positioning of these three psychological components.

In contrast, Melanie Klein considered play as the child’s way of engaging in free

association by means of object relations (Landreth, 2002). This is an extension of Freudian

theory, in that free association forms an essential part of the therapeutic repertoire (Freud,

1946). Specifically, while adults engage in free association verbally, wherein their selected

themes inevitably gravitate toward their strongest complexes, children’s engagement in free

association lacks the verbal or imaginary apparatus necessary for a similar use of verbal

skills. Therefore, displays of imagination must take on the form of physical, observable play,

but this activity then theoretically manifests themes that similarly gravitate toward the child’s

strongest complexes (Klein, 1955). From this perspective, a therapist may analyze a child’s

internal perspective through observation and interpretation of patterns or themes in play.

Klein thus gave play symbolic meaning, believing that play activities actually lead to


transference (Klein, 1955). Such activities therefore encourage children to develop insights

into themselves, understanding about their own motivations, and appreciation of their

relation to the rest of the world (Klein, 1955).

Finally, Virginia Axline (1947) believed that children’s behaviors are the product of

internal drives that amount to aspirations for self-realization. Axline thus approached play in

a nondirective manner (i.e., treating it more like free association). As a student of Carl

Rogers (1951), Axline applied the theory of client-centered (or person-centered) therapy to

children, and this approach evolved into a concept of child-centered play therapy (Landreth,

2002). Axline believed that children should have the freedom to be self-directed in play

activity and saw the role of the therapist as one that should seek to reflect the feelings and

thoughts expressed by the child in this manner (1947). Axline considered the development

of a safe and trusting relationship between the child and therapist as constituting the most

salient element to the play experience. Axline’s (1947, 1950) insights into this area form the

basis for modern conceptions of play therapy.

Directive and nondirective play. It is conceivable for the therapist to direct a child in

play or to wait for the child to choose a form of play without guidance, such as in a playroom

that features many options (Axline, 1950, 1969). Axline (1969) believed that the principle of

free association remains crucial to enabling the child to engage in healthy developmental

activity, so she made sure to distinguish between these two approaches in terms of the

relationship between the therapist and the child. Through childhood generally, free

association in this sense is important, and only in later years does directive play emerge.

Axline (1969) outlined eight basic principles of a nondirective approach (p. 73). These are

construable as follows:

1. The therapist seeks first to nurture a friendly, supportive alliance with the child.


2. The therapist exhibits behavior that communicates unconditional acceptance of

the child.

3. The therapist expresses a permissiveness to invite the child to express feelings

freely and openly.

4. The therapist is attentive to the child’s emotional expressions and reflects

observed feelings back to child in such a way as to serve as a source of insight to

aid in the child’s development of trust and understanding in the relationship.

5. The therapist maintains a belief in the child’s identity as the force for change and

ability to solve problems without assistance, if given the opportunity.

6. The therapist refrains from directing the child’s conversations or actions.

7. The therapist allows the child time to process information at a pace of the child’s

effective choosing.

8. The therapist establishes limits only insofar as these are necessary to keep the

child in the realm of reality, with a sense of personal responsibility.

The advantage of the nondirective, child-centered approach to assessment is that it

allows children to use their play language to express how they think and feel about their

world (Axline, 1950). That is play as self-expression is the most significant consideration in

play therapy. Structured, directed approaches can at times contaminate observations of

children’s play activity, whereas nondirective approaches tend to create more opportunity for

learning about the child (Greenspan & Greenspan, 2003; Shelby & Felix, 2006). For

example, in a case study of a grieving girl of five years of age, LeVieux (1994) reported that,

when using a nondirective approach, the young girl developed an opportunity to manage

what had previously seemed unmanageable, as she felt free to direct her own self-expression

of feelings symbolically through her play.


A second advantage of the nondirective approach is that it gives the child a sense of

control over the environment. Initially, the therapist’s role is to assist the child in

experiencing the playroom as a safe place, to serve as a secure base for the child (Gil, 1991;

Goodyear-Brown, 2010; Shelby & Felix, 2006). One of the most widely known cases of play

therapy is that of Dibs, a withdrawn child of five years of age, described as a therapeutic

enigma (Axline, 1964). The description of this child includes being mute, in a practically

catatonic state, punctuated by exhibitions of violent temper tantrums. The child appeared to

have a cognitive disability, but revealed superior intelligence. Through nondirective play,

this child was able to begin the journey of healthy child development, without the

encumbrance of a diagnosis of mental illness (Axline, 1964). Within a safe environment, the

child was able to explore and reclaim the attributes of childhood according to the models of

Piaget and Vygotsky. The approach to assessment based on nondirective play utilizes the

expressive methods of nonverbal communication to encourage children to engage and

externalize their thoughts and feelings in an accepting, non-threatening environment (Axline,

1947; Gil, 1991; Landreth, 2002).

After a child has gained safety and security in an environment of nondirective play,

the therapist may subsequently begin to direct the child in those forms of creative play that

will be most beneficial and developmentally appropriate (Jones, Casado, & Robinson, 2003).

In this manner, the therapist uses this structured environment to focus attention on particular

domains of functioning and behavior, to stimulate activity, gain information, and make

interpretations (Landreth, 2002; O’Connor & Schaefer, 1994). Thus, what begins as purely

nondirective play is analogous to verbal free association, but as the child develops according

to the noted models of psychological development (Greenspan & Greenspan, 2003), directive

play serves as a way to building an experiential dialogue between the therapist and the child.


In this way, it is analogous to following free association with directed inquiries into an adult

patient’s specific concerns or complexes. In essence, play serves as the operating language

for the therapist’s practice with the child, while verbal expression, which employs the fully

developed human imagination, analogously serves as the operating language for the

therapist’s practice with the adult.

Summary. The governing theories of child development are the developmental

models of Jean Piaget and Lev Vygotsky. These models explain what occurs psychologically

and in terms of learning, at progressively more mature stages of childhood development and

lead to Virginia Axline’s theory of play therapy, based in further measure on Carl Rogers’

client-centered therapy. Axline’s theory essentially applies the Freudian practice of free

association to the mechanism of play, rather than using explicit verbal language. In so doing,

it obeys the relevant principles outlined by Piaget and Vygotsky. Because trauma is capable

of interfering significantly with normal psychological development among children,

therapists need an effective way to build a trusting relationship with a child client who has

experienced trauma.

Play therapy thus benefits from strong, practical effectiveness and strong grounding

in the theoretical models that drive it. The literature suggests that play therapy is a viable

approach and, indeed, that it may be the most viable approach to enabling a therapist to build

a trusting relationship with a child client. Given the general effects of trauma, particularly as

they relate to the child’s sense of a lack of control over the events, particularly in the case of

the sudden deprivation of parental protection, creating a new bond of trust to enable the

child’s capacity for reengagement with a protective figure is critical to restoring the child’s

natural development toward higher stages of cognitive complexity. Interestingly, producing

this outcome seems to depend on creating a setting in which the traumatized child returns to a


position of experiencing control over events, this time in the safe setting of the therapist’s

workspace. Meanwhile, the presence of the fully supportive therapist may serve to restore

the child’s needed sense of having a source of parental protection on which to rely to engage

in the imagination-building activities that justify the encounter.

The next chapter describes the methodological model for this study and discusses the

parameters for using the Extended Play-Based Developmental Assessment, developed by

Eliana Gil (2011). For the purposes of this research, the design was a qualitative, collective

case study, with the objective to explore generalizable themes of experience in using the

play-based assessment with direct subjects.


Chapter 3

Research Design and Methodology

Introduction. The fo llow ing chapter provides an overview o f the methods and

procedures implemented in the study, as well as discussion o f the philosophical worldview

and rationale for the methodology. Further detailed in this chapter is information concerning

the participant selection, credibility o f therapist, and intake/exit procedures. Description o f

setting, materials, the EPBDA fie ld procedures, methods o f data collection and analysis

follow.

Rationale for qualitative research. The purpose o f this study was to explore the

experiences o f the child, the parent/caregiver, and the therapist in the use o f the EPBDA

model. This qualitative study followed a constructivism perspective which emphasized the

importance o f the participant’ s view, the play room setting in which experiences were made,

and the meanings behind these experiences (Creswell, 2005; Denzin & Lincoln, 2000). An

interpretive theoretical approach was utilized in order to focus on the participant’ s

interpretation o f interactions w ith each other and to gain a deeper understanding o f their

perspective in using the EPBDA model (Hesse-Biber & Leavy, 2006). Denzin and Lincoln

(2000) clarified qualitative research as,

.. .a socially constructed nature o f reality, the intimate relationship between the

researcher and what is studied, and the situational constraints that shape inquiry.

They seek answers to questions that stress how social experience is created and given

meaning (p.8).

A collective case study design was the primary mode o f inquiry for this research, which is

tied to the ethnographic tradition, and can be explained as the process o f describing and


interpreting behavior (Creswell, 2005, Crane, 2005; Levin, 1992); specifically in this study as

the experiences of participants in using the EPBDA model.

Overview of research. The central goal in this study was to understand the

participants experiences and individual meanings as fully as possible. Research in case

studies is strengthened in the collection of multiple sources of evidence (Creswell, 2009;

Crane, 2005); therefore, data collection included interviews, questionnaires, direct

observation, documentation, and audio/visual materials.

The research question was: What are the experiences of the participants (child, parent,

and therapist) as they partake in t EPBDA model? The guiding questions in this study were:

1. How did the child respond to the use of the EPBDA model?

2. What was the experience from the parent perspective?

3. How will the therapist describe the assessment experience when using the

EPBDA model?

The supporting question was: What was and was not helpful with this assessment approach?

The research questions were focused on the experiences of all participants’ in the use of this

clinical model of child assessment.

Credibility of therapist. The therapist/researcher held a Masters Degree in

Counseling Psychology, and a license as a Mental Health Counseling Associate in the State

of Washington, with over two years experience in counseling practices (1U years post MA).

Play therapy training consisted of graduate level courses and seminars, and active

membership in the Association of Play Therapy. Clinical supervision was provided by the

Clinical Director for Cedar Park Counseling Network, Dr. Phil Templeton, LMFT. The

therapist/ researcher played the role as participant/observer.


Participants. Careful consideration in the selection of participants was imperative

due to the potential nature of the child’s trauma history. The research focused on children

between the ages of five to nine years of age with symptoms of maladaptive behaviors due to

abuse or environmental stressors. The selection procedure followed a two step process which

involved initial screening via phone calls, and intake and collection of consents.

Participants were referred through the Cedar Park Counseling Network website, and

programs that advocate for children, as well as individual therapists, pediatricians, and

churches. Letters, brochures, phone calls, and personal contacts were utilized to inform these

referral sources of the study opportunity (Appendix A). Clients who met the following

criteria were invited to participate in the study: (a) the child must be between the ages of five

and nine years at the onset of study; (b) the child must demonstrate symptoms of maladaptive

behaviors due to trauma or environmental stressors; (c) the child should not be not currently

enrolled in any other type of therapy; (d) the child and guardian must agree to interview

questionnaires and video recording of sessions; (e) the child and guardian must agree and

sign the informed consent.

Procedures. Initial screenings were conducted over the phone to ensure children met

the inclusion criteria, to discuss basic information about the study, to answer any questions,

and to arrange for an intake session. The intake session included parents/caregivers of the

child participant and therapist/researcher. The following criteria were addressed during

intake meetings; (a) participants verification of legal guardianship if not biological parent of

child (e.g. foster parent); (b) participants were informed about the nature of the study; (c)

participants were informed about the video/audio recording and observation; (d) participants

reviewed clients rights and consent forms.


Upon agreement between all parties, informed consent and clients rights (Appendix

B) were signed, and participants completed the child background information (Appendix C)

and standard paperwork as required by Cedar Park Counseling Network protocols. At the

conclusion of the intake, appointments were arranged to begin the child’s assessment.

