Child-Centered Play Therapy and ACEs

Journal of Counseling & Development | 2021, Vol. 100, Issue 2, p. 134-145

Child-centered play therapy and adverse childhood experiences: A randomized controlled trial

Dee C. Ray; Department of Counseling and Higher Education, University of North Texas, Denton, Texas, USA

Elizabeth Burgin; School Psychology and Counselor Education, William & Mary, Williamsburg, VA, US

Daniel Gutierrez; School Psychology and Counselor Education, William & Mary, Williamsburg, VA, US

Peggy Ceballos; Department of Counseling and Higher Education, University of North Texas, Denton, Texas, USA

Natalya Lindo; Department of Counseling and Higher Education, University of North Texas, Denton, Texas, USA

Adverse childhood experiences (ACEs) are described as “childhood exposures to traumatic events which are cumulatively implicated in the development of chronic physical and mental health problems,” with evidence showing that “the more adverse experiences reported in childhood, the more dire the consequences on physical and mental health in both childhood and adulthood.” Children with ACEs are more likely to experience “learning and behavior problems,” “mental health concerns, illness, and socialization problems,” and impairments in “emotional regulation and trauma symptoms.” At the same time, research has emphasized that social-emotional competencies such as “empathy, self-regulation, and social skills” can serve as protective factors. Despite extensive research documenting outcomes, “treatment studies are still rare,” and “few studies exploring intervention focused on the construct of ACEs” exist, particularly those directly providing mental health services to children. Child-centered play therapy (CCPT) is described as a “developmentally responsive, play-based mental health intervention” that emphasizes a therapeutic relationship characterized by “acceptance, empathy, and understanding.” The purpose of the study was “to explore the impact of CCPT with children who have experienced two or more ACEs on the fostering of social and emotional assets and decrease of demonstrated behavioral problems” (p. 134-137).

Participants were recruited from five Title 1 elementary schools, with inclusion criteria requiring children to be in Kindergarten through third grade and to have “a caregiver reported a minimum of two ACEs.” A total of 120 participants were randomized, with 112 included in the final analysis, consisting of children aged 5–9 years with a mean ACE score of 4.20. The study used a randomized controlled design in which participants were “randomly assigned to the experimental CCPT group or the waitlist control group.” Children in the treatment group received “two 30-minute CCPT sessions per week for a total of 8 weeks… resulting in a total of 16 sessions.” Measures included an expanded ACE questionnaire assessing “events… that adversely impact functionality,” the SEARS-P to assess “social-emotional competencies” such as self-regulation, social competence, and empathy, and the Direct Observation Form (DOF) to evaluate “children’s observed behavior, affect, and interpersonal interactions at school.” Data were analyzed using a “repeated measures linear mixed model” to examine changes over time and differences between treatment and control groups (p. 137-140).

Analyses indicated that “positive changes in the intervention group compared to the lack of change in the waitlist control” were observed across outcomes (see Table 1, p. 8). Significant Time × Group effects were found for “Empathy… Self-Regulation/Responsibility… Social Competence… and also the Total Score,” with “moderate to large effects between the groups.” Children in the CCPT group demonstrated increases in social-emotional competencies, while “children’s scores in the waitlist control group remained unchanged.” Behavioral outcomes also improved, as “data analysis also resulted in a significant Time Group interaction” for total behavior problems, indicating reductions in observed problems among children receiving CCPT. Overall, children who participated in CCPT showed improvements in both parent-reported competencies and independently observed behavior in school settings” (p. 141).

The findings indicate that children with multiple ACEs who participated in CCPT “statistically significantly improved with practically clinical effects… in the building of empathy, self-regulation/responsibility, and social competence,” and were “observed to have significantly less behavioral problems after participation in CCPT as compared to the waitlist control group.” These improvements were supported “across multiple critical environments by both parent report and blind rater observation,” strengthening the validity of the results (p. 141-142).

A key finding is the impact on self-regulation, as “the most notable finding was the positive impact of CCPT on self-regulation indicating that CCPT may be a particularly viable intervention for children with ACEs.” CCPT is described as providing “a relationship and setting in which the counselor facilitates expression… for children to develop understanding, self-acceptance, and strong self-concept,” allowing children to “learn to regulate themselves… and learn the power of choice… with self-responsibility” (p. 141-142).

In addition, children demonstrated gains in empathy and social competence, suggesting that “social skills of children with ACEs may deteriorate… without intervention, yet social skills are positively affected by relationship with a nurturing adult.” The therapeutic relationship in CCPT, characterized by empathic communication such as “I am here. I hear you. I understand. I care,” is emphasized as central to change. Overall, the findings support CCPT as an intervention that can directly address the social-emotional and behavioral effects associated with cumulative adversity in childhood (p. 141-142).

