Running head: EVIDENCE-BASED ARTICLE

Evidence-Based Article James Stewart Touro University Nevada

EVIDENCE-BASED ARTICLE Research Question

Do playgroups, known as group play therapy in the literature, enhance development in atrisk preschool children? APA Reference Baggerly, J. (2004). The effects of child-centered group play therapy on self-concept, depression, and anxiety of children who are homeless. International Journal of Play Therapy, 13(2), 31-51. How does this study relate to your research question? This study focuses on the effects of group play therapy on self-concept, depression, and anxiety for children who are homeless. All of these psychosocial issues will have a profound effect on the development of any child, homeless or not. However, children who are homeless are at great risk in these area and are, therefore, at great risk for developmental delay. Children who are homeless lack resources and focus more basic needs, needs that must be met before other areas can be addressed. The children in this study are not preschool age. No studies involving preschool children were found. Nevertheless, the effectiveness of group play therapy can still demonstrated through this study. Interventions are often effective for multiple populations. Further research would need to be performed specific to preschool age children. What is the purpose of the study? The purpose of the study was show the effectiveness of child-centered group play therapy for children who are homeless. The key areas being addressed are self-concept, depression, and anxiety. What are the research questions/hypotheses?

EVIDENCE-BASED ARTICLE

The hypothesis is that group play therapy will improve self-concept, decrease depression, and decrease anxiety for children who are homeless. What is the study design/type of study? What is the level of evidence? The study is a non-randomized, control trial-one group, utilizing pre-test and post-test data. This type of design ranks in the middle of the hierarchy of levels of evidence as a level four. How many participants? all together and in each group if applicable 52 participants signed up for the study, with only 42 participants actually beginning therapy. Ten participants moved before the therapy sessions began. Only 25 participants completed at least nine of the group play therapy sessions. How were the participants recruited and selected? All children who participated in the study resided at a homeless shelter and attended the charter school located at the homeless shelter. Those children who had emotional or behavioral issues were especially encouraged to participate in the study. Children who had parents sign consent forms and were willing to perform pre- and post-tests participated in the study. If applicable, how were participants assigned to groups? The original research design was to have a treatment group and a control group. With the dropout of about half the participants, the author decided to provide treatment to all participants due to the ethical principle of beneficence. How are the participants described demographics e.g. diagnosis, age, gender, race Of the original 42 participants who began the study, 31 were male and 11 were female, with 30 being African American, 7 Caucasian, and 5 Hispanic. The age of the participants ranged from five to eleven years old, having a mean age of eight years old.

EVIDENCE-BASED ARTICLE What are the variables? Independent and dependent if applicable.

The independent variable was the group play therapy and the dependent variable was the level of depression, anxiety, and self-concept. What measures were used? The Joseph Pre-School and Primary Self Concept Screening Test (JPSPSCS) was used to measure self-concept. The Childrens Depression Inventory (CDI) was used to measure depression. The Revised Childrens Manifest Anxiety Scale (RCMAS) and Child Anxiety Scale (CAS) were used to measure anxiety levels. All measures were based on self-report from the participant. If applicable, what is the intervention? The intervention was nine to twelve sessions of group play therapy, consisting of two children per group. Sessions were conducted once or twice a week, for 30-minute sessions. The playroom was small and toys were limited. Toys consisted of real life items, aggressive release items, and creative items. Therapists used a child-centered approach to play: allowing the child to lead the play, tracking play behavior, reflecting feelings and content, returning responsibility, encouraging, building self-esteem, facilitating understanding, and therapeutic limit setting (Baggerly, 2004, p. 36). What statistical analyses were used? A paired sample t-tests was conducted. This statistical analysis is used when using a pretest, post-test research design. The author also calculated effect sizes to determine level of significance. What are the findings?

EVIDENCE-BASED ARTICLE Within the JPSPSCS, participants showed statistically significant increases in SelfConcept and Competence, with no improvement in General Evaluative Contentment or Significance scores. This finding demonstrates that children who are homeless may feel

empowered by group play therapy and possibly help prevent their homelessness as adults. Within the CDI, participants showed statistically significant decreases in Negative Mood and Negative Self-Esteem, with no decreases in Total, Interpersonal, Ineffectiveness, and Anhedonia scores. This finding demonstrates that children who are homeless may feel happy when taken out of their circumstances and become lost in group play. Within the RCMAS and CAS, participants showed statistically significant decreases in overall anxiety and physiological anxiety, with no decreases in Worry or Social Concern scores. This finding demonstrates that children who are homeless may seem safe and relaxed when participating in group play therapy. All findings showed moderate to large effect sizes. Do these findings support the hypothesis? These findings confirm that hypothesis that group play therapy will increase self-concept, decrease depression, and decrease anxiety. How do the findings relate to previous research? The author compared the findings to many previous research studies and theories. She related the increases in competence to the work of Bandura, stating that competence affects academic and social skills. She related the lack of effectiveness on overall depression to the work of Stuart and Bowers, stating that the combination of medication and counseling are often needed to treat depressive symptoms. She related the decrease in anxiety to the work of Piaget, stating that symbolic play often affords children a safe means of resolving traumatic conflicts. Does the author state any clinical implications for the findings?