Procedures for all sessions followed protocol as directed in the EPBDA model,

(Appendix D). Essentially, the study consisted of 8-10 sessions each, 50 minutes in length,

on a weekly or biweekly interval. In the beginning, six to eight sessions were conducted with

the child; the first two to three assessment sessions were non-directive approaches, which

included creative play to encourage expression and allow the child freedom of choice in play

and ample time to develop a relationship with the therapist. The remaining assessment

sessions included an integrated non-directive and directive approach that incorporated art

work, sand play, developing a family genogram (identification of family members), and

developing a feelings chart (affect recognition). After completion of child sessions, a parent

session was arranged to discuss assessment evaluation and referral recommendations. To

give closure to the assessment process, a final session was arranged to allow closure, family

adjustment, and to complete exit questionnaires.

Video recording. A video recorder was set up in the play room with a full range of

the room. Participants were informed of the camera and recordings continued throughout the

duration of each session. Recordings were kept confidential throughout the study, and upon

completion of this dissertation were deleted. Consent forms informed participants of video

recordings and rights to discontinue participation at any time during the research (Appendix

B).

Human subjects review board. Initial planning discussions of this research were

engaged between the researcher, Dr. Phil Templeton (Clinical Director of CPCN), Dr. Joe


Fuiten (Senior Pastor of Cedar Park Church), and Ben Waggoner (Cedar Park Church

Attorney). In support of the research, the Cedar Park Counseling Network and Cedar Park

Church granted the research project space in the CPCN Children’s Center at no charge to the

therapist or participants. The counsel of the CPCN Attorney, Ben Waggoner, was utilized in

the development of intake documents and the consent forms to be given to subjects of this

research, and in accordance to Washington Administrative Code (WAC) and the Revised

Code of Washington (RCW) regulations. Subsequent application to the Northwest University

Human Subjects Review Board (HSRB) was submitted for approval to proceed with

research. Upon approval from the HSRB, intake appointments were arranged.

Materials. The Extended Play-Based Developmental Assessment (EPBDA)

developed by Eliana Gil (2006, 2010) was designed as:

A clinical model to assist in determining a child’s overall functioning by: identifying

current clinical symptoms; identifying trauma impact, if any; assessing a child’s

perception of parental support and guidance; and determining a child’s perceptions of

their internal and external resources. (p.2).

Procedures for the EPBDA model were followed. The list of protocols is exhaustive,

and therefore has been provided in detail in Appendix E.

The Child Background Information form (Appendix C) was developed specifically

for this study to collect the following demographic information; the parent’s description of

presenting problems, environmental stressors, and family of origin history, child’s

developmental history, academic history, external systems, and support network. This survey

was completed by the child’s parent/caregiver.

Setting. The study was conducted in the Cedar Park Counseling Network’s

Children’s Center, on site of Cedar Park Christian Schools, (building A), located in Bothell,


Washington. An exclusive play room was developed for this study. It was equipped with

standard protocol play room materials considered necessary to engage the child in play

activity for therapeutic procedures (Landreth, 2002). Room size was approximately 20 by 20

feet, and included a child size table and four child sized chairs, a chalk board, shelves with

toys, a puppet center, an art center, two sand trays (dry and wet), and a storage cabinet for

miniatures used in sand trays (Play Materials, Appendix E). The play room had a dual role

as office space for the therapist; as a result, the room also included a desk, a file cabinet, and

a couch.

Data collection and analysis. The participant observer role was congruent to that of

a typical therapist role, in which the therapist actively participated in the assessment process

of collecting case notes, case management, and evaluation (Creswell, 2009; Hesse-Biber &

Leavy, 2006). Observations of child and parent participants were documented in the Play

Assessment Observation Forms (Appendix F) directly following the conclusion of each

session. Parents completed questionnaires (Appendix G) describing their experiences at the

conclusion of the study. The therapist (participant observer) also completed a questionnaire

describing the experience with each participating family at the end of each assessment

closure (Appendix G). The therapist (participant observer) took field notes after each session,

and observed and noted the video recordings of all sessions. A research volunteer, a senior

undergraduate student from Northwest University, also observed recordings and assisted in

coding observations. These records shall be maintained in confidentiality possession of the

researcher post study.

The first step of the analysis process was the organization of data in preparation of

coding. Participants in this study were considered one case, and data from participants were

analyzed collectively. Data included in formatting consisted of unstructured video data of


sessions, unstructured therapist observer field notes of sessions, and unstructured text data

obtained from responses to questionnaires.

The second step in the analysis process included coding data into categories and

themes. A second coder assisted the researcher in the development of codes, examining for

overlap and redundancy, and collapsing these codes into broad themes common amongst

participants. The process of coding into themes followed several steps (Creswell, 2005).

1) All data were proof read for understanding.

2) Data were divided into segments of information.

3) Segments of information were labeled with codes.

4) Codes were reduced to avoid overlap and redundancy.

5) Codes were collapsed into themes.

In addition, there were several types of themes that occurred from the data.

Predetermined themes (things that were expected to be found), emergent themes (things that

were a surprise to be discovered), hard to classify themes (themes that did not fit with other

themes), and major/minor themes (representations of major ideas, or secondary ideas)

(Creswell, 2005). Data were analyzed between all participants to provide several viewpoints

in support of a theme. The description and development of themes in the data focused on the

principal research questions in order to form an in-depth understanding and accurate

interpretation of the participant’s experience.

Summary. In an attempt to address a void in play-based assessment research, the

researcher of this study aimed to thoroughly investigate the participant’s experiences with a

play-based assessment for children with a trauma history. In a qualitative approach, the goal

of this study was to explore the experiences of the child, the parent/caregiver, and the

therapist in the use of the EPBDA model. The results of this study contribute to the body of


knowledge in play therapy and the assessment of children with trauma history. Moreover,

this study utilizes a practical model that clinicians can easily replicate in their respective

practices and research. The subsequent chapter describes the findings of this study.


Chapter 4

Data Analysis

In troduction . The purpose of this study was to describe the experiences of the

participants with the Extended Play-Based Developmental Assessment. The approach of a

qualitative, collective case study design is linked to the ethnographic tradition, and can be

explained as the process of describing and interpreting behavior (Creswell, 2005, Crane,

2005; Levin, 1992). Data analysis and subsequent themes are an interpretation of the

culminating behaviors and statements of the participant’s experiences.

Data analysis. The preliminary steps in the analysis included categorizing and

coding data, examining emerging themes, and triangulating themes to support the research

question. The data included video recordings of 30 sessions, child questionnaires, parent

questionnaires, and therapist field notes and questionnaire. Coding was the primary mode of

data reduction and analysis. Through the use of codes for given behaviors, questionnaire

responses, and therapist field note comments, I was able to distinguish and cluster data codes

as they related to the research inquiry. Triangulation procedures were implemented to

strengthen emergent themes, as well as contribute to the credibility and trustworthiness of the

findings in this study (Glasser & Strauss, 1967; Creswell, 2009). The categorization and

triangulation of data themes created the essential foundation for the data analysis, thus

allowing me to decipher the participant’s experiences.

In consideration of the potential for researcher bias because of the participant-

observer role, a second coder was incorporated. As a means to maintain the client’s identity,

the children and families were given pseudonyms in this report.


Snapshot of children.

Andrew. The following information was collected during a parent interview on May

1, 2011. Andrew was 8.6 years old at the onset of the study. He presented with a history of

family maladjustment and behavioral problems in school. Andrew recently experienced the

loss of his younger sibling to Sudden Infant Death Syndrome, compounded with his parents

divorce, and having to move to a new home and school. Presenting symptoms endorsed on

the ASEBA included nightmares, headaches, periodic encopresis and enuresis; at home he

was reported to be argumentative, displaying tantrums with physical and verbal aggression.

At school he was reported as fighting with peers, breaking rules, and telling lies. Andrew’s

mother participated in the research and presented with significant measures on domains of

Depression, Isolation, and Total Life Stress, as indicated in the Parent Stress Index.

Bobby. The following information was collected during a parent interview on May 2,

2011. Bobby was 6.11 years old at the onset of the study. He presented with a history of in

utero drug exposure and early childhood trauma. Andrew was born addicted to

methamphetamine, eventually removed from his biological family, placed into foster care,

and subsequently experienced physical abuse. He was reassigned to a new foster home which

later adopted him. Presenting symptoms endorsed on the ASEBA included significant levels

of anxiety and depression (fears, crying, nail biting, worries), psychosomatic symptoms

(nightmares, headaches, nausea, stomachaches, enuresis), attention issues (can’t concentrate,

daydreams, inattentive, stares off), and aggressive behaviors (argues often, destroys things,

physically fights, tantrums, and cruelty to animals). Bobby’s adoptive mother participated in

research and presented with significant measures in domains of Isolation, Health, Role

Restriction, and Total Life Stress, as indicated in the Parent Stress Index.


Carlton. The following information was collected during a parent interview on May

18, 2011. Carlton was 5.0 years old at the onset of the study. He presented with a history of

maladjustment to his parents’ divorce and his mother’s recent move. Carlton recently had

returned to his father due to increasing signs of distress which developed during a six month

stay with his mother. Presenting symptoms endorsed on the ASEBA included worrying, cries

easily, afraid to sleep alone, nightmares, stomachaches, overly tired in day, sleeps less at

night, arguing and tantrums. Carlton’s father participated in the study and presented with

significant measures on the domain of Spouse with Parent Stress Index, indicating he had

reasonably adapted in all other domains, specifically to his son’s behavior and family

adjustment.

Dawn. The following information was collected during a parent interview on May 2,

2011. Dawn was 5.11 years at the onset of the study. She presented with a history of

attachment difficulty and sexual abuse. Dawn was removed from her biological parents

within her first year and subsequently lived within the foster care system for three years, until

she was adopted at four years of age. Presenting symptoms endorsed on the ASEBA included

withdrawn and nervous, cries easily, headaches, nausea, significant social problems (jealous,

suspicious, difficulty getting along with peers), and significant aggressive behaviors

(argumentative, demanding, fighting, and tantrums). In addition, Dawn was reported as

having a tendency to overeat. Dawn and Bobby are biological siblings, adopted by the same

family. The adoptive mother’s reports are stated above.

Findings.

Video observation o f children. Assessment sessions with the therapist and child

were video recorded, and later observed by the researcher and a second coder; behaviors

were documented and coded into themes. Overall, 30 sessions were recorded, eight sessions


each with Andrew and Dawn, and seven sessions each with Bobby and Carlton. Focusing on

what the child did and what the child said in assessment sessions provided a basis for

accurately reconstructing the experiences of the four children. Each session helped

qualitatively to enlighten the researcher of the children’s experiences.

Careful consideration of camera placement provided ample footage, although there

were times when the observer was unable to determine facial expression or decipher the

child’s comments. However, these occurrences were few and observations are considered a

good representation of the children’s experiences. Preliminary viewing of video footage of

one session from each child assisted observers in familiarization with the data and in

development of a rubric (Appendix H) which supported the coding of various behaviors.

These data contributed to the interpretation of the child’s experience.

Coding o f behaviors. Code’s for children’s behaviors was determined by analyzing

the nature of the speech, facial expressions, and body language. (i.e. if a child made eye

contact while talking to therapist, eye contact was coded; if a child did not invite therapist to

play, behavior was coded as disengaged; if the child refused a play directive, behavior was

coded as un-accepting of play directive, or vice versa). By coding and tallying behavior, a

pattern of each child’s experience emerged, yielding themes in behavior that aided in the

description of participants experience, the focus of the study.

Coding was developed within the following categories: Speech - talkative (surface

subjects), overall quietness, talks to therapist (in-depth feelings and thoughts), talks to self,

laughs, and cries. Facial Expression - smiling, frowning, eye contact, and no eye contact.

Body Language - active in play, withdrawn into play (self oriented), agitated, restless, calm,

rejects play directive, accepts play directive, engages therapist (invites therapist into play),

and does not engage therapist (does not invite therapist into play). See rubric (Appendix H).


