Received 12/02/18

Revised 04/14/19
Accepted 04/14/19
DOI: 10.1002/jcad.12300

Intensive Child-Centered Play Therapy

for Children on the Autism Spectrum:
A Pilot Study
April A. Schottelkorb, Karrie L. Swan, and Yumiko Ogawa

To investigate the effectiveness of intensive child-centered play therapy (CCPT) for children diagnosed with autism
spectrum disorder (ASD), the authors randomly assigned 23 children with diagnosed ASD and symptoms of ASD on
the Social Responsiveness Scale–2nd Edition (Constantino, 2012), to an intensive CCPT condition (n = 12) or a no-
intervention control group (n = 11). Children who participated in 24 sessions of CCPT showed a statistically significant
decrease in ASD core symptoms and behavioral symptoms, such as externalizing problems, attention problems, and
aggression, compared with children in the control group. Implications are discussed.
Keywords: autism spectrum disorder, externalizing problems, play therapy, randomized controlled trial, treatment

Autism spectrum disorder (ASD) is the fastest growing 2015). Researchers have found that 30%–75% of children di-
neurodevelopmental disability in the United States, with agnosed with ASD exhibit symptoms of ADHD (Grzadzinski,
an estimated incidence of 1 in 59 individuals diagnosed Dick, Lord, & Bishop, 2016; Johnston et al., 2013). Likewise,
with autism (Centers for Disease Control and Prevention researchers have discovered that aggression is a common
[CDC], 2014, 2018). Over the last 2 decades, the prevalence behavioral manifestation for children on the autism spectrum
of ASD has increased by 435%, resulting in increased calls (Farmer et al., 2015; Kanne & Mazurek, 2011; Tsiouris,
for researchers to study autism symptoms, etiology, and Kim, Brown, & Cohen, 2011). In a clinical population study,
treatments (Ameis et al., 2018; Snyder, de Brey, & Dillow, Kanne and Mazurek (2011) interviewed caregivers of indi-
2016; Tonge, Bull, Brereton, & Wilson, 2014). Generally, viduals with ASD and found that 56% of 1,380 children and
children diagnosed with ASD exhibit a range of core autism adolescents displayed aggressive behaviors to their primary
symptoms, including communication and language deficits, caregiver. The combination of ASD, ADHD, and external-
social impairment, and restricted and repetitive behaviors izing behaviors such as aggression appears to create myriad
(American Psychiatric Association [APA], 2013). Conse- complicated outcomes, including decreased quality of life,
quently, children with ASD have difficulty engaging in social adaptive functioning, and educational achievement (Farmer
relationships, understanding complex communicative cues et al., 2015; Grzadzinski et al., 2016; Salazar et al., 2015).
and gestures, and using self-regulatory skills (APA, 2013). For many children on the autism spectrum, core autism
Co-occurring psychiatric disorders are common for chil- symptoms remain stable and the severity of functioning in
dren on the autism spectrum. The most common diagnoses adulthood is related to severity of autism symptoms as well
include attention-deficit/hyperactivity disorder (ADHD), as comorbid diagnoses (Matson & Horovitz, 2010; Szatmari
oppositional defiant disorder (ODD), obsessive-compulsive et al., 2009). Specifically, individuals with ASD face enduring
disorder (OCD), and generalized anxiety disorder (GAD; difficulties, including restrained educational opportunities
Angold & Egger, 2007; Skokauskas & Gallagher, 2010; van and employment, hindered social networks, and restricted
Steensel, Bogels, & de Bruin, 2013). Correspondingly, in a access to leisure activities (Howlin, Goode, Hutton, & Rutter,
population study, researchers found that children with ASD 2004; Liptak, Kennedy, & Dosa, 2011; Shattuck et al., 2012).
have an increased risk of emotional and behavioral problems, Because of this, researchers across disciplines have reached
including aggression and attention problems (Salazar et al., consensus that early intervention is critical, and treatments

April A. Schottelkorb, North Valley Hospital, Whitefish, Montana; Karrie L. Swan, Department of Psychology, Eastern Washington
University; Yumiko Ogawa, Department of Counselor Education, New Jersey City University. April A. Schottelkorb is now at Big Sky
Pediatric Counseling and Consulting, Kalispell, Montana. This research was supported by a grant from College of Education, Boise
State University. Correspondence concerning this article should be addressed to April A. Schottelkorb, Big Sky Pediatric Counseling
and Consulting, 500 Birchwood Court, Kalispell, MT 59901 (email: bigskypediatriccounseling@gmail.com).

