The North Dakota Nurse - July 2022

July, August, September 2022 The North Dakota Nurse Page 19
Play Therapy in Autistic Children
Appraised By:
McKenna Johnson SN,Jessica Hansen SN, Ryley Gunderson SN, Kimberly
San Juan SN, Rachel Leblanc SN
Allison Sadowsky MSN RN Assistant Professor of Practice (Faculty)
(NDSU School of Nursing at Sanford)
Clinical Question:
In autistic children, what is the effect of play therapy on behavior?
List of Articles:
Baranek, G.T., Boyd, B.A., Crais, E.R., Dykstra, J.R., Watson, L.R. (2012). The impact
of the Advancing Social-communication And Play (ASAP) intervention on
preschoolers with autism spectrum disorder. Sage Pub, 16 (1), 27-44.
Hillman, H. (2018). Child-centered play therapy as an intervention for children with
autism: A literature review. International Journal of Play Therapy, 27(4), 198-204.
https://doi.org/10.1037/pla0000083
Schottelkorb, A. A., Swan, K. L., & Ogawa, Y. (2020). Intensive Child-Centered
Play Therapy for Children on the Autism Spectrum: A Pilot Study. Journal of
Counseling & Development, 98(1), 63–73. https://doi-org.ezproxy.lib.ndsu.nodak.
edu/10.1002/jcad.12300
Tilmont Pittala, E., Saint-Georges-Chaumet, Y., Favrot, C., Tanet, A., Cohen, D.,
& Saint-Georges, C. (2018). Clinical outcomes of interactive, intensive and
individual (3i) play therapy for children with ASD: a two-year follow-up study.
BMC pediatrics, 18(1), 165. https://doi-org
Tseng, K. C., Tseng, S. H., & Cheng, H. Y. (2016). Design, development, and clinical
validation of therapeutic toys for autistic children. Journal of physical therapy
science, 28(7), 1972–1980. https://doi.org/10.1589/jpts.28.1972
Synthesis of Evidence:
Autism spectrum disorder (ASD) is the fastest growing
neurodevelopmental disorder in the U.S. The prevalence of ASD calls for
study on symptoms of autism, etiology, and treatments. Symptoms of ASD
include communication and language deficits, social impairment, and
restricted and repetitive behaviors. ADHS, oppositional defiant disorder
(ODD), obsessive-compulsive disorder (OCD), and generalized anxiety
disorder (GAD) are common in children on the autism spectrum. These
children are at risk for emotional and behavioral problems. Children
diagnosed with ASD may have decreased quality of life, adaptive
functioning, and educational achievement. As stated above, further study
is needed on treatments/management for autism (Schottelkorb, 2020). Five
articles including a single case study, a systemic review of four case studies,
a randomized control trial, quasi-experimental and quantitative exploratory
studies were reviewed as evidence in this report.
Baranek (2012) conducted a single case study to examine the effect of
the Advancing Social-communication And Play (ASAP) intervention on
preschoolers with autism in public school classrooms. The study addressed
if the implementation improved social-communication and play skills in
these children and if the implementation of ASAP in both a group setting
and one-to-one setting resulted in further improvements. The design utilized
three phases for each participant. In Phase A, pre-data was collected as
children received their typical instruction in the classroom. In Phase B,
teachers and/or teaching assistants were trained and began implementing
the ASAP interventions during already occurring group activities in the
classroom. In Phase C, the speech-language pathologist was trained
and began to implement ASAP, making social-communication and play
intervention a part of both one-to-one and group settings. The study results
showed at least some improvement in social communication and play skills.
All participants showed either increases in frequency or more stability in
targeted behaviors such as initiating social interactions.
Hillman (2018) conducted a systematic review of four studies. The
systematic review had two case studies and two single case designs. They
threw out one of the studies so I will only talk about three of them. The
studies included nine children ages 4-11 that had autism and were receiving
play therapy, seven boys and two girls in all the studies. The intervention they
used was child centered play therapy, which is when the children, instead
of the therapist, control the pace, direction, and content of the therapeutic
journey. The findings overall showed an increase in social and emotional
behaviors, and a reduction in ritualistic behaviors from the use of playtherapy.