Overview o f observations. Andrew was observed over a period of eight sessions, three

nondirective/free play, four directive/structured play, and one closure session. Andrew

initially presented as withdrawn and quiet, using mostly nonverbal modes of communication

(pointing, smiling, and nodding) and very few words. He made good eye contact. As sessions

continued, Andrew’s behavior presented with increasing amounts of smiling and laugher. He

appeared to become less agitated, less impulsive, and calmer; however, his appearance of

sadness, as evidence in frowning, was displayed in the last session. Throughout the

assessment Andrew gradually increased in talking to the therapist, becoming more accepting

of play directives, and interacting with the therapist. Andrew appeared increasingly engaged

in the assessment; however, he appeared agitated and disengaged during the self-portrait

drawing.

Bobby was observed over a period of seven sessions, two nondirective/free play, four

directive/structured play, and one closure session. Bobby initially presented with a great deal

of self talk during play, which gradually transferred to talking to the therapist. He held

consistent eye contact with the therapist, smiling often, with episodes of laughter. He

appeared hyperactive and restless near the beginning of the assessment, as evidence of

darting about the room and jumping from one activity to another. Gradually, Bobby

developed a calmer, purposeful, slower pace, and engaged with activities. Occasionally,

Bobby would withdraw back into playing alone and talking to self.

Carlton was observed over a period of seven sessions, two nondirective/free plays,

four directive/structured play, and one closure session. Carlton initially presented as quiet

and somewhat guarded, as evidenced by shifting eye contact and lack of dialogue.

Eventually, he increased his smiling, eye contact, and laughter. Carlton gradually became

more engaged with the therapist and play directives, slowly decreasing from withdrawal into


play, and increasing his level of talking to the therapist. Carlton displayed increasing

amounts of calmness, however during the sand tray and the feelings chart he appeared

agitated.

Dawn was observed over a period of eight sessions, three nondirective/free play, four

directive/structured play, and one closure session. Dawn’s initial behavior demonstrated high

energy and little display of emotion. However, she held a consistently adequate measure of

eye contact and eventually increased her smiling and laughter. She displayed a high measure

of talking to the therapist. Dawn varied in her activity in play and engaging the therapist, as

sometimes she would engage and others times she would want to play alone. Initial signs of

agitation and withdrawal into play quickly dissipated as she became calmer; however, she

was slightly agitated during the self-portrait drawing.

Categories and themes. Emerging codes and common themes from observation

included the following descriptions. In the Facial Expression category all four children

demonstrated more smiling and eye contact as compared to frowning and no eye contact

from the beginning to the end of the study. Looking at the Body Language category all four

children showed increasing measures of engagement with the therapist and accepting play

directives with each successive session. Three out of four children displayed more calmness,

and less agitation and restlessness across sessions. In the Speech category throughout

sessions, three out of four children presented an increase in talking to the therapist; three out

of four children also showed a decrease in quietness; and three out of four children

demonstrated a general increase in laughter. Overall themes from video observations

comprised of smiling and eye contact, an increase in talking to the therapist, a decrease in

quietness, and an increase in laughter, increases in engaging therapist and accepting therapist

directives, and overall calmness.


In addition, it is noteworthy to describe the equally distributed demonstrations of

withdrawing into play, where as two children increased and two children decreased in this

pattern of body language. Likewise, were the demonstrations of self talk and talkativeness, as

two children showed an increase and two children showed a decrease in these categories of

speech.

Table 1 Video Observation Categories and CodesChild Facial Expression Body Language SpeechA n d re w + s m ilin g

+ ey e c o n ta c t- n o ey e c o n ta c t- f ro w n in g

> e n g a g e s th e ra p is t> a c c e p tin g p la y d ire c tiv e> a c t iv e in p la y< w ith d ra w n in to p la y + c a lm n ess - a g ita tio n /re s tle ss

> ta lk s to th e ra p is t< q u ie tn e ss> s e l f ta lk> ta lk a tiv e> la u g h te r

B o b b y + s m ilin g + ey e c o n ta c t- n o ey e c o n ta c t- f ro w n in g

> e n g a g e s th e ra p is t> a c c e p tin g p la y d ire c tiv e < a c t iv e in p la y> w ith d ra w n in to p la y= c a lm n e s s a n d re s tle s s n e s s

> ta lk to th e ra p is t> q u ie tn e ss< s e l f ta lk< ta lk a tiv e< la u g h te r

C a r lto n + s m ilin g + ey e c o n ta c t - n o ey e c o n ta c t

> e n g a g e s th e ra p is t> a c c e p tin g p la y d ire c tiv e ac tiv e in p la y< w ith d ra w n in to p la y + c a lm n ess- a g ita tio n a n d re s tle s s n e s s

> ta lk s to th e ra p is t< q u ie tn e ss> s e l f ta lk> ta lk a tiv e

> la u g h te r

D a w n + s m ilin g + ey e c o n ta c t - f ro w n in g

> e n g a g e s th e ra p is t> a c c e p tin g p la y d ire c tiv e ac tiv e in p la y> w ith d ra w n in to p la y + c a lm n ess- re s tle s s n e s s a n d a g ita tio n

< ta lk s to th e ra p is t< q u ie tn e ss< s e l f ta lk< ta lk a tiv e= la u g h te r

(+ more than; - less than; > increase; < decrease; = equally distributed)

Child questionnaires. The opportunity to deepen the rapport and gather data on

individual experiences occurred during child questionnaire interviewing. As part of the

closure procedures, each child responded verbally to a standard set of questions in an effort

to form comparisons amongst the data sources (Appendix G). Responses were documented

verbatim in writing by therapist/participant. All children responded eagerly to participation in

answering questions about their experience with the Extended Play-Based Developmental

Assessment (2011). The therapist/participant worked to allow the data to emerge naturally,

encouraging the children to elaborate on their thoughts until a natural end to a line of inquiry


occurred. The children’s responses about their experiences served as an essential data source

for this study.

Coding of child questionnaires focused on categorizing and deciphering meaning

from responses. Codes from the emerging questionnaire data describing the collective

experiences of the child participant’s embraced a broad interpretation, which was collapsed

with codes from video observations into developing themes, and triangulated with other data

sources. Table 2 provides a guide to the development of meaning in codes which emerged

from this data source.

Table 2 Child Questionnaire

Meaning in Codes in Responses Examples

M e a n in g tie d to p lay ro o m experience : A n d rew : “It w a s fin e ” “It h e lp ed m e ta lk ” “th e to y s w ere• F u n fu n ”• E n jo y e d th e to y s (san d b o x ) B obby : “I t w a s rea lly , rea lly fu n ”

• T alk in g C arlton : “I t w a s g o o d ” “I t ’s fu n ” “I lik ed th e sand b o x ” D aw n: “I t w a s fu n ” “ T here are lo ts o f to y s”

M e a n in g tie d to fe e lin g safe u sing E P D B A : A n d rew : “I feel safe h e re ” “I feel I can tru s t y o u ” B obby : “I fe lt sa fe ... .very sa fe”

• S afe ty C arlton : “I feel s a f e . I feel safe h ere w ith y o u b u t n o t in m y x x x x h o u se ”D aw n: “ I fe lt safe w ith y o u ”

M e a n in g tie d to fe e lin g c o m fo rtab le w ith ac tiv ities: A n d rew : “I w as fin e ” “I rea lly lik ed th e sa n d b o x ” “N o th in g• C o m fo rt w as u n c o m fo rtab le ”• F u n w ith a c tiv ities (e sp ec ia lly san d b o x ) B obby : “I w a s c o m fo rtab le ” “I h ad fu n to o ”

C arlton : “ Y e s” . “E v ery th in g w a s fu n ” D aw n: “I t w a s all c o m fo rtab le ”

M e a n in g tie d to m o s t h e lp fu l aspect: A n d rew : “H a v in g so m eo n e to ta lk to ”B obby : “I am rea lly h ap p y h ere , I am n o t h ap p y o th er

• H av in g so m eo n e to ta lk to p lac es”• B e in g ab le to p lay C arlton : “P la y in g ” “ in th e san d b o x , h a , ha , h a . .w ith the

b o a t, th a t’s m y fa v o rite ”D aw n: “ju s t p l a y i n g . t h a t ’s a ll”

M e a n in g tie d to u n h e lp fu l aspect: A n d rew : “E v ery th in g w a s h e lp fu l” B obby : “E v ery th in g w a s h e lp fu l”

• N o th in g w a s un h e lp fu l C arlton : “ I d o n ’t k n o w . n o th in g ”D aw n: “I lik ed e v ery th in g , I d o n ’t like d is lik e an y th in g ”


For example, Andrew reported his experience as “It was fine, I liked all the toys”

(personal communication, June 7, 2011). Bobby reported in the questionnaire his experience

was “really, really fun” (personal communication, June 2, 2011). Carlton reported his

experience was “good”, that he would tell other children “about the toys”, and added he “I

liked the sandbox. that was fun” (personal communication, July 21, 2011). Dawn reported

her experience as “It was fun, I liked being here.”;she would tell other kids “there are a lot of

toys, and a sandbox, two sandboxes, and puppets, and a doll house, and animals, and a tea

stuff and lots of s tu ff .it was so much fun”(personal communication, June 2, 2011). An

overview of the codes from child questionnaires includes: experiencing fun, helpfulness, and

enjoyment, safety, and comfort, talking to someone, and having playtime.

Parent questionnaire. Questionnaires were presented to each parent at the

conclusion of the parent meeting when the child’s evaluation was reviewed (Appendix G).

Parent responses were documented, categorized and deciphered for meaning in describing the

collective experiences of the parent participant’s, which was then coded and triangulated

with other data sources.

For example, Parent A described her experience with the EPBDA as “very good,” she

added “My son is always happy to come in for his appointment” and “I feel secure in

knowing that (e.g. he is happy)” (personal communication, June 20, 2011). She reported the

most helpful part of the assessment was “helping me to understand my son’s emotions, and

what he is going through” (personal communication, June 20, 2011). Parent B responded in

describing his experience as “very professional,” and “my son has enjoyed his play time and

looks forward to it each day I bring him,” and “We all feel great relief in having him come

here” (personal communication, July 22, 2011). He also reported the most helpful part of the

assessment was “knowing our son is getting help, we are very grateful” (personal


communication, July 22, 2011). Parent C responded with “My experience was enjoyable

since the children were not stressed, but rather they looked forward to it (e.g. coming to

sessions)” (personal communication, June 6, 2011). She reported the most helpful part of the

assessment was “gaining a rounded view of their current emotional issues,” and added “the

summary reports were right on” (personal communication, June 6, 2011). Parent C also

shared her disappointment in that she felt “too optimistic” in the assessment process, as she

had hoped to have her child’s issues solved and realized it would require ongoing therapy to

fully process the trauma experiences (personal communication, June 6, 2011).

Provided in Table 3 is a guide to the meaning of codes which emerged from this data

source. Overall themes in parent questionnaire included: good, enjoyable, gratified, security,

relieved for help, and parent gaining an understanding about their child, and parent

disappointment

Table 3 Parent Questionnaire

Meaning of Codes in Responses ExamplesM e a n in g t ie d to e x p e r ie n c e w ith E P B D A : P a re n t A : “ I t h a s b e e n v e ry good .

• G o o d “M y s o n is a lw a y s h a p p y to c o m e to h is a p p o in tm e n t, I f e e l s e c u re in

• S e c u rity k n o w in g th a t”

• R e l ie f P a re n t B : “ M y s o n h a s e n jo y e d h is p la y t im e , a n d lo o k s fo rw a rd to it e a c h d a y ”

• E n jo y a b le “ I f e e l g re a t r e l i e f k n o w in g th a t”

P a re n t C :”M y e x p e r ie n c e w a s e n jo y a b le s in ce th e c h ild re n w e re n o t s tre sse d , b u t ra th e r lo o k e d fo rw a rd to c o m in g ” .