© 2020 by the American Counseling Association. All rights reserved.

Journal of Counseling & Development ■ January 2020 ■ Volume 98 63
 Schottelkorb, Swan, & Ogawa

that target both core ASD symptoms and comorbid behaviors through in-depth interviews that young adults with autism
are needed. face immense pressure to act normal in a neurotypical world
(Prizant, 2015). Similar results from a grounded theory study
Interventions for Childhood ASD indicated that parents desire collaborative approaches that
foster their children’s independence, self-regulation, and sense
Across the literature, psychosocial treatments for improving
of happiness (Pfeiffer, Piller, Giazzoni-Fialko, & Chainani,
emotional and behavioral outcomes for children with ASD
2017). Because ASD core symptoms may serve as strategies
are classified into two categories: focused or comprehensive.
for coping with dysregulation, there is a need to explore
In focused approaches, children with ASD are taught to dis-
comprehensive interventions that promote attachment; self-
criminate between appropriate and inappropriate behaviors, to
regulation; choice; and natural, unsolicited play (Morgan
monitor and record their behaviors, and to use reinforcement
et al., 2018). One approach that is important to consider is
strategies for maintaining appropriate behavioral responses
child-centered play therapy (CCPT).
(Lopata et al., 2012; National Autism Center [NAC], 2015).
Focused approaches may include applied behavior analysis,
pivotal response training, discrete trial training, functional
CCPT
communication training, and antecedent-based intervention CCPT is a comprehensive, relational counseling approach
(Odom, Collet-Klingenberg, Rogers, & Hatton, 2010; Stah- based on Virginia Axline’s (1947) developmental construction
met, Ingersoll, & Carter, 2003). Whereas focused approaches of person-centered therapy. According to Landreth (2012),
demonstrate decreases in core ASD symptoms following play therapy is “a dynamic interpersonal relationship between
intervention, evidence shows that children with ASD do not a child (or person of any age) and a therapist trained in play
always generalize or maintain treatment effects (Lopata et therapy procedures who provides selected play materials
al., 2012; Strain & Schwartz, 2001). Additionally, evidence and facilitates the development of a safe relationship for the
shows that focused approaches are more appropriate for older child (or person of any age) to fully express and explore self
children and adolescents with relatively high-functioning (feelings, thoughts, experiences, and behaviors) through play,
ASD than for younger children or adolescents with more the child’s natural medium of communication, for optimal
severe forms of ASD (NAC, 2015). growth and development” (p. 11). CCPT is grounded in the
Conversely, comprehensive treatments are typically manu- belief that an attuned and therapeutic relationship, expressed
alized, provided over a span of months or years, and designed in terms of unqualified acceptance of the child and empathic
to impact developmental growth and broad strands of pro- resonance, is curative (Axline, 1947; Landreth, 2012; Ray,
social behaviors and social-emotional assets (Odom, Boyd, 2011). Through the CCPT process, children engage in self-
Hall, & Hume, 2010; Odom, Collet-Klingenberg, et al., 2010). directed play, exploring their experiences and emotions and,
Comprehensive interventions include the Denver model, the as a result, gaining a sense of mastery and control over their
Lovaas model, the Princeton Child Development Institute world and, ultimately, becoming more integrated human be-
program, and the Treatment and Evaluation of Autistic and ings (Landreth, 2012; Ray, 2011).
Communication Handicapped Children program (Odom, For children on the autism spectrum, some researchers
Collet-Klingenberg, et al., 2010). Although there are relatively maintain that the play experience and core relational tenets
few comprehensive interventions for improving core features lead to increased joint attention, environmental exploration,
of ASD, there is a growing body of evidence demonstrating and self-regulation (Kasari, Freeman, & Paparella, 2006;
that comprehensive, developmentally oriented interventions Kasari, Paparella, Freeman, & Jahromi, 2008; Prizant, 2015).
increase IQ test scores, joint attention, and reciprocal com- Ray, Sullivan, and Carlson (2012) reasoned that the experienc-
munication for children with ASD (Magiati, Moss, Charman, ing of an accepting, genuine, and empathic relationship in a
& Howlin, 2011). Although these results are promising, there nondirective play environment may contribute to improved
remains a need to explore treatments that will reduce ASD relational engagement and communication. Similarly, Porges
symptoms and comorbid behavioral problems. (2011) argued that in relational experiences such as CCPT,
In recent years, some researchers have cast doubt on which create a soothed autonomic nervous system and secure
the use of current treatments for treating ASD symptoms, attachment, children may experience what neuroscientists
highlighting that said approaches treat a person with ASD refer to as neuroception of safety. Thus, the process of CCPT
as “a problem to be solved rather than an individual to be allows children with ASD to experience safety in a relation-
understood” (Prizant, 2015, p. 17). Additionally, qualita- ship, express affective arousal and dysregulation, and practice
tive interviews of individuals with autism have revealed a self-regulatory skills and varying forms of self-expression
need for approaches that affect self-esteem, well-being, and (Porges, 2011; Schore, 2001).
quality-of-life indicators (Crane, Adams, Harper, Welch, & As an intervention, CCPT has been used for more than
Pellicano, 2019). In one study, Crane et al. (2019) discovered 60 years in the successful treatment of a variety of present-

