Psychiatry - October 2008 - (Page 26)

attention-seeking behavior. Also, as much of his play involved things being broken, needing to be fixed, and the idea of punishment by being hit on the head, the therapist was able to extrapolate that the symptoms also served as self punishment. By repeating these themes in the face of safe, gentle correction by the therapist, all symptoms resolved for the most part within four sessions. Snow, et al., described two case studies followed over a six-week period.11 One case was a three-yearold boy brought in by his grandmother for increasing aggressive behavior and violent tantrums. The other case was that of a six-year-old boy showing regressive behavior in imitation of and perhaps competition with his younger, disabled brother. The caregiver filled out the Child Behavior Checklist of Thomas M. Achenbach and Craig Edelbrock so that the authors could primary caregiver. Many subjects showed a trend toward clinical improvement (8 of 26), but the Reliable Change Index formula failed to show a statistical difference. Baggerly advocates for the use of play therapy with homeless children to help them “gain in fantasy what [they] long for in reality.”13 Mullen, et al., explored the use of play therapy with young people, “facing transitions as a result of relocation.”14 He presents a case study of a middle-school–age girl upset by her family’s move to a more affluent neighborhood. She was able to work through the effects of this relocation and come to terms with the change through bringing the material up in the context of play therapy. In another study, play therapy was used in the preoperative period to reduce state anxiety scored in children. Li, Lopez, and Lee found a reduction in state consistent over age, gender, and presenting issues. The largest effects were seen in therapies that involved the parents. The importance of conducting well-designed, outcomebased studies on play therapy is illustrated by another meta-analysis of published and unpublished play therapy outcome studies where poorly designed or incomplete studies were included. Rogers-Nicastro found only a between-group effect size of 0.18, indicating a lack of evidence to make any strong conclusions about play therapy.19 CASE PRESENTATION: WHAT DOES PLAY THERAPY LOOK LIKE? Rather than focusing on a particular setting or diagnosis, the following case is presented as an introductory vignette to play therapy—an example of how a typical nondirective play thereapy session might progress. Mike is a six-year-old boy with a diagnosis of oppositional defiant disorder. His mother’s behavioral concerns include noncompliance with adult requests, disrespecting attitude toward others (especially women), and explosive tantrums. Mike has been expelled from several daycares. Mike lives with his mother and grandmother. His parents divorced when he was four after a marriage marked by significant tension and disagreement. Mike witnessed their arguments, and on occasion, he saw his mother being hit and shoved by his father. Mike’s father has remarried and has a newborn. The custody agreement states that Mike’s father has regular visits every other weekend and one day a week; however, he has been very inconsistent. Typically, the father misses visits or cancels at the last minute. Mike: (Looking around the room) I don’t think I feel like playing today. Psychiatrist: You don’t know if you want to do anything. Practice point. The psychiatrist reflects back what the child has said. This intervention shows the Play therapy offers a direct route to engage children on their terms, in their world, giving them a chance to, “play through what adults talk through.”2 The goal is to identify and address themes that arise in the course of play, although children’s relative strengths and weaknesses do become apparent in terms of cognitive processing and social skills. track the course of behavioral outcomes. The authors tracked the themes present in play from session one to session six based on a standard format. Of note was that changes in play themes in therapy were paralleled by changes in behavior at home. Outside of the context of specific psychiatric diagnoses, play therapy has been used in a variety of other settings. Scott, et al., conducted a 10session “client-centered” study on the use of play therapy with 26 victims of sexual abuse, ages 3 to 9. Here “clientcentered” refers to a slight variation in how the play therapy session is run, although the overall format still consists of play based on themes and interests initiated by the child. However, their findings showed only mixed support for the use of play therapy in this setting.12 A pre-test and post-test assessment battery were completed both by the patient and the 26 Psychiatry 2008 [ O C T O B E R ] anxiety scores and fewer negative emotions at induction of anesthesia.15 Two hundred and three children admitted for day surgery were randomly assigned to experimental or control groups. In the experimental group, the children received therapeutic play while the control group received “routine information preparation.” The authors found a reduction in state anxiety scores and fewer negative emotions at induction of anesthesia.16 A growing body of research supports the clinical effectiveness of play therapy for children with selfconcept issues, behavioral adjustment, social skills, emotional adjustment, intelligence, and anxiety/fear.17 In a review of 93 controlled-outcome studies published between 1953 and 2000, Bratton, et al., found an overall treatment effect of 0.80 standard deviations.18 This effect was felt to be

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Psychiatry - October 2008 Editor’s Message Editorial Advisory Board Contents Psych Rx Treatment of Migraine and the Role of Psychiatric Medications Play Therapy: A Case-based Example of a Nondirective Approach Delirium and Antipsychotics: A Systematic Review of Epidemiologyand Somatic Treatment Options Severely Mood-disordered Youth Respond Less Well to Treatment in a Community Clinic than Youth with Bipolar Disorder Beyond Informed Consent: The Ethics of Informing, Anticipating, and Warning Asthma: Wheezing, Woes, and Worries Classified Advertising Journal Watch Information for Authors

Psychiatry - October 2008

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