M e a n in g t ie d to th e m o s t h e lp fu l a sp e c t o f E P B D A : P a re n t A : “H e lp in g m e to u n d e rs ta n d h o w to b e t te r u n d e rs ta n d m y• G a in in g u n d e rs ta n d in g a b o u t C h ild s o n ’s e m o tio n s a n d w h a t h e is g o in g th ro u g h ” .

• G ra tif ic a tio n P a re n t B : “ K n o w in g m y s o n is g e tt in g h e lp h a s b e e n v e ry g ra tify in g . W e ’re g ra te fu l”

• In d e p th s u m m a ry re p o rts h e lp fu lP a re n t C : “ I t w a s v e ry h e lp fu l in so fa r as g a in in g a ro u n d e d v ie w o f th e i r c u r re n t e m o tio n a l is su e s . T h e s u m m a ry re p o r ts fo r v e ry h e lp fu l” .

M e a n in g t ie d to w h a t w a s n o t h e lp fu l in E P B D A : P a re n t A : “ I c a n ’t th in k o f a n y th in g ” .• N o re p o rts• P a re n t d is a p p o in tm e n t P a re n t B : “N o th in g c o m e s to m in d ”

P a re n t C : “ I f e e l I w a s a b i t to o o p tim is tic in h o p in g m y c h ild re n w o u ld g a in th e a b ili ty to fu lly p ro c e s s th e i r e x p e r ie n c e s , b u t I g u e ss th a t w ill c o m e w ith o n g o in g th e ra p y ” .


Therapist field notes and questionnaire. As therapist/participant my subsequent

observations and diagnostic field notes served as an important data source as these entries

provided a guide to the study’s emergent design. Field notes of each child were gathered and

incorporated into supporting responses to the therapist questionnaire. Questionnaires were

completed after the last meeting with each parent (Appendix G). As with previous

questionnaires, my responses were categorized into codes, aiding in the description of my

experience later to be triangulated with other data sources for development of a collective

interpretation of themes. Provided in Table 4 is a guide to the meaning of codes which

emerged from this data source.

Emerging codes from the therapist questionnaire consisted of: satisfying, flexible,

encouraged development of communication, non-directive sessions created calming

environment for two of the children and directive sessions created calming environment for

the other two children; development of trusting bond between therapist and child; the sand

tray was the most popular activity with the children and the most enlightening activity for

therapist; and the genogram activity seemed unproductive.


Table 4 Therapist field note/questionnaire

Meaning Codes to Responses ExamplesM e a n in g t ie d to e x p e r ie n c e in u se o f E P B D A :

• S a tis fy in g• N o n -d ire c tiv e = C a lm in g

e n v iro n m e n t• D ire c tiv e = c a lm in g• S im p le fo rm a t• E n c o u ra g e d p o s itiv e b o n d b e tw e e n

th e ra p is t a n d c h ild

I f e l t v e ry s a tis f ie d w ith th e s im p lis tic p ro c e ss o f th e E P B D A in s tru c tio n s a n d fo rm a t. It w a s e a s y to u se a n d m a d e m y w o rk sa tis fy in g .

T h e n o n -d ire c tiv e s e s s io n s h a d a c a lm in g e f fe c t to th e p la y ro o m e n v iro n m e n t, s p e c if ic a lly w ith C a r l to n ’s re s tle s s n e s s a n d a g ita tio n d u rin g se s s io n s 4 -6 .

B o b b y n e e d e d th e s tru c tu re in th e d ire c tiv e p la y a c t iv itie s to g a in g ro u n d in g ; th e n o n d ire c tiv e s s e e m e d ra th e r o v e r s t im u la tin g a n d c h ao tic .

A n d re w w a s m o re a r tic u la te c o m p a re d to th e o th e r c h ild re n , h o w e v e r th e a c tiv itie s w e re s till e n g a g in g a n d h e s e e m e d e n th u s ia s tic to p a r tic ip a te .

D a w n n e e d e d s e v e ra l n o n -d ire c tiv e s e s s io n s (1 -3 ) to re la x , to b e c o m e le ss d e m a n d in g , a n d to g a in m y tru s t.

M e a n in g t ie d to m o s t h e lp fu l a sp e c t o f E P B D A :• H a v in g g u id e lin e s fo r a c tiv itie s .• F le x ib ili ty• D e v e lo p m e n t o f c o m m u n ic a t io n

It w a s h e lp fu l to h a v e sp e c if ic p ro to c o ls to fo llo w fo r e a c h sess io n .

I t w a s h e lp fu l to h a v e th e S a n d tr a y as a n a c t iv ity to w o rk w ith C arlto n .I t w a s h e lp fu l to h a v e m a n y o p tio n s o f p la y a c t iv it ie s to w o rk w ith A n d rew .

B o b b y a n d C a r lto n o n ly n e e d e d tw o n o n -d ire c tiv e s e s s io n s , so it w a s h e lp fu l th e m o d e l is d e s ig n e d to h a v e th e f le x ib ili ty to m o v e th ro u g h s e s s io n s to m e e t c h i ld ’s n e ed s .

M e a n in g t ie d to n o n h e lp fu l a sp e c t o f E P B D A : I fo u n d th e g e n o g ra m a c t iv ity le ss d e s ira b le c o m p a re d to th e o th e rs , a n d fo u n d th e p ro to c o l’s a b i t c o n fu s in g to fo llo w .

• G e n o g ra m p ro to c o ls w e re c o n fu s in g .C a r lto n , A n d re w , a n d D a w n w e re c h a l le n g e d in th e g e n o g ra m d ire c tiv e s a n d h a d d if f ic u lty a s s o c ia t in g fa m ily m e m b e rs w ith m in ia tu re f ig u re s . In fo rm a tio n g a th e re d fro m th is a c t iv ity s e e m e d a m b ig u o u s .

M e a n in g t ie d to a c t iv itie s in E P B D A : A c tiv itie s w e re fu n a n d th e re fo re a n e n jo y a b le e x p e r ie n c e b e tw e e n c h ild a n d th e ra p is t w h ic h a s s is te d in d e v e lo p m e n t o f a p o s it iv e b o n d . H o w e v e r , A n d re w d id n o t lik e th e

• F u n (e x c e p t d ra w in g fo r 1 )• E n lig h te n in g e x p e rie n ce .• S a n d b o x b ig h it ( fu n )

d ra w in g ac tiv itie s .

N o n d ire c tiv e a c t iv it ie s su c h as m a k e b e lie v e , d o ll h o u s e , a n d p u p p e ts e n c o u ra g e d in te ra c tio n b e tw e e n th e ra p is t a n d ch ild , a n d d e v e lo p m e n t o f d ia lo g u e in p lay .

T h e s a n d b o x w a s m o s t re q u e s te d p la y a c tiv ity , a n d v e ry e n lig h te n in g in g a th e r in g in fo rm a tio n th ro u g h o b s e rv a tio n o f e m e rg in g th e m e s in p la y a n d c h i ld ’s se lf- ta lk .

B o b b y w a s v e ry e n th u s ia s tic to b e in v o lv e d in a ll a c tiv itie s .

M e a n in g t ie d to re la tio n a l e x p e r ie n c e b e tw e e n c lie n t/fa m ily /th e ra p is t:

D a w n b e n e f it te d th e m o s t f ro m n o n -d ire c tiv e p la y as th is a llo w e d h e r s p ac e a n d tim e to g a in se c u r ity in e n v iro n m e n t a n d w ith m e.

• H e lp e d d e v e lo p c o n v e rsa tio n A n d re w w a s a b le to d e v e lo p a sen se o f t r u s t a f te r tw o s e s s io n s , a n d b e g a n s h a r in g m o re a b o u t h is th o u g h ts a n d fe e lin g s c o n c e rn in g h is e x p e r ie n c e s a t h o m e a n d sch o o l.

• D e v e lo p in g tru s t in g b o n dB o b b y n e e d e d th e re s o u rc e s to b u ff e r h is e x p e r ie n c e a n d a llo w a d ju s tm e n t to m e , a n d th e p la y ro o m . H e e v e n tu a lly w a s ab le to b e m o re re la x e d a n d w il l in g to e n g a g e in p la y a n d ta lk in g w ith th e ra p is t.

C a r lto n b e c a m e m o re tru s t in g o v e r t im e ; h o w e v e r h e d is p la y e d a g ita tio n a n d re s tle s s n e s s d u rin g a c t iv itie s in se s s io n 4 -6 . C a r l to n ’s sy m p to m s w e re re p o r te d to h a v e re d u c e d a t h o m e .

D a w n b e c a m e m o re a c c e p tin g o f p la y d ire c tiv e a n d le ss d e m a n d in g ; sh e b e g a n to tru s t a n d d e v e lo p a b o n d w ith m e . P a re n t w a s e n c o u ra g e d b y a le ss s tre s s e d ch ild .


Triangulation. Review of the coded data gathered from observational footage, child

questionnaire, parent questionnaire, therapist field notes, and therapist questionnaire were

analyzed and descriptive themes were generated. Through the process of triangulation of

data, common themes were identified, resulting in a narrative interpretation of the collective

experiences of the children, the parents, and the therapist in the use of the Extended Play-

based Developmental Assessment (2011).

In carrying out the triangulation process, first I compared the eight emergent codes

from video observation data (smiling and eye contact, an increase in talking to therapist, a

decrease in quietness, and an increase in laughter, increases in engaging therapist and

accepting therapist directives, and overall calmness) and the seven emergent codes from

child questionnaires (experiencing fun, helpfulness, and enjoyment, safety, and comfort,

talking to someone, and having playtime) and collapsed them into four common themes to

include fun, calming/comforting, safe/ helpful, and development of dialogue.

Secondly, I examined emergent themes from the child participants, with the

remaining data sources from parent and therapist participants. Themes which developed from

the parent questionnaires included feeling good, enjoyable, gratification, security, relief for

help, parent gaining understanding of the child, and parent disappointment. Themes which

developed from therapist questionnaire and field notes included fun activities, ease and

flexibility, development of a calming environment, development of a trusting bond,

development of communication, popular sand tray activity, and less effectiveness of the

genogram.

Summary. Analysis of the three data sources revealed three common themes. First,

the most obvious pattern in the data was the narrative theme, experience o f enjoyment, as

represented by the child’s experiences of fun and playing, which associated with the therapist


experiences of satisfying, which positively triangulated with the parent’s experience feeling

good, enjoyable, and gratified. Secondly, the child’s experience of calmness/comfort and

safety associated with the therapist experience of a calming environment and development of

a trusting bond, which related with the parent’s experience of security and feeling relieved to

have help. This theme was narrated as experience o f calmness. Third, the child’s experience

in engaging and talking with therapist linked with the therapist experience of development of

communication, which positively triangulated by the parent’s experience of gaining insight

and understanding of their child. This theme was narrated as the experience o f enrichment.

Themes which did not seem to parallel with participant experiences included the therapist’s

experiences of flexibility in the EPBDA, and a parent’s experience of disappointment (too

optimistic).

This chapter presented the findings of a study which explored the experiences of

participants (child, parent, and therapist) with the EPBDA model. Qualitative data including

multiple sources were examined to elucidate the collective experiences of the participants.

The final chapter report’s conclusions from these results and discusses the interrelated

implications for clinicians and researchers, as well as suggestions for further research in play-

based assessments.


Chapter 5

Conclusion and Implications

Introduction. Children who have experienced trauma and abuse require special

provisions to navigate successfully through the initial phase of therapy, in particular the

assessment process, which suggests the use of a more child friendly, play-based model of

assessment (Shelby & Berk, 2009; Cattanach, 2008; Gil, 2006; Greenspan & Greenspan,

2003). Putting this into context, the idea for this study initiated from the researcher’s

experiences as a clinician - one who was knowledgeable of best practices in play therapy,

mindful of the modalities of child-friendly assessments, but faced with the dilemma of

mandated empirical research methods that often times did not support those ideas. Rarely are

issues of clinical play-based practices one-dimensional, rather there are multiple layers in

need of examination and understanding, specifically the experiences of the individuals

involved. This is the dilemma (or perhaps opportunity) that play-based researchers and

practitioners face. Therefore, having identified not only a gap in research, but also the

potential to affect practice, the researcher sought to describe the experiences of the children,

parents, and therapist as participants in using a more child friendly, play-based assessment, in

particular the EPBDA.