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Child-Centered Play Therapy for Children on the Autism Spectrum

ing problems and diagnoses (Bratton, Ray, Rhine, & Jones, Method
2005; Jensen, Biesen, & Graham, 2017; Leblanc & Ritchie,
2001; Lin & Bratton, 2015; Pester, Lenz, & Dell’Aquila, Participants
2019). Studies suggest that CCPT reduces attention prob- Research participants were recruited from five elementary
lems (Ray, Schottelkorb, & Tsai, 2007; Robinson, Simp- schools in the northwestern United States. The first author
son, & Hott, 2017; Schottelkorb & Ray, 2009; Swank & contacted the school counselor from each school to explain
Smith-Adcock, 2018); decreases internalizing problems as the study parameters. The school’s counselor then identi-
well as symptoms of anxiety (Gholamalizadeh, Asghari, & fied and contacted all parents of children in their respective
Farhangi, 2018; Mosavi & Koolaee, 2016; Stulmaker & Ray, schools with diagnoses of ASD to determine their interest in
2015); improves externalizing problems, including aggres- participating in this study. Next, the first author met with all
sion and conduct problems (Garza & Bratton, 2005; Ray, interested parents from each school in individual meetings
Blanco, Sullivan, & Holliman, 2009; Swan & Ray, 2014; to review informed consent and participation requirements.
Wilson & Ray, 2018); and decreases symptoms relating If parents provided consent for participation, the first author
to trauma and adverse childhood experiences (Patterson, continued with intake and initial assessment to determine
Stutey, & Dorsey, 2018; Schottelkorb, Doumas, & Garcia, whether all qualifications for participation were met.
2012). Despite these promising results, limited research ex- Children were included in the study if they met the follow-
ists on the effectiveness of CCPT for children with ASD. In ing criteria: (a) had a diagnosis of ASD either by a medical
a recent investigation, Salter, Beamish, and Davies (2016) professional or school psychologist, (b) were between 3 and
investigated the effect of CCPT on social and emotional 12 years of age, (c) scored on the Social Responsiveness
growth for three children with ASD. Through analysis of Scale–2nd Edition (SRS-2; Constantino, 2012) in the mod-
single-case research data, these researchers found that all erate to severe impairment of functioning for ASD, and (d)
participants demonstrated increases in social skills, com- were not participating in counseling services. Twenty-five
munication, and prosocial behaviors (Salter et al., 2016). children’s parents agreed to participate and completed pre-
In another single-case design, Balch and Ray (2015) found test assessments; however, two participants did not qualify
improvement for children with mild to moderate levels of with clinical levels of ASD on the SRS-2 and thus were not
ASD in ratings of empathy, social competence, and self- included in the study.
regulation. Beyond the highlighted studies, there are no Participants included 23 children (ages 4–10) diagnosed
randomized controlled trials examining the effectiveness with ASD and having moderate or severe levels of symptoms
of CCPT for children with ASD. as reported on the SRS-2. As CCPT is typically used for
children ages 3 to 10 (Ray, 2011), our participants’ age range
Purpose of the Current Study of 4 to 10 was appropriate. Of the 23 children enrolled in the
Our preliminary search of the literature revealed that study, 19 (83%) were male and four (17%) were female; 22
comprehensive psychotherapy-based approaches for treat- children were White, and one child was Black. Five (22%)
ing core autism symptoms and comorbid behaviors are children attended half-day, public developmental preschools,
scarce. A need thus exists to explore the efficacy of CCPT and 18 (78%) attended full-day public elementary schools.
in improving both core ASD symptoms and externalizing In the initial meeting, we asked parents about their children’s
behaviors, such as attention and aggression problems. In diagnoses and services received. Of the children included in
this study, we examined the behavioral effects of CCPT the study, many had co-occurring diagnoses of ADHD (n =
for children with ASD. We primarily aimed to (a) test the 13), OCD (n = 3), GAD (n = 2), pica (n = 1), or ODD (n =
efficacy of CCPT using validated rating scales to measure 1) as reported by parents.
core autism symptoms, attention problems, aggression No children were participating in counseling services at the
problems, and externalizing problems; (b) examine the time of the study. Depending on their individualized education
feasibility of implementing CCPT in school settings for plans, the children received varying supports at school, with
children with ASD; and (c) implement an intense CCPT speech and occupational therapy (OT) services most typically
intervention with sessions occurring four times per week provided. More narrowly, as per their parents’ report at pretest
over a period of 6 weeks. assessment, children participated in supports such as speech
We designed a randomized controlled trial to include two services inside and/or outside school (n = 16), OT services
conditions: (a) CCPT intervention and (b) wait-list control. inside and/or outside school (n = 11), medication manage-
At the outset, we hypothesized that children with ASD in the ment for their symptoms (n = 7), one-on-one assistance in
CCPT condition would show improved core ASD symptoms the regular classroom setting from a paraprofessional (n = 3),
and decreased behavioral problems when compared with and/or feeding therapy outside school (n = 3); three students
the control group. received no services. The first author asked all parents at