“The most obvious implication of the current study is that CCPT appears to be a practical and effective intervention for children who have experienced ACEs and at-risk for trauma disorder. The large sample composed of a representatively diverse sample of young children who have experienced multiple ACEs provides credible evidence that CCPT is a culturally inclusive intervention that can be delivered practically over 8 weeks. However, because the current study did not focus on the effectiveness of CCPT between cultural groups (i.e., race/ethnicity, poverty), future research exploring levels of effectiveness with varying populations is recommended.

CCPT acknowledgment of relationship as the therapeutic change agent for children appears to match the needs of children with ACEs. Our focus in the present study on building strengths for children of ACEs through the development of social emotional assets offers a unique contribution to ACEs intervention. We propose that counselors trained in CCPT can offer play therapy as an intervention to build coping skills for children who have experienced adversity and complex trauma. Additionally, CCPT counselors may also consider exploring the number and categories of ACEs for their clients at intake in order to assess the level of possible trauma exposure. Based on procedures employed in the current study, we recommend that counselors who assess for ACEs consider the need for sensitivity regarding the intrusive nature of ACEs questions for parents. We also highlight the limitations of using an ACEs questionnaire due to various unstandardized versions available and lack of attention within current assessments to cumulative effects of single ACEs.

Future research would further the exploration of CCPT in the context of ACEs and trauma. We suggest an examination of the relationship between CCPT, ACEs, and trauma symptoms by adding a trauma measure such as the Trauma Symptom Checklist for Young Children (TSCYC; Briere, 2005) in the study of CCPT effectiveness. By exploring relationships between variables, the mediating influence of ACEs could be identified, allowing for clearer identification of children who would benefit the most from intervention. Although it was beyond the scope of the current study, we recommend exploring the relationship between cumulative effects of ACEs through measurement of repeated events and CCPT intervention. ACEs questionnaires typically only identify types of ACEs, thereby not accounting for complex trauma experienced through repeated acts of the same ACE. Capturing the frequency and repeated number of ACEs provides a better understanding of the intervention process with children who suffer from complex trauma. Finally, research involving the role of relational variables as mediators in intervention effectiveness is essential to enhanced insight for the facilitation of CCPT as a humanistic counseling intervention. Because authors of ACEs literature strongly advocate for nurturing relationships as the antidote to the effects of ACEs and because CCPT proposes relationship as the fundamental cornerstone of therapy, we believe that further exploration of the therapeutic relationship will provide a deeper understanding of the therapy process with children who have experienced ACEs” (p. 143).

“Limitations of this study included the use of the ACE-E measure, a measure that used the original 10 ACEs questionnaire items plus additional items selected due to their use in previous literature. In a review of ACEs measures, Bethell et al. (2017) identified 14 different measures used in the ACEs literature and concluded that there has been no consensus on framework to evaluate measurement of ACEs. In our review of ACEs identification literature, we found the original items to be missing essential ACEs, specifically community-level adverse events. Based on ACEs research, we added the most common additional items identified in the literature, such as bullying, neighborhood violence, discrimination, natural disaster, adoption, and foster care. However, there was no standardized expanded version of the ACEs questionnaire available for the current study. Another limitation related to the ACE-E measure was the reliance on parent report. Due to the sensitive nature of ACE-E items, parents may have not answered the questions honestly, especially after they were informed of child abuse reporting procedures. Additionally, parents may not be aware of all ACEs experienced by their children. It is likely that ACEs were underreported for participants. As a research team, we discussed the sensitivity necessary in the administration of the ACE-E and developed procedures to help parents feel safe and more comfortable in their responses but we are uncertain to what degree we achieved this goal.

A final and notable limitation of this study was the overrepresentation of boys comprising 76% of the sample. CCPT literature commonly has an overrepresentation of boys presumably due to the elevated identification of boys in elementary schools as exhibiting problem behaviors. With the focus of the current study on ACEs, we anticipated a more even number of girl and boys participants. Previous ACEs literature reports no difference in ACEs number between males and females or higher reported ACEs for females. Although our analysis did not indicate a difference in outcomes based on gender, we recognize the limitation of a sample comprised mostly of males. We theorize that because we conducted the study in a school environment, recruitment was influenced by the school's staff preference to refer students who exhibit more externalizing behavioral problems, most likely resulting in over-referral of boys” (p. 142-143).