Conclusions of the study. Through the interpretation of the participants point of

view, the researcher set out to explore the experiences of participants with the Extended

Play-based Developmental Assessment (Gil, 2011), revealing aspects of play-based

assessment that may enrich current theory, while demonstrating practical application. The

design of this study in seeking an interpretive understanding derived from the qualitative

paradigm. As Denzin and Lincoln (2000) have noted, the case study approach accurately

produces insights only regarding the case in question, with limited generalizability of


observations: “The utility of case research to practitioners and policy makers is in its

extension of experience” (p. 104). The anticipated result is new insights that are impractical

to construct without the in-depth exploration characteristic of an interpretive approach. Thus,

the researcher comes to know what has happened partly in terms of what others reveal in

their own experience. The role of the case researcher is therefore to interpret experience, to

preserve its comprehensibility in other contexts, and thereby engage in knowledge

construction (Denzin & Lincoln, 2000; Creswell, 2005). The results of this collective case

study are especially valuable in terms of promoting a continuing dialogue regarding play-

based assessment models for children with trauma histories, in particular the use of The

Extended Play-Based Developmental Assessment (Gil, 2011).

In the previous chapter, results were organized in a linear way consistent with the

concept of experience, that is, what the participants did and said in reference to the EPBDA

model. The following conclusion is an integration of experiences describing the broader

themes that were suggested and/or supported by the findings. Those themes include (a)

enjoyment, (b) calmness, and (c) enrichment. Within each of these themes key findings are

discussed. Accordingly, my intention for this chapter is to articulate the contributions of this

study, review the results, and discuss implications for future research and practice.

Calmness. The theme of calmness manifested in the case in that the children

gained a sense of control over their environment through the non-directive approach. From

there, they gradually moved toward partial control. This provided them the impetus to

externalize their thoughts and feelings in an accepting, non-threatening environment. Within

this structure, the therapist and child were able slowly to develop a trust-based relationship

reducing anxiety and freeing the child of inhibitions against healthy self-expression.


In reference to Axline’s (1947, 1950) theory of the most crucial consideration in the

play experience, the play assessment environment created a nurturing and supportive alliance

between therapist and child, which expressed openness and acceptance of the child’s

feelings. The therapist reflected back to the child observed feelings, through interaction and

conversation, which encouraged further development of trust and understanding in the

relationship. This exchange reduced the amount of stress and anxiety in the child, therefore

creating a calm environment for the child to return and build upon with each new session.

The therapist was able to assist the child in experiencing the playroom as a safe place, to

serve as a secure base for the child (Landreth, 2002; Gil, 1991; Goodyear-Brown, 2010;

Shelby & Felix, 2006). Thus, within the context of play, the child was able to explore and

reclaim attributes of childhood expected in the models of Piaget (1969) and Vygotsky (1978).

In addition, as the child became less anxious, and more trusting of therapist and playroom,

the experience of the parent increased in relief and security in the assessment process and the

therapist-child dyad.

Enjoyment. The theme of enjoyment was manifest in the case in that the

time the children spent in the playroom featured satisfying, child-friendly activities. The

children had several options to attract their creative attention, while finding the assessment

directives to be fun and entertaining. Play activities included make believe dress-up, playing

in the doll house, storytelling with puppets, and board games, drawing and painting, and sand

tray. The most popular activity among all child participants was the use of the sand tray,

within the non-directive and directive methods. This activity allowed the children to have a

sense of control over their environment, to move freely within the play room setting,

ultimately gaining association to their inner world. The amount of self-expression in this

exercise allowed for greater insight for the therapist.


While the interaction between therapist and child produced the clinical results that the

therapist needed to further the child’s psychological interests, the child and therapist also

simply had fun. In addition, parents accompanying their children to assessment sessions were

encouraged by their child’s excitement and anticipation to participate in the assessment

process, which supports the overall experience of feeling enjoyment.

Enrichment. The theme of enrichment was manifest in the case in the fact that, as

the therapist applied the appropriate assessment procedures and concluded the associated

sequence of activities, the amount of information on the child that the therapist gathered was

rich, resembling the transference through play themes. The children’s participation in play

gave the therapist the opportunity to observe their behavior, while encouraging the children

to express their experiences in a combination of language and symbolic behavior with the

help of toys and activities.

In consideration of Vygotsky’s (1978) theory of the necessity for pivots, the children

used play as a form of language to imagine, manipulate ideas, create new ideas, and then

share those ideas. Through this exchange the children placed meaning to their thoughts and

then through words, leading to a more enriching environment between the therapist and

children’s experience. The therapist analyzed the children’s internal perspective through the

observation and interpretation of patterns and themes in play. Thus the free association

through the play assessment developed into experiential dialogue between the therapist and

child, and resulted in creating an enriching experience.

Implications for clinical practice. In the present study, the main focus was with

children between the ages of five and nine years old who have experienced trauma. In this

realm, it seems apparent that a play-based model of assessment has ample value to offer in

future cases evaluating the problematic domains of a child’s functioning and providing a


systematic framework for examination of development, mood, relational capacity, affect, and

use of space (Greenspan & Greenspan, 2003). In this respect, The Extended Play-Based

Developmental Assessment (Gil, 2011) was instrumental in drawing out the experiences of

enjoyment in the play-based assessment, in developing an enriching interaction and

environment, and a sense of calming within the child, the parent, and therapist.

Further, it is sufficient to suggest that replication of the EPBDA model to closely

matched cases in similar clinical settings is probable. In addition, therapists may wish to set

up playrooms equipped for non-directive and directive play that will enable children with

trauma history the ability for free association through the tangible world of play and activity,

and therefore observe whether this modality provides insight and understanding more than

what was previously attainable. A notable advantage with play-based therapy and assessment

is that the worst case is simple ineffectiveness; essentially, play encourages children to

develop insights into themselves, understanding about their own motivations, and

appreciation of their relation to the rest of the world (Klein, 1955). The general exposure of

play itself is not harmful to children for its own sake (Greenspan & Greenspan, 2003).

Implications for future research. Based on the findings of this study, several

recommendations for future research can be made. First, this study represented an initial

investigation in the participants experience in use of the EPBDA. Replicating this study with

a larger sample size, in multi settings, in various geographical regions, and by other clinician-

researchers is needed to expand the evidence for the EPBDA toward recognition as an

evidence-based model for assessing children.

Secondly, different strategies and different media are certainly likely to produce

variations on the results achieved herein. In consideration of the disappointment of the

genogram exercise to produce the expected result, further research could validate or refute


this phenomenon. The possibility that there are certain tools available in the full repertoire of

play mediums is immense. Some researchers may wish to try to determine what features of

play-mediums are most supportive in the play-based assessment process.

Finally, once it has become possible to collect sufficient examples to support more

generalizable conclusions, the personality characteristics of the therapist may become an

important focus of exploration, to identify possible connections between professional or

trainable qualities, and the suitability of play therapy to a given therapist’s array of clinical

options.

Limitations. As explained previously, the case study method limits the

generalizability of observed results. The conclusions that arise from this study are therefore

strictly applicable to each participant’s experiences, rather than to all conceivable cases.

Nevertheless, despite the inability to generalize theoretical findings from the observable

interactions that happened to characterize the case at issue to larger populations, the results

are quite useful in their capacity to promoting play-based assessments and of the EPBDA

model in particular.

Moreover, within the dual-role interpretive framework of researcher and observer, the

active connection between the inquiring role and that of participant in the phenomenon of

study creates further distinctiveness in the case method. In this respect, it is essential to

acknowledge that play therapy therefore constitutes a method of study that demands

investigation at the level of interaction between the participants within the study, rather than

at that of the nuances of behavior present during the actual interaction. Generally, within this

structure, the therapist’s entry into engagement with the client always carries theoretical

presuppositions with it (Green, 2008). However, the therapist’s unusually active participation

in the case of play-based assessment resembles the assumptions of Jungian psychology more


strongly than is the case w ith traditional (e . g . , post-Freudian) methods (Green, 2008). The

generalizable facet o f play-based assessment involves comparisons o f methods or strategies,

rather than specific behavioral detail during the associated sessions themselves.

Another lim itation is that the EPBDA model is intended fo r trained play therapists,

which have already invested time and resources in the development o f a play room setting

and have training in use o f play room materials. The cost in developing a play room setting,

and collecting the appropriate materials necessary to incorporate all the activities suggested

in the EPBDA, can be an exhaustive endeavor i f the therapist is not already using play

mediums (e.g. the sand trays and miniatures necessary fo r two o f the activities are estimated

to cost well over $500.00; the doll house ranges from $200.00 to $400.00, depending on size,

and furniture and fam ily selections). In order to obtain the array o f play materials suggested

(Appendix E) a therapist would need to spend ample time collecting selective toys and

searching in th rifty ways to avoid the expense o f buying new items. It is highly

recommended that therapists who are new to play therapy and who w ill be working w ith

children w ith trauma histories collaborate and consult w ith other professionals such as

pediatric mental health, forensics, and social work.

Retrospective commentary. What was most satisfying about this study was that the

conclusions drawn from the observations were in close alignment w ith the theoretical

material that justifies play-based assessment as a practical clinical method. M y experience

w ith actual use o f the EPBDA model was a positive one. First, it was enjoyable to w ork w ith

the children as they participated in the noted activities, while developing a dialogue w ith

them. The activities were enjoyable fo r the children, and it was quite apparent they helped

develop the rich environment which enabled this researcher to engage in learning about the

children’ s self-perceptions. I t was as though the mode provided a linguistic medium that


would have been unavailable. The most effective aspect o f the EPBDA was the range o f play

activities to determine each ch ild ’ s emotional state and psychological development.

Thus, through the medium o f a structure o f directive and non-directive activities, a

therapist using the play-based assessment can create an enriching experience necessary to

accommodate tangible communication despite the children’ s lim ited linguistic and emotional

development. W hile my experience w ith the genogram exercises was a little disappointing,

both in terms o f the vague information gathered and in the d ifficu lty that characterized the

implementation o f the activity w ith the children, the other activities in both directive and

non-directive play were actually quite easy to manage and w holly elucidating in their ability

to generate psychological data. The Extended Play-based Developmental Assessment model

was instrumental in fostering a positive relationship between therapist and child. The play

was fun, even fo r me, and the activities succeeded in illum inating my fu ll understanding o f

the child ’ s inner world.

Summary. To conclude this study, the results o f the experiential research

demonstrate that the use o f play-based assessments support valid theoretical premises in

assessing children. In particular, the observation is The Extended Play-based Developmental

Assessment was effective in drawing out the experiences o f enjoyment in the play-based

assessment, allowing the child ease in interaction w ith the therapist, and therefore display o f

affect, mood, and observation o f use o f space. In addition, the EPBDA produced a sense o f

calming w ith in the child and the environment, as well as the parent and therapist, ensuring a

foundation for the child to develop a sense o f security in the assessment process and

therapist-child dyad. Finally, the use o f the EPBDA was effective in developing enrichment

from interaction in activities and observation o f the child ’ s development. Therefore, the


EPBDA supports the creation o f a safe, nurturing, and child friendly environment for

children w ith trauma history and is beneficial in assessing a ch ild ’ s functioning.


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Appendix A

Webpage and Brochure Announcement

Research Study Seeking ParticipantsFREE Co uns e l i ng A s s e s s m e n t for chi ldren 5 to 9 years old for exploring a play b a s e d a s s e s s m e n t for chi ldren w h o have e x p e r i e n c e d trauma.

This study defines ‘trauma’ as an identifiable incident(s) which caused the child to feel helpless, overwhelmed, and continues to cause the child emotional, social, or behavioral difficulties.