EVIDENCE-BASED ARTICLE The author states that three aspects of using a child-centered approach were especially helpful: allowing children to direct the play, returning responsibility to the children, and facilitating decision-making. These helped the children feel a sense of ownership in the therapy session and allow them to exercise control, something they lack. Environmentally, having the children play in a quiet, separate room allowed the children to feel safe and protected. What are the limitations that the author identifies? The author states that the limitations were inability to use a randomized control trial study, lack of a control group, and the use of self-report on the assessments. Does the author discuss implications for future research? The author states that a randomized control trial should be conducted using short-term

intensive therapy sessions, completing the study before families move. The author also states that studies should be conducted showing the effectiveness of group play therapy on academics and problem behavior. Finally, the author states that studies should be conducted comparing group play therapy with other interventions. What would you say about the sample size? Do you think it is adequate? I think that the sample size of 25 was too small. The original sample size of 52 participants would have been adequate for this research study. It should be expected by the author to have participants drop out of the study. In order to compensate for the dropout, the author could have started with a larger sample size. If the researcher did not find a significant difference between the groups, is it possible that this is due to a Type II error? If so, why do you think so? The author found a significant difference between pre- and post-test data; therefore, a type II error could not have been committed.

EVIDENCE-BASED ARTICLE Is there a control or comparison group? If so, is the control or comparison group comparable to the experimental group on key features? The study used a pre-test, post-test format, utilizing a control group of time. Therefore, the control group was the participants themselves before treatment, making the control and comparison group exactly the same in all characteristics. Are those administering the outcome measures blind to group assignment? No group assignments were made, thus having the therapists be blind is not applicable. Are the participants blind to group assignment? Again, no group assignment were made, thus having the participants be blind is not applicable. Does the researcher account for drop-outs in the study? Could drop outs have influenced the outcomes? As previously stated, the dropout rate was close to half of all participants. The author compensated for the dropout by changing the nature of the design from a randomized control trial to a non-randomized control trial-one group. She stated that this was done for the ethical reason of beneficence, providing treatment to all participants because of the small sample size. Does the researcher report reliability and validity of the outcome measures? Are there questions about the outcome measures chosen? The author reports the reliability and validity scores of all outcome measures. Scores ranged from moderate to high. The only questionable measure was the RCMAS, showing a testretest reliability score of .68. This lower score may be due to the fact that anxiety levels can be highly variable and change over time as stressors increase and decrease. What confounding factors could contribute to or influence the study outcomes?

EVIDENCE-BASED ARTICLE Random assignment was not used when pairing children into playgroups, potentially

confounding child pairing and the group play therapy itself. Measures were based on self-report, with participants potentially providing false information. This also could have showed the effectiveness of the intervention instead of the intervention itself. What are the major strengths of this study? (list 3) 1. The study used multiple measures to gauge the effectiveness of group play therapy, allowing for a greater ability to detect outcome changes. 2. The author recognized the need to be ethical and changed the study from a randomized control trial to a non-randomized control trial-one group, allowing all children to benefit from intervention. Many may consider this a flaw of the study because of the lowered level of evidence; however, I consider it a strength because the author considered the ethical needs of the participants. 3. This study showed the effectiveness of group play therapy in spite of many environmental factors at the homeless shelter that could impede progress: loud noise level, a stark appearance, and frequently overcrowded, chaotic atmosphere (Baggerly, 2004, p. 41). What are the major weaknesses of the study? (list 3) 1. The study only incorporated participants from one homeless shelter, limiting the generalizability of the results. 2. The study used measures that were not applicable to all children because of the age range of the assessments, not allowing all children to receive the same assessments. 3. The study lacks a control group, not accounting for the how changes in the environment could affect intervention outcomes.

EVIDENCE-BASED ARTICLE How would you use this article as a therapist?

I had already believed that play groups, or group play therapy, was an effective means of supporting and increasing development. This article confirms that belief. I will promote the use of playgroups with the parents that I will work with, using this article as evidence to support its use. I will state that children are positively affected by the use of group play. I will also promote the use of playgroups within the facility that I work, facilitating play between clients. How does this article support/not support participation in occupation and the field of occupational therapy? This article supports participation in the occupation of play, a childs primary occupation, showing that group play therapy furthers the psychosocial development of children who are homeless, an at-risk population for developmental delay. The one stipulation is that group play should be child-centered and non-directive, having children develop decision-making skills and creativity. The field of occupation therapy is supported by this article because play is a major component of occupational therapy intervention for children. As discussed in class, play is used as an intervention goal and as a modality to achieve other skills. This article supports the use of play to achieve psychosocial goals in order for children to achieve greater participation in their various occupations.