Schottelkorb, A. A., Swan, K. L., & Ogawa, Y. (2020) conducted a
randomized control trial that aimed to test the efficacy of Child-Centered
Play Therapy (CCPT) using validated rating scales to measure core autism
symptoms, attention problems, aggression problems, and externalizing
problems. Participants were recruited from five elementary schools in the
Northwestern United States. Play therapy rooms were established at each
participant’s school. The participants consisted of 23 children aged 4-10 (19
male, four female) who displayed moderate to severe symptoms on the SRS-
2 scale. The items of the SRS-2 were used on a likert scale to measure the
symptoms of social impairment. Additionally, the items of the Child Behavior
Checklist were used on a likert scale to examine emotional and behavioral
problems as well as adaptive functioning. The children in the CCPT group
showed a decrease of eight points on the SRS-2, while the control group’s
score increased by four. In addition, the children in the CCPT group showed
an eight-point decrease in attention problems, a six-point decrease in
aggressive problems, and a five-point decrease in externalizing problems,
while the children in the control group showed a two-point increase in
attention and externalizing problems (aggressive behavior remained the
same).
Tilmont Pittala, Saint-Georges-Chaumet, Favrot, Tanet, Cohen, and
Saint-Georges (2018) conducted a quantitative prospective exploratory
study. The study aimed to “assess the outcome of 20 Autism spectrum
disorder (ASD) subjects who followed the 3i method for 24 months.”
Using appropriate scales, they estimated the course of developmental
and behavioral skills and autism severity. The 3i method was used as the
intervention in this study which included the study occurring in a specific
room for one on one interaction and designed to reduce unwanted
sensorial stimuli, focuses on sensory specificities of the child, provides
participants with developmental roadmap that improves understanding
of the present abilities and difficulties on their developmental path and
it distinguished three developmental age stages in their corresponding
agenda (0-18 months, 18-36 months, and older than 36 months). The study
found an increase by 83% in the socialization and an increase by 34% in
communication. There was an increase in imitation scores by 53%. CARS
(Chilhood Autism Rating Score) scores dropped significantly since the
beginning of the study where 94% of the patients were considered severely
autistic and 6% were moderately autistic and at the end only 21% remained
severely autistic and 53% progressed to moderate autistic and 26% could be
considered to no longer have autism.
Tseng (2016) conducted a quasi-experimental study aimed at helping
autistic children to “experience healthy growth and development and
improve their language ability, behavior, and social interaction.” The
study had four stages, all except one took place in a playroom at Taiwan
university hospital. This playroom used direct observation with hidden
cameras and microphones and measured the interaction using the Penn
Interactive Peer Play Scale (PIPPS). The first stage included two autistic boys
and results showed mainly passive behavior; the second stage included
13 boys and showed the interaction increased significantly between
neurotypical child; the 3rd stage included just the psychiatrists and
they discussed the effectiveness of the toys from their point of view and
concluded that the play needed fixed rules and progressive variations;
the last stage only discussed types of toys and beneficial features. Overall
test results showed after the introduction of the cooperative play toy into
the autism play therapy, the interaction between the children increased
significantly; 2.1419 whereas it was 2.8571.
Conclusions:
The studies conducted in the articles included: a systematic review, a
single case study, a randomized control trial, a quasi-experimental study
and a quantitative prospective exploratory study with 3-23 participants
in each study. Each study implemented some sort of play therapy such as
the use of blocks, sensory play or pretend play. The results of all five articles
indicated an improvement in social interaction with the implementation
of play therapy in children with ASD. Implementing play therapy improves
social and emotional behaviors and reduces negative behaviors.
Implications for Nursing Practice:
There is evidence to suggest implementing play therapy into interactions
with children who have ASD improves social interaction and decreases
negative behavior (ex. aggression). The evidence supports improvement
in both group settings and one-on-one settings. The effects of this
implementation will be beneficial to children with ASD and to healthcare
team members when working with this specific pediatric population in all
healthcare settings. Collaborating with Child Life Specialists to implement
the delivery of developmentally appropriate play activities within the
healthcare settings, whether it be in the patient’s room or in the play room,
will promote positive behavior and social communication. The goal of
implementing play therapy is to promote healthy growth, development,
and improve their language ability, behavior, and social interaction. Using
cooperative play to create a bridge between staff and the child with
autism to overall improve the delivery of care.