Confidentiality is priority to this study.Supervision and research conducted by licensed therapists.Research supported by Northwest University and Cedar Park Church

For more information contact:Janet O’Donnell, MA, LMHCA

425-939-H90 (ext 1243) [email protected]

mailto:[email protected]


Participants...

...fora study exploring play based assessment for childhood trauma.

Twelve sessions will be provided for the children and families chosen as participants. Children ages 5 to 9 years of age.

This study defines 'trauma' as an identifiable incident(s) which caused the child to feel helpless, overwhelmed, and continues to cause the child emotional, social, or behavioral difficulties.

Location

Cedar Park Counseling Network

Children's Center

Located at:16300 112th Ave NE, Bothell, WA 98011

(A Building, basement)Once you enter Cedar Park Assembly of God, follow the flow of traffic around the building. Straight ahead you will see a building with a big "B" on it. To the left of that is the A building. On the right side of the A building is a cobblestone path. Follow that down, and the Children's Center office is last door on the left.

FREECounselingAssessment

fo rTraumatized

Children

Study Procedures

Participants will:

* Attend weekly 50 minute sessions for 6 to 12 weeks, using the Extended Play Based Developmental Assessment.

* Parents complete in-depth intake interview and final evaluation meeting.

* Complete paperwork asnecessary.

The study will be supervised by professional, licensed

Mental Health Professionals and Play Therapy Specialist.

All sessions will be audio/video recorded.

Confidentiality & Client Rights

Participant's confidentiality is top priority in this research.

Reported data will use pseudonyms and will remove or change identifying information.

Only individuals bound by legal and ethical confidentiality mandates will be allowed to observe sessions and interviews.

During the initial screening session, questions will be addressed and an indepth description of the study and clients rights will be explored.

Contact Person

Janet O'Donnell is a Licensed Mental Health Counseling Associate in the State of Washington. She received your Masters of Arts degree in Counseling Psychology from the Graduate School of Behavior and Social Sciences at Northwest University. She is a Doctoral Candidate at Northwest University.

This study is supported by Cedar Park Counseling Network and Cedar Park Church.

For more information or to express your interest, contact:

Janet O'Donnell, MA, LMHCA 425-939-1490 (ext 1243)

[email protected] www.cedarparkcounseling.org

Thank You

mailto:[email protected]

http://www.cedarparkcounseling.org


Appendix BIn fo rm ed Consent and Clients Rights

In fo rm ed Consent fo r P artic ipa tion in Research

Dear Parents,

My name is Janet O’Donnell and I am a doctoral student at Northwest University. One of the requirements of the doctoral program is to carry out a research study which contributes knowledge to our field. My chosen study will examine the use of a play-based assessment for children who have experienced trauma. For this study, I will provide play-based approaches to assess a child to see if the child benefits from the participation in this research process.

Play therapy is helpful to children who may be experiencing difficulties after a traumatic event. Play is a natural way for children to communicate, and is more beneficial for children than trying to talk to them about their life. The play-based assessment is conducted in a therapeutic play room which allows for privacy, and makes a variety of carefully selected toys available to the child to use and play with. The therapist interacts in non-directive and directive approaches with the child while he or she plays to smooth the process of the assessment.

My interest in working with children with trauma experiences is based on information that suggests emotional and psychological issues are not always addressed in the assessment with this particular group of children. My hope is that the child will gain the ability to process their experiences more effectively after participation in a play-based assessment.

Procedure: Intakes for this research study shall be conducted utilizing the intake protocols of Cedar Park Counseling Network, and shall include all intake forms to be completed prior to conducting intake interview. Sessions will be held at the Cedar Park Counseling Network’s Children’s Center, located at the Bothell campus of Cedar Park Church/School. A total of 12 sessions, each lasting 50 minutes will be scheduled. Sessions will be held weekly (or twice a week, depending on schedules). Each week you and I will communicate so that I can learn about your child’s behavior in between sessions. As part of the research, you will be required to complete pre and post assessment surveys, a parent questionnaire, and agree to video/audio tape sessions. It may be possible to continue counseling following the research process, although I cannot guarantee the availability of service. I will refer you to a therapist on staff with CPCN, as well as therapist in your community, for your child’s counseling needs.

Therapist/Researcher: I am a licensed Mental Health Counselor Associate, a child specialist with CPCN, with training in play therapy interventions. During this research study I will be supervised by Dr. Phil Templeton, LMFT (Clinical Director of CPCN). My research advisors are Jacqueline Gustafson Ed.D. (Committee Chair), Sarah Drivdahl, Ph.D., and Kim Lampson, Ph.D.

Appointments: If you need to cancel an appointment, please notify me as soon as you can, at least 24 hours prior, in efforts that we can reschedule you child as quickly as possible. Your child’s progress in this study is dependent on he or she attending sessions regularly. You will have access to my email and office phone number and are encouraged to contact me with any concerns.

Fee Waiver: The usual fees for assessment are waived for the purpose of this research study.

Confidentially: The names and identities of all participants in this research shall be kept strictly confidential. Any reportable data will use pseudonyms and will not use any identifying information. Research records shall remain with CPCN and will be treated as confidential according to state and


federal law. There are exceptions to confidentiality, which are mandated by state and federal law, such as court order, suspected abuse, or threat to self of others.

Video/Audio Recording: Sessions of the assessment will be recorded by video and audio recorders for purposes of this research study. These recordings shall be kept confidential and stored in secure location throughout the duration of the study. All video/audio tapes will be destroyed within three years of the publication of the study’s results.

Risks: This study is not designed to cause discomfort to the participants. However, possible risks of the study may be that the families may experience include an impact from the time requirements of the study, some stress from dealing with potentially painful issues or uncomfortable feelings in honestly sharing negative reactions about the process. I will work with you and openly discuss any concerns to reduce any potential risks. Please note: participation is completely voluntary. You and your child may decide to participate in this study, and if you do begin participation, you may still decide to end and withdraw from participation. You and your child’s decision will be respected - with no coercion, prejudice, or negative consequences.

A copy of this form will be made available to you. If you have any concerns about you and your child’s treatment as a participant in this research, please contact:

Human Subjects Review Board, Northwest University, Provost: Dr. James Huegel-425-889-5237Cedar Park Counseling Network, Clinical Director: Dr. Phil Templeton, 425-939-1490

I have read the above and understand the nature of this study and agree to participate. I understand that by agreeing to participate in this study I have not waived any legal rights. I understand I have the right to refuse to participate at any point within the study. I agree to allow the Researcher to record our sessions by video and audio recording. I further attest that I have the authority as the minor’s parent or legal guardian to consent to the video and audio recording of these research sessions.

Parent/Guardian (print) Parent/Guardian (signature) Date

Parent/Guardian (print) Parent/Guardian (signature) Date

Therapist (print) Therapist (signature) Date

Supervising Therapist Supervising Therapist (sig) Date


Appendix CChild Background Information

D ate: ___________________________________ P a tien t is: □ le ft-handed □ righ t-handedN am e __________________

Last

Sex: M /F_____ Birth Date

P aren t/G uard ian : _______Lives w ith _______________

PREGANCY/INFANCY HISTORY

F irst M idd le In itia l

A g e ______ G rade L e v e l_______ E thn ic ity______________________

Pregnancy ComplicationsPlease check the fo llow ing fo r the m other o f the child : T rue N ot T rue D on 't Know1. Had b leed ing during the firs t 3 m onths ______ ______ ______2. Had b leed ing during the second 3 m onths ______ ______ ______3. Had b leed ing during the last 3 m onths ______ ______ ______4. G ra ined less than 15 pounds, spec ify : ______ ______ ______5. G a ined m ore than 30 pounds, specify : ______ ______ ______6. Had p reec lam ps ia or toxem ia ______ ______ ______7. Had to take m ed ica tions; list ______ ______ ______8. T oo k narco tic d rugs; list ______ ______ ______9. D rank a lcoho l; am oun t ______ ______ ______10. Had p rev ious m iscarriage ; num ber ______ ______ ______11. Had p rem atu re baby(ies) ______ ______ ______12. Sm oked 1 pack or m ore o f c iga re ttes da ily ______ ______ ______13. Labor lasted less than 2 hours ______ ______ ______14. Labor lasted m ore than 12 hours ______ ______ ______15. Had a d ifficu lt labor ______ ______ ______16. W as put to s leep fo r d e live ry ______ ______ ______17. W as g iven m ed ica tion fo r labor; spec ify ______ ______ ______18. D e livery w as norm al ______ ______ ______19. D e livery w as breech, caesarian , fo rceps, induced ______ ______ ______

20. H ow w as the m other's health during the p regnancy o f th is ch ild? _ __ good _ _ _ fa ir _ __ poor ___ dk21. H ow old w as the m other w hen th is ch ild w as b o rn ? ________________22. W as th is ch ild born on s c h e d u le ? ___ <8 m ths ____ te rm (8-10 m ths) ___ >10 m ths ___ d on 'tknow23. W ha t w as th is ch ild 's birth w e igh t? ___po un ds _____ounces24. Is th is ch ild adopted? ___ yes ___ no If yes, at w ha t age?_________25. N um ber o f p rev ious p regnanc ies :__________________26. N um ber o f liv ing ch ild ren :___________________

Newborn Infant Problems(firs t m onth o f life) T rue N ot T rue D on 't Know1. Born w ith cord around neck ______ ______ ______2. In jured during birth ______ ______ ______3. Had troub le breath ing ______ ______ ______4. Jaund iced (turned ye llow ) ______ ______ ______5. C yanosis (turned b lue) ______ ______ ______6. W as a tw in or tr ip le t ______ ______ ______7. Had an in fection ______ ______ ______8. Had se izu res ______ ______ ______9. W as g iven m ed ica tions, specify : ______ ______ ______


10. N eeded oxygen11. W as in hosp ita l m ore than five days12. Born w ith a heart de fec t13. Born w ith o the r de fect(s), spec ify14. Had troub le sucking15. Had skin prob lem s16. C olic17. S leep prob lem s

DEVELOPMENTAL FACTORSW hen did th is child do the fo llow ing: ( If you canno t reca ll the age, w rite e ithe r early, norm al, o r late.)

No 0-3mo

4-6mo

7-12m o

1318mo

1924mo

2-3yrs

3-4yrs

4-5yrs

5-7yrs

7+yrs

1. Hold up head2. Roll fron t to back3. S it a lone4. C raw l5. W a lk a lone6. S peak s ing le w ords (not m am a/dada)7. S tring tw o or m ore w ords to ge th e r8. T o ile t tra ined (b ladder contro l)9. T o ile t tra ined (bow el contro l)10. A ttend pre -schoo l11. A ttend k indergarten12. H ave d ifficu lty sepa ra ting from parents13. Thum b-suck ing14. Fears (what?)15. N igh tm ares16. H urt se lf, o thers, an im als17. P lay w ith fire18. Run aw ay19. T em p e r tan trum s20 O pen M astu rba tion21. A fra id to go to schoo l22. B ehav io r p rob lem s at schoo l23. A ca de m ic p rob lem s at schoo l.