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 Schottelkorb, Swan, & Ogawa

posttest assessment about any changes in services received those specific models, as many would have required parent
during the 6-week experimental period of the study, and all education and training components. For this investigation,
parents denied any changes in interventions provided to or we wished to determine the effectiveness of CCPT without
medications used by the participants. the interference of parent training and education and, thus,
simply reported play themes and solicited parent feedback
Counselors and Treatment Integrity about changes noted at home. All parent information was
The CCPT intervention was provided by three graduate-level documented in parent-consultation session notes, which were
counseling students and two licensed counselors who held later used in social validity reported in the Results section.
professional credentials in the northwestern United States.
All of the therapists were trained in using CCPT and in Instruments
implementing procedures outlined in the CCPT treatment SRS-2. To assess the effectiveness of CCPT for children
manual (Ray, 2011). To ensure treatment fidelity, counselors with ASD, we had parents complete the SRS-2 (Constantino,
received weekly supervision from the first author and at the 2012) at preintervention and postintervention periods. The
conclusion of the study, the research team (the authors) exam- SRS-2 is a 65-item rating scale that measures and quanti-
ined treatment adherence. One member of the research team fies the severity of symptoms of social impairment relating
observed one full session from each therapist and used the to ASD. In our study, parents rated the items on the SRS-2
Child Centered Play Therapy–Research Integrity Checklist on a 4-point Likert-type scale ranging from 1 (not true) to 4
(CCPT-RIC) to conduct fidelity, as recommended by Ray, (almost always true). The SRS-2 is well regarded for helping
Purswell, Haas, and Aldrete (2017). In their examination, identify ASD core symptoms in school-age children and is
Ray et al. (2017) found that the CCPT-RIC had a high level of also recommended for use in assessing intervention impact on
interrater reliability (.95) in defining verbal CCPT responses social behavior, communication, and stereotypic behaviors of
among a panel of CCPT experts. Ray (2011) reported that over children with ASD (Bruni, 2014). The SRS-2 provides a total
90% adherence to CCPT indicates good treatment fidelity. score as well as scores for subscales of Social Awareness, So-
In this study, we found that the therapists used verbal CCPT cial Cognition, Social Communication, Social Motivation, and
responses in their sessions 96% of the time, demonstrating Restricted Interests and Repetitive Behavior. The total SRS-2
good adherence to CCPT. score is the most reliable score (Bruni, 2014) and thus was
used for determining overall change in core ASD symptoms
Treatment in this study. More specifically, an SRS-2 total score of 76
CCPT was provided initially to the 12 children in the in- or higher indicates severe impairment of social functioning,
tervention group across 6 weeks, with each child attending scores from 75 to 66 indicate moderate impairment, scores
four (30-minute) individual sessions weekly for a total of 24 from 65 to 60 indicate mild impairment, and scores under 60
sessions at their school. Play therapy rooms were established indicate a lack of social difficulties associated with an ASD
at each participant’s school, and the rooms were furnished in diagnosis (Bruni, 2014). The SRS-2 is a strongly reliable
accordance with materials recommended by Landreth (2012). instrument (with a total reliability coefficient of .95) and
Additionally, all playrooms were equipped with cameras so valid for identifying individuals with ASD, particularly with
that therapists could record all play sessions to assist with the school-age form (Bruni, 2014).
supervision of skills and treatment integrity. Therapists in Child Behavior Checklist (CBCL). In addition to the SRS-
