Play Therapy for Prevention — A Pound of Cure
By Mary Anne Peabody, LCSW, RPT-S
Social Work Today
Vol. 6 No. 4 P. 20

A respected play therapy project provides attention to children in the gray areas who just need “a little more time” and screening of children with more serious difficulties so a social worker can intervene.

Social workers who work with young children often wonder whether the bucket in which we put our daily energy has a hole. So many complex needs surround the families we work with, such as community norms and expectations and the ever-changing demands on the educational system. With so many needs on the treatment end of the continuum, it is easy to understand why little attention gets focused on prevention. Yet, we all know that whether it is mental health or physical health, the cost of prevention is far less than the cost of treatment.

Have we forgotten about prevention? I think not. However, it takes a dedicated effort to spend part of your energy in the field of preventive mental health. It is not just “pie in the sky,” Pollyannalike wishful thinking that we can change the tide sooner or plug up the holes earlier. It takes dedicated action by social workers to carve out a part of their professional job description to devote time and effort to the work of preventive mental health.

There are many social workers across the country who have chosen to do just that. These social workers can prove with quantifiable outcome data that the time and effort they spend in prevention is working. From school social workers to agency-based social workers collaborating with schools, they are part of an effort to screen children for an array of mental health services and provide interventions from prevention to treatment. They are part of a national trend to implement an evidence-based prevention program that focuses on emerging difficulties in young children.

Nearly 50 years ago, a talented team of social workers, psychologists, and researchers knew that for prevention to work, a team effort was necessary. They knew there was an earlier and more effective way to screen for social and emotional needs. They took their different approaches and training backgrounds to develop the Primary Mental Health Program. Now nearly five decades later, Primary Project continues to work.

When you see schools that are able to successfully intervene along the entire continuum of mental health services for children, you can’t help but be excited. When you see community behavioral and mental health agencies joining forces to collaborate with schools, you realize the social work belief is evident: Mental health needs of children must be shared by the entire community. And when that program successfully links academic achievement with the inherent need for young children to build relationships through play, you know they did their homework. Finding an effective program based on sound research that addresses the link between school achievement and school adjustment makes the discovery even better.

Primary Project
Nationally recognized by the U.S. Surgeon General Report on Mental Health in 1999 as one of five exemplary prevention programs in the country, Primary Project has won several awards over its 48 years. It has received the Lela Rowland Award for Outstanding Prevention Program by the National Mental Health Association. It has been designated a “Promising Prevention Program” by the Federal Department of Education’s Safe, Disciplined, and Drug-Free Schools, and by the Substance Abuse and Mental Health Services Administration.

Currently, Primary Project operates in more than 2,100 elementary schools in 14 states and internationally in Brazil and Canada. The flagship project of Children’s Institute in Rochester, NY, it is affiliated with the University of Rochester. Throughout its history, it continues to have roots in evidence-based research, targeted at improving the social and emotional competence of young children.

Primary Project recognizes that positive school adjustment is a key developmental task of all school-aged children. Inherent in the program is the belief that a child experiencing adjustment problems can become better adjusted and more socially and emotionally competent when allowed to engage in the developmentally appropriate activities of play (Cowen et al., 1975; Cowen et al., 1996).

Children face many challenges in school: increased structure, adherence to schedules, the need to work cooperatively, and increased expectations for academic achievement. Some begin to worry or lose confidence. Others have difficulty getting along, following rules, or staying on task. By providing opportunities for safe, nurturing relationships with adults in school, Primary Project can help children adjust more quickly and learn to succeed.

Therefore, Primary Project’s early interventions are provided within a structured environment staffed by carefully selected and trained paraprofessionals otherwise referred to as child associates. The child associates receive training to be therapeutic change agents while under the watchful supervision of a school-based social worker, counselor, or psychologist. It is similar to filial therapy, which is associated with Bernard Guerney’s (1964) work in training parents to use methods derived from child-centered play therapy with their children. Filial therapy has been shown to significantly improve children’s behavior, parental acceptance, and parental behavior (Oxman, 1971).

Because it is not a counseling relationship and the direct service is provided by a trained paraprofessional, it is not considered direct play therapy. However, as in filial therapy, we hope to make the child associates therapeutic agents of change by using specific, nondirective, child-centered skills to build a relationship with the child through play. Both the supervisor (social worker or other school mental health professional) and the child associate receive training in the play-based intervention and the skills of emotionally responsive language.

Social workers become the supervisors of the child associate to ensure that the children selected are appropriate and not in need of more intensive counseling services. Through weekly supervision, they have the opportunity to hear about the play sessions and ongoing changes and to provide guidance for the paraprofessional.

Primary Project has been highlighted in two play therapy texts that may be of interest to other social workers. These are “School Based Play Therapy” (Drewes et al., 2001) and “Empirically Based Play Interventions for Children” (Reddy et al., 2005).

Children seen by child associates are characterized as having mild to moderate school adjustment difficulties. This approach supports the notion that between the majority of elementary students who are well adjusted and not in need of services, and the small percentage of children who have been identified or diagnosed with more severe mental health problems, lies a number of students who experience mild adjustment problems characterized by shyness, withdrawal, or socially inappropriate behavior.

Somewhere between the children who are well adjusted to school and the children who are significantly at risk lies a group of children who are just beginning to struggle.

When children experience difficulty with school routines, or forming relationships with other children or adults, then school can be difficult. School can be a painful experience when learning is more confusing than exciting. Left unattended, these children often become more disengaged, withdrawal from the learning process, or develop behaviors that interrupt the flow of the classroom experience. These are the children for which teachers wish they had “just five more minutes.”

These children rarely need intensive counseling or remedial learning support. What they do need is someone to notice their uniqueness. They need individualized time. They are the “gray area children” who, if left unattended, often rise to the surface in a more serious way.

The Need to Play
Early childhood educators have always considered play to be a fundamental practice in early childhood classrooms. But with the growing demands for academic accountability, many educators are finding that play is simply being pushed out of the curriculum. At the same time, many teachers feel the tension between what they know about the significance of play and the demands placed on achievement. Teachers must increasingly defend the use of play in their classrooms to principals, parents, and other teachers. They feel an obligation to prove that play not only facilitates the development of social competencies but also promotes the learning of preacademic concepts and skills.

In a comprehensive review of numerous studies on play, researchers found evidence that play contributes to advances in “verbalization, vocabulary, language comprehension, attention span, imagination, concentration, impulse control, curiosity, problem-solving strategies, cooperation, empathy, and group participation” (Smilansky & Shefatya, 1990). Recent research provides additional evidence of the strong connections between quality of play in preschool years and children’s readiness for school instruction (Bowman et al., 2001; Ewing Marion Kauffman Foundation, 2002; Shonkoff & Phillips, 2000).

Ask any early childhood educator and he or she will tell you that social and emotional competencies are the foundational blocks for successful learning. As one first-grade teacher commented, “As much as I would like to give every child in my classroom the undivided attention they crave, it is simply impossible. Time with the Primary Project child associate makes them feel heard. They return confident and much more ready to learn.”

The core five key components of Primary Project are:

1. Focus on early childhood. The program is geared for children in preschool through third grade.

2. Systematic screening and selection. Just as schools have historically screened children for physical health (eyes and ears), the classroom teacher screens all children in the targeted grades for social and emotional competencies. This provides a safety net, helping to identify children who stand to benefit most from the Project. The screening process addresses a need identified in the Surgeon General’s Conference on Children’s Mental Health: Developing a National Action Agenda to increase access to mental health screens and assessments for all children. “This is especially critical for the youngest children—mental health screens can identify problems that require immediate attention. If and when there is evidence of a potential problem, children should receive a more comprehensive assessment to determine appropriate treatment and services” (Children’s Defense Fund, 2002). For some schools, the screening also provides a roadmap not only for the children who will benefit from Primary Project but identifies and quantifies the needs of all children in targeted age ranges.

3. Highly trained and consistently supervised paraprofessional staff. These key individuals are the heart and soul of the project. They are trained in adapting child-led play techniques that help form a caring and supportive relationship. Selected for their ability to work with young children, they are provided ongoing training and supervision to enhance their understanding and skill development.

4. Changing role of the school mental health professional. School-based mental health professionals meet weekly to supervise and provide ongoing training for the paraprofessional. They continue with their own caseload, but as direct prevention services are delivered, they are able to geometrically expand the number of children being serviced. They remain the key liaison with parents and teachers.

5. Ongoing evaluation. In this day and age of evidence-based programming, Primary Project has a long-standing and rich, evidence-based foundation. Recent data shows that children in Primary Project displayed increased coping skills, decreased aggressiveness, and were less disruptive over time. Significant improvements in assertiveness highlight improved participation and expression of ideas, increased leadership, and decreased shyness. Lastly, the results indicate that significant changes in peer sociability were noted that demonstrate an increase in the quality of peer relationships and an increase in social skills among children in the Project.

A sixth component is emerging: program integration. How does the project fit into the overall services for children in the school community and the larger community? How are school staff normalizing the notion of healthy school adjustment and positive mental health for children?

Expected outcomes of implementing the intervention include improvements in behavior control, task orientation, assertiveness, and peer sociability of children with school adjustment problems. Outcomes will be measured with the use of the T-CRS 2.1 (Teacher-Child Rating Scale). The T-CRS 2.1 is a quick and easy way to use teacher assessment that measures student competencies and problem behaviors (task orientation, behavior control, assertiveness, and peer social skills) [Perkins & Hightower, 2002]. It is completed before a child is seen and again at termination to measure program impact for the individual child. Evidence from various validity studies support the T-CRS 2.1 as a measure of children’s socioemotional adjustment (Perkins & Hightower, 2002).

As one administrator commented, “The data is critical. I can show parents and members of the school board that we can quantify social and emotional competence. I can show that the dollars spent on prevention do make a difference.”

And for parents, the comments are heart-warming. Many thank the school for paying special attention to the relational needs of their children. Many report that the children look forward to their time with the child associate and feel a connection to this place called “school.”

The gaps of two-sided debates in education are many. Yet, the schools across the country that have embraced Primary Project in addressing early school adjustment issues are closing the gap. They are treating social and emotional health screening of all children in the targeted grades as normal a process as the physical health screening of the children’s eyes and ears.

They are embracing the concept that play is still vital to young children; that “special time” with a highly trained and sensitive adult is key to successful relationship building and thus to successful school adjustment.

Primary Project schools are successful in meeting the social and emotional needs of young children before they become problematic. They are experiencing what it feels like to truly work in the field of prevention. By working on both sides of the continuum from prevention to treatment, they are able to effectively plug up that hole earlier and earlier. Social workers are working collaboratively and supportively, expanding not only their skills but also the number of children and families they can reach.

Isn’t that what preventive social work is all about?

For more information on implementing Primary Project in your school or agency, visit www.childrensinstitute.net.

— Mary Anne Peabody, LCSW, RPT-S, is a private practitioner and a clinical associate with the Children’s Institute in Rochester, NY.

References
Bowman, B., Donovan, M. S., & Burns, M. S. (2001). Eager to Learn: Educating Our Preschoolers. Washington, DC: National Academy Press.

Children’s Defense Fund. (2002). The Children’s Mental Health Resource Kit: Promoting Children’s Mental Health Screens and Assessments. Retrieved from http://www.childrensdefense.org

Cowen, E. L., Hightower, A. D., Pedro-Carroll, J. L., Work, W. C., Wyman, P. A., & Haffey, W.C. (1996). School-based prevention for children at risk: The Primary Mental Health Project. Washington, DC: American Psychological Association.

Cowen, E. L., Trost, M. A., Lorion, R. P., Dorr, D., Izzo, L. D., & Issacson, R. V. (1975). New Ways in School Mental Health: Early Detection and Prevention of School Maladaptation. New York: Human Sciences Press.

Drewes, A. A., Carey, L., Schaefer, C. E., eds. (2001). School Based Play Therapy. New York, John Wiley and Sons, Inc.

Ewing Marion Kauffman Foundation. (2002). Set for Success: Building a Strong Foundation for School Readiness Based on the Social-emotional Development of Young Children. Kansas City, MO.

Guerney, B. (1964). Filial Therapy: Description and rationale. Journal of Consulting Psychology, 28, 304-310.

Oxman, L. (1971). The Effectiveness of Filial Therapy. A Controlled Study. Unpublished doctoral dissertation, Rutgers University, New Brunswick, NJ.

Perkins, P. E., & Hightower, A. D. (2002). T-CRS 2.1 Teacher-Child Rating scale: Examiner’s Manual. Rochester, NY: Children’s Institute.

Reddy, L. A, Files-Hall, T. M., Schaefer, C. E. (2005). Empirically Based Play Interventions for Children. Washington, DC: American Psychological Association.

Smilansky, S. & Shefatya, L. (1990). Facilitating Play: A Medium for Promoting Cognitive, Socio-emotional, and Academic Development in Young Children. Gaithersburg, MD: Psychological and Educational Publications.