2 4 . H o w w o u ld y o u ra te th e a c t iv ity le v e l o f th e c h ild a s an in fa n t/ to d d le r?________ v e ry a c t iv e _______a c t iv e _______a v e r a g e ________ le s s a c t iv e ________ n o t a c tiv e

2 5 . A p p ro x im a te ly h o w lo n g d id to i le t tra in in g ta k e fro m o n s e t to c o m p le t io n ?______ le s s th a n 1 m o n th _____ 1-2 m o n th s _____ 2 -3 m o n th s ______ m o re th a n 3 m o n th s


MEDICAL HISTORYP le a s e ra te y o u r c h ild in e a c h o f th e fo llo w in g a re a s :

G O O D F A IR P O O R1. H e a lth2. H e a rin g3. V is io n4. G ro s s M o to r C o o rd in a t io n5. F in e M o to r C o o rd in a t io n6. S p e e c h A r t ic u la t io n

7. P le a s e id e n t ify a n y p a s t m e d ic a l in ju r ie s a n d i l ln e s s e s /b e g in n in g w ith m o s t re c e n t:D e s c r ip t io n D a te A g e E ffe c ts / Im p a c t

8. P le a s e c h e c k th e fo llo w in g p ro b le m s : Y E S N O D O N 'T K N O W• S u s p ic io n o f a lc o h o l/d ru g u s e _______ _______ _________• H is to ry o f p h y s ic a l/s e x u a l a b u s e _______ _______ _________• S le e p in g p ro b le m s _______ _______ _________• Is th is c h ild a re s t le s s s le e p e r _______ _______ _________

9. D o e s th is c h ild h a v e b la d d e r / b o w e l c o n tro l p ro b le m s ?Y E S /N O DAY (how often ) N IG H T (how often) W hen did th is begin?

B ladderBow el

10. P le a s e lis t a n y p re s c r ip t io n o r n o n -p re s c r ip t io n m e d ic a t io n s th is c h ild is p re s e n tly ta k in g .Medication Dosage Purpose

11. W h e n w a s th is c h ild 's la s t m e d ic a l e x a m ? ___________________________________W ith w h o m :_________________________________________________________________________P h o n e : ______________________________________________________________________________W h a t w a s th e re a s o n ? _____________________________________________________________

12. H a s th is c h ild e v e r h a d a n y p s y c h o lo g ic a l t re a tm e n ts ? If so , p le a s e id e n tify :a ) W ith w h o m :______________________________________________________________________


P h o n e :_________________W h a t w a s th e re a s o n ?

b) W ith w h o m :________P h o n e :_________________W h a t w a s th e re a s o n ?

FAMILY HISTORY1. P le a s e id e n t ify th e fo llo w in g :

M O T H E R 'S H IS T O R Y /M A T E R N A L FA TH E R S H IS T O R Y /P A TE R N A LS ubstance Abuse : S ubstance Abuse :

Learn ing D isab ilities: Learn ing D isab ilities:

P sych ia tric D iagnosis: P sych ia tric D iagnosis:

A nx ie ty /D epress ion A nx ie ty /D epress ion :

B ehav io r P rob lem s: R age /B ehav io r P rob lem s:

M ed ica l P rob lem s: M ed ica l P rob lem s:

P hys ica l/S exua l A buse P hys ica l/S exua l Abuse :

A rrests : A rrests :

A u tism Spectrum : A u tism Spectrum :

2. P le a s e d e s c r ib e fa m ily h o m e : ____H o u s e _____A p a r tm e n t ____ C o n d o _____ o th e r______ n u m b e r o f ro o m s _______ n u m b e r o f b a th ro o m s _______n u m b e r o f b e d ro o m s

3. P le a s e in d ic a te w h o s le e p s in e a c h b e d ro o m :

4. P le a s e d e s c r ib e y o u r n e ig h b o rh o o d :

5. W h o h a s ta k e n c a re o f th e c h ild m o s t o f th e ir life ?

6. W h o is th e p r im a ry d is c ip lin a r ia n in th e fa m ily ?

7. D o p a re n ts a g re e o n th e is s u e s o f p a re n tin g , ru le s , a n d d is c ip lin e ? ____________A re th e y _ _ _ s tr ic t _ _ _ le n ie n t

8. D o p a re n ts g e t a lo n g w ith o n e a n o th e r ? ____a lw a y s _____u s u a l ly _____s o m e t im e s _____ra re ly

9. T o w h a t e x te n t a re y o u (a n d s p o u s e ) c o n s is te n t w ith re s p e c t to d is c ip lin a ry s tra te g ie s ?____m o s t o f th e t im e _____s o m e o f th e t im e _____n o n e o f th e t im e


10. W h a t w o u ld y o u like to c h a n g e a b o u t y o u r fa m ily ?

11. P le a s e m a rk a n y o f th e s ta te m e n ts b e lo w w h ic h a p p ly to y o u r fa m ily .Y e s N o

O u r fa m ily is w a rm a n d lo v in g ____ ____P e o p le a re a lw a y s f ig h t in g ____ ____E v e ry o n e g o e s h is o r h e r o w n s e p a ra te w a y ____ ____P e o p le s a y w h a t is o n th e ir m in d ____ ____

12. H a v e th e re b e e n o r a re th e re c u rre n t ly a n y m a jo r c h a n g e s o r s tre s s o rs in th e fa m ilyw h e re th e c h ild w a s ra is e d ? _____ Y e s _______N oIf y e s , p le a s e c h e c k a ll th a t a p p ly :

In P a s t C u r re n t (6m o /le s s )F in a n c ia l _______ _______F re q u e n t m o v e s _______ _______J o b C h a n g e s _______ _______D r in k in g /d ru g u s a g e _______ _______A rg u m e n ts b e tw e e n p a re n ts _______ _______S e p a ra t io n o r d iv o rc e o f p a re n t 's _______ _______R e m a rr ia g e o f p a re n t _______ _______S e p a ra t io n fro m s ib l in g 's _______ _______S e p a ra t io n fro m o th e r fa m ily m e m b e r 's _______ _______F re q u e n t p h y s ic a l p u n is h m e n t _______ _______P h y s ic a l c o n fro n ta t io n s b e tw e e n p a re n ts ______ ______S e p a ra t io n fro m s ig n if ic a n t n o n - fa m ily m e m b e r ______ ______M e n ta l i l ln e s s in fa m ily _______ _______P h y s ic a l il ln e s s in fa m ily _______ _______P s y c h ia tr ic h o s p ita liz a t io n o f a p a re n t _______ _______D e a th in th e fa m ily _______ _______S e x u a l p ro m is c u ity o f in c e s tu a l b e h a v io r in fa m ily ______ _______F a m ily fe e ls is o la te d _______ _______O th e r________________________________________________ _______ _______

13. H o w h a s fa m ily b e e n c h a n g e d b y th e c h ild 's p ro b le m (s )?

14. W h a t is th e fa m ily 's e x p e c ta t io n o f t re a tm e n t?

15. W h a t d o e s th e fa m ily s e e a s th e ir ro le in tre a tm e n t?

16. W h a t d o y o u b e lie v e a re th e fa m ily 's s tre n g th s ?

17. W h a t d o y o u b e lie v e a re th e fa m ily 's w e a k n e s s e s ?


SOCIAL HISTORY1. H o w d o e s th is c h ild g e t a lo n g w ith h is /h e r s ib lin g s ?

____N o n e _____B e tte r th a n a v e ra g e _____A v e ra g e ______ W o rs t th a n a v e ra g e .2. H o w e a s ily d o e s th is c h ild m a k e f r ie n d s ? ____V e ry E a s y ____A v e ra g e ____ N o t v e ryE a s ily .3. O n a v e ra g e , h o w lo n g d o e s th is c h ild k e e p fr ie n d s h ip s ?

____le s s 6 m th s _____6 m th s to y e a r ______ 1+ y e a r4. Is th e c h ild a b le to fo rm c lo s e re la t io n s h ip s ? _____ Y e s ______ N o5. H o w w o u ld y o u d e s c r ib e a ty p ic a l d a y fo r th is ch ild :

SCHOOL HISTORY1. P le a s e s u m m a r iz e th e c h ild 's p ro g re s s in s c h o o l:

2. H a s th e c h ild e v e r b e e n in a n y ty p e o f s p e c ia l e d u c a t io n a l p ro g ra m , a n d if so , h o w lo n g ?

L e a rn in g D is a b ilit ie s :

S p e e c h /L a n g u a g e T h e ra p y :

A d v a n c e p la c e m e n t:

3. C h e c k a n y o f th e fo llo w in g th a t a p p ly :In w h a t g ra d e

D is ru p t c la s s ________In a tte n tiv e in c la s s ________R e fu s e to g o to s c h o o l ________F a il to tu rn in w o rk ________D e te n tio n ________In -s c h o o l s u s p e n s io n ________O u t-o f-s c h o o l s u s p e n s io n ________E x p e lle d fro m s c h o o l ________

4. H a v e a n y a d d it io n a l in s tru c t io n a l m o d if ic a t io n s b e e n a t te m p te d ? _____ n o n e_____ b e h a v io ra l p r o g r a m _____ d a ily /w e e k ly re p o r t c a rd _____o th e r

5. H a s th is c h ild h a d a n y e d u c a t io n a l te s t in g ? _____ Y e s _____ N o If y e s , w h a t?_______________________________________________________________________________(b r in g in c o p ie s ) .


1. W h a t a re y o u r p r im a ry c o n c e rn s a t th is t im e ?

2. W h a t a re o th e r ( re la te d ) c o n c e rn s ?

3. W h a t s tra te g ie s h a v e b e e n u s e d to a d d re s s th e s e p ro b le m s ? (c h e c k th o s e th a t a p p ly a n d c irc le th o s e th a t h a v e b e e n s u c c e s s fu l) :

V e rb a l re p r im a n d s _______ T im e o u ts _______R e m o v a l o f p r iv ile g e s ______ R e w a rd s y s te m ______P h y s ic a l p u n is h m e n t _______ G iv in g in _______A v o id in g is s u e s _______ O th e r _______

4. H o w w o u ld y o u ra te y o u r c h ild 's o v e ra ll fu n c t io n in g ? (c irc le )

1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10

unable to unable to se rious m ild to m in im a l no d ifficu ltyfunction in function in d ifficu lty m odera te d ifficu lty

a ll a reas in m ost a reas function ing d ifficu lty

5. W h a t are yo u r goa ls fo r trea tm en t and des ired ou tcom e?

P aren t / G uard ian S igna tu re Date

P aren t / G uard ian S igna tu re Date

T he rap is t S igna tu re Date


Appendix D

Procedures fo r Sessions: Extended Play-Based Developmental Assessment

Sessions 1 through 3 - Free Play Activ ities

Free Play Directives

• Free play allows the child to be creative, expressive, and engage in cooperative play at his/her own pace and in unique ways.

• Free play also empowers the child to have insight into his or her personal choices, and reinforces the curative nature o f play.

• D IRECTIVE: “ This is the play therapy room. Let me show you around. Feel free to look around and decide how you’d like to spend your time today. This is a place you can play and talk as much or as little as you want. W e’ll get to know each other a little and you’ ll decide how we spend our time. Later on, I m ight invite you to do some specific art or play activities or talk together about important topics.”

Free Drawing Directives

• I f the child is interested in drawing or painting, they are invited to do anything they like.

• It is important fo r non-art therapists to understand that the process o f making art has inherent curative properties. Thus, clinicians should not talk, ask questions or otherwise interrupt children while they draw or paint. I f children talk to clinicians, they listen but don’t actively engage in conversation.

• D IRECTIVE: “ You can draw or paint whatever you like and whatever comes to mind.”

• The fo llow ing is a therapeutic question clinicians can pose after the child is finished w ith a free art activity: “ Tell me about your picture.”

• Stay at the periphery o f this activity w ithout initiating idle chatter that distracts from or diffuses engagement w ith the activity.

• Remain engaged, yet don’t initiate questions or idle conversation.• Respond briefly to questions, i f asked.• Help child i f help is requested but avoid the urge to anticipate the ch ild ’ s needs;

providing assistance that guides the child but doesn’t take the lead away.• Restrain from making evaluation comments; i f you do, children can become

accustomed to wanting/needing external validation.• Become fam iliar w ith the vast literature on children’ s art and play.

Excerpted from EPBDA, Developed by Eliana Gil (2010)


Session 4 - In d iv id u a l Play Genogram

Directives

• Miniatures/ organized by categories• “ Find a miniature that best shows your thoughts and feelings about everyone in the

fam ily, including yourself. Put that miniature(s) on the square or circle o f hat person.”• Once choices are made, view the completed Genogram w ith the child.• Express interest and listen as they tell you about their Play Genogram.• The fo llow ing are examples o f some therapeutic questions to pose after the child is

finished w ith activity:- “ Say as much or as little as you want about the Play Genogram.”- “ Tell me about the (miniature)?”- “ What is it like fo r the (miniature) to _____ ?”- “ How do (miniature A ) and (miniature B ) get along?”What would (miniature A ) say to (miniature B ) i f it could?”- “ What is (miniature) thinking/doing/feeling/wanting?”- “ What is (miniature) like when not be ing_____ ?”- “ How was it fo r you to do this activity? Most people report it as more

d ifficu lt than it looks.”• Some children may choose more than one miniature for a fam ily member; this is

accepted and adds to the complexity o f the relationship or mixed feelings.• Ask questions, make observations, but don’t interpret. Stay w ith in the metaphor

language o f the child. Instead o f saying “ the bear looks angry” , say “ I notice you picked a bear that’ s showing its teeth. W hat’ s he/she thinking, or feeling?”

• I f a child feels frustrated by not finding the precise miniature desired, observe how the child tolerates frustration or resolves the problem. A helpful next step is to offer the child a piece o f clay so that they can mold whatever they want or to ask them what object they would have used had it been available.

• Some children m ight have d ifficu lty verbalizing their thoughts /feelings about the Genogram. Do not ask the child to explain why he or she chose a particular object. Beginning a question w ith “ why” often puts children on the spot and asks them to explain choices which they may not fu lly understand. Instead, ask children to tell you more about the miniature, what kind o f miniature it is, what the miniature likes or dislikes to do, etc.

• Use an open and expansive dialogue in which the child can volunteer a broad range o f information. Don’t ask questions that e lic it “ yes/no” responses.

• Ask to take a photograph o f the Individual Play Genogram, so you can keep this in your file



Session 5 - B u ild a W o rld in the Sand

Directives• Sand tray: waist-high, waterproof, painted blue inside. 19.5 x 28 and 3 inches deep.• Clinicians maintain the role o f silent witness and provide unconditional acceptance,

exhibiting interest in the sand try scenario, modeling that i t ’ s worth “ taking in.” However, clinicians do not initiate conversation while children are building their sand scenarios, and i f children talk to them, they acknowledge the child but resist active engagement in conversation.

• “ Using as few or as many miniatures as you would like, build a world in the sand. There is no right or wrong way to do this.”

• Or say “ Using the miniatures, make anything you would like in the sand.”• Asking for a “ world” may have an organizing or confusing effect fo r children. The

broader directive sometimes results in activities such as drawing a happy face in the sand. A fter the child creates the sand scenario, walk around the sand box, modeling observation and valuing what’ s been created. Tell children that they can say “ as much or as little ” as they want. A llo w for spontaneous communication. I f you are so inclined, you may ask about the sand world creation w ith questions such as the following:

- “ tell me about your world”- “ tell me what kind o f world you’ve bu ilt”- “ what is going on in your world”- Ask about objects, i.e. “ I noticed the firs t thing you chose to place in the

sand w as______ , tell me a little about______ ?”- “ How did it feel to make this part o f the world?”- Ask about groupings/areas, for example “ tell me about th e ____ in the left

corner o f the world?”- “ What does_____ see or think or feel?”

“ What is your favorite part o f the world?”- “ What is it like to make your world?”- “ What kind o f reaction do you have when you look at what you built?”- “ What surprised/delighted/intrigued you about the world you built?”

• I f time runs out, take a picture o f sand world, and process during the next session.• C linician sits opposite o f builder, yet close enough to see (don’t hover)• Stay silent, yet answer briefly i f client poses questions• Keep miniatures organized by categories• Display undivided attention.

Rules for Sand tray• Sand stays in tray (provide this information when child needs it, vice at beginning)• C linician does not break plain o f tray; yet touch the outside o f tray• Clinician does not leave room• Clinician does not dismantle tray in front o f child/client.



Session 6 - C olor Y o u r Feelings

Directives

• Use Gingerbread template, crayons, markers, colored pencils and paper• “ Lets make a lis t o f the feelings you feel most o f the time”• Clinicians or youngsters lis t these feelings on le ft hand o f paper.• Clinicians draw a box on right hand o f paper that corresponds to the words written on

left column.• Clinicians then say “ pick a color that best shows each feeling and f i l l in the box w ith

that color” .• Use the gingerbread template - “ use your color code to show the feelings you have,

and color in on this gingerbread person how big or little those feelings are, and where those feelings are in your body”

• Clinicians may ask the fo llow ing questions after child has finished the activity:- “ Tell me about your picture?”- “ What do you notice about your picture?”- “ What do you think is the same or different between the two?”

• Clinicians m ight also make comments such as:- “ It seems you feel a lo t o f worry when you’ re w ith your mother. Tell me

about the worries that you feel” .- “ You seem to have two opposite feelings about his person/situation. Say a

little b it about each o f these feelings that you have.”• I f child is unable to th ink o f names o f feelings, use feeling cards to assist child in

labeling feelings.

Session 7 - Self P o rtra it

Directives

• Use o f art supplies• “ Draw a picture o f you”• I f children look fo r more direction, tell them whatever they do is fine and that there is

no right or wrong way o f doing this drawing.• Clinicians may ask the fo llow ing questions after the child has finished the activity:

- “ Tell me about your picture?”- “ What is going on in your picture(s)?”- “ What is this little girl/boy thinking in this picture?”- “ How does the little girl/boy feel in this picture?”

• I f the child refuses to make self-portrait, go to another activity, fo r example, a free drawing. Do not engage in power struggles.

• Emphasize to children that they can make whatever kind o f picture they want, including an abstract self-portrait (using lines, shapes, colors, images, etc...)



Session 8 - K ine tic Fam ily Drawings

Directives• Use o f art supplies• “ Draw a picture o f yourself and your fam ily doing something.. .some kind o f action.”• Clinicians may ask the fo llow ing questions after child has finished the activity:

- “ Tell me about your picture or drawing?”- “ What is going on in this picture?”- “ How do the figures in the drawing feel about one another?”- “ I f they could speak, what would they say to each other?”- “ I f the g irl could speak, what would she say to ___?”- “ I wonder what this person is thinking. I wonder what he/she is thinking or

feeling?”- “ I f your fam ily wasn’t doing this activity, what else would they do?”

In all o f these sessions, clinicians should stay in the periphery o f the activity w ithout initiating idle chatter that distracts from or diffuses engagement w ith the activity. Providing silent involvement; allowing the drawing to proceed w ithout interruption. Use an open dialogue in which the child volunteers a broad range o f information. Ask open-ended questions, being cautious not to impose value-laden words - such as asking “ I noticed that you seem smaller than everyone in the drawing, tell me more about that?”

Sessions 9 - 12 Closure: Parent meetings - sharing assessment interpretations and recommendations and fina l session w ith ch ild

Directives• “ As you know, we are going to have our last meeting o n ______ , and I would like us

to do a few things before then.”• First I would like us to look back at when you firs t came here, the things we have

done together, the activities you have enjoyed, and what you’ve learned about yourself” .

• “ I would then like to give you and your parent some ideas about were we go from here and what I think m ight be helpful fo r you.”

• I would also like to plan a goodbye session and celebration so I would like to hear how you would like to celebrate our last assessment meeting.”

• Clinicians may want to present children w ith a little booklet w ith pictures and activities that were completed during the assessment.



AppendixPlay Room M ateria ls

doll, doll bed, clothes, pacifier, bottle, dress up clothes, jewelry, hats, crown, m irror doll house, wooden doll furniture, bendable doll families (multiethnic) plastic food, dishes, tea pot and tea cups/saucers

rubber knife, toy gun, dart gun & board games (therapeutic in nature), hand cuffs, balls (various), Squish balls books, puppets old cell phone, building blocks,

chalkboard, colored chalk, eraser, whiteboard w / markers, construction paper, crayons, colored pencils, paper/several types, watercolors, clay, play-doh tape, paste, pipe cleaners, popsicle sticks, magazine clippings (pictures and words) two sand boxes, dry and wet, w ith miniatures

M in ia tures

Peoplefam ily sets (various sizes) bride/groompeople who look frightened, happy, sad, etc..

Professionsvet, doctor, police, firemen, sports, nurse, astronaut, m ilitary

Historical cowboys & Indians knights & horses pirates, settlers, modern figures

Boundaries fences, popsicle sticks, wooden blocks

Animalszoo animals, farm animals, dinosaurs, domestic and w ild animals, insects, fam ily o f animals, (all o f various sizes)

Nature Othertrees, bushes, rocks, shells, volcano, marbles, jewels/sparkly things,coconut shell (cave), branches/twigs treasure chest, paper flags/umbrella

Vehiclescars, trucks, airplanes, boats ambulance, police, fire trucks

Religious/Spiritualminister, Jesus, devil, crosses

Fantasywizard, fairy, mermaid, dragons, ghost, skeleton

Structureswishing well, bridges, buildings plastic rocks/stones,


Appendix F

Play Assessment Observation Form

Date_______________Child'sName______________________________________________Child's age__________Gender________ Culturalbackground________________Does child use play room alone □ or with parent □?Sessions occur in play therapy room □ adult room with toys □ or selected toys taken to other environment □Physical functioning:

Is child's communication primarily verbal □ non-verbal □ expressive □

Is child's affect primarily expansive □ or constrictive □

Is child's affect appropriate □ inappropriate □

Is child capable of affect tolerance □ affect modulation □

Is child's typical attention span limited □ average □

Can child begin and end one project/activity before moving on to another?

Yes^ No □

Non-directive work:Toys selected and sequence of play

Themes in play

Excerpted from EPBDA, Developed by Eliana Gil (updated 2010)


Stories Told

Interaction with therapist during play

Depth and richness of symbolic play

Culture-specific symbolism

Issues suggested by the play

Is child's play mostly adaptive □ Mostly non-adaptive □

Signs of suicidality □ Homicidal ideation □ Dissociation □ Other □

How does child appear to clinician before/during/ after play therapy?

How do parents or others report child acts before and after play therapy?



Directive work:What toys did you select for the child to play with?

Why? What were your goals?

How did you introduce toys/game to child?

Did child engage easily with your idea?

Was there any specific resistance to play?

Did the child initiate interaction with therapist?

Did the child respond to:Reflective comments □ Specific questions □ Specific interpretations □ How did the child respond?

Did you feel that your interventions were helpful □ not helpful □ neutral How so?

What ideas do you have for follow up to selected play interventions?

Countertransference responses

Other comments:



Did you meet your goals for this session? Yes □ No □ Plan for next session?

Issues for supervision/consultation



Appendix G

Research Questionnaires


Therapist Research Questionnaire

1. Describe your experiences in using the EPBDA?

2. Describe what you believe has been helpful and effective in using the EPBDA?

3. Describe what has not been helpful in using the EPBDA?

4. Did most activities go smoothly? Yes___ No____ If not, what was the challenge?

5. Describe how the use of the EPBDA affected your relational experience with the client/family?


Parent Questionnaire

1. How would you describe your experience w ith the EPBDA?

2. Describe what you feel has been helpful for you?

3. Describe what you feel has not been helpful fo r you?


Child Questionnaire

1. What was it like fo r you to be here in the playroom? What would you tell another child coming to the playroom?

2. D id you feel safe w ith all the things we did in the playroom? Yes____ NoI f no, can you explain what you feel is unsafe?

3. D id you feel comfortable w ith all the activities? Y es____N o ____I f no, can you describe what activities you were uncomfortable with?

4. Can you describe what has been the most helpful fo r you?

5. Can you describe what has not been very helpful for you?


Appendix H

Video Observation R ubric

Speechta lkativeQuietTalks to TxTalks to selfLaughsCries/whinesFacialExpressionsmilefrownEye contactNo eye contactBodyLanguageActive in playW ithdrawn in playAgita ted/fearRestless/hypercalmRejects play d irectiveAccepts play d irectiveEngages with txDoes not engage w / therapist

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