the study were asked to complete a play therapy session sum- 2, parents also completed the CBCL (Achenbach & Rescorla,
mary after each session, documenting each child’s significant 2001). The CBCLs for children ages 1½ to 5 and 6 to 18 are
verbalizations, play behaviors, play themes, and changes instruments of the Achenbach System of Empirically Based
across sessions. Additionally, therapists conducted in-person Assessment. Both measures are used for examining emotional
parent-consultation sessions weekly for a total of six sessions. and behavioral problems as well as adaptive functioning of
Because parent consultation is typically considered part of children as rated by parents/guardians. In our study, parents
CCPT treatment, as recommended in the CCPT treatment rated the items on the CBCL on a 3-point Likert-type scale
manual (Ray, 2011), we desired to include that component ranging from 0 (not true) to 2 (very true or often true).
in this investigation. For this study, therapists followed a The instruments are designed to evaluate child behaviors
specific parent-consultation protocol established by the first across three domains—externalizing, internalizing, and
author, which required that each therapist share play therapy total behavior problems—using various subscales. Due to
themes and behaviors noted in session to parents, and that the varied ages of participants in this study, the two different
therapists solicit any behavioral changes noticed by parents CBCL versions were used. Because the two versions offer
at home. Although other parent-consultation models affiliated differing subscales, we focused on comparing pre-post
with CCPT have been described in the literature (e.g., Schot- data from those subscales that were consistent across the
telkorb, Swan, & Ogawa, 2015), our study did not use any of two types: Attention Problems, Aggressive Behavior, and

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Child-Centered Play Therapy for Children on the Autism Spectrum

Externalizing Problems. Scoring procedures for the CBCL meaningful effect size. Practical significance was calculated
involve calculating T scores and percentiles for each subscale. using partial eta squared as the measure of effect size, and we
T scores between 60 and 63 are considered borderline, interpreted meaning using Cohen’s (1988) guidelines of .01
suggesting an area of concern, and T scores higher than 63 as a small effect, .06 as a moderate effect, and .14 as a large
are considered clinical. Both versions of the CBCL (1½–5 effect. Using G*Power (Version 3.1; Faul, Erdfelder, Lang,
and 6–18) are reliable (test-retest coefficients between .68 and & Buchner, 2007), an a priori power analysis for a repeated
.92) and valid for identifying individuals with internalizing measures, within-between ANOVA with a medium to large
and externalizing behaviors (Achenbach & Rescorla, 2001). effect size of .30, a probability of .05, a power of .80, two
groups, and two measures indicated a total sample size of
Procedure 24 participants was needed. Because the current study was
This study was approved by a university institutional review intended as a small, pilot randomized controlled trial, effect
board. Informed written consent was obtained from parents size for power analysis was adjusted accordingly (Purswell
prior to inclusion in the study. Following consent, parents of & Ray, 2014).
child participants were asked to complete the SRS-2 and the
CBCL, and then children were randomized into two groups: (a) Results
CCPT treatment or (b) wait-list control. The first author used
Data Preparation
a random number generator with all participants to randomly
assign all children to their group. The randomization resulted in Participants in both the play therapy group and wait-list
12 children receiving CCPT and 11 children receiving no treat- control group completed all pre-post measures; hence, there
ment. After children were assigned to groups, the experimental were no missing data. We examined the effect of CCPT on
intervention began and lasted for 6 weeks. At the conclusion of child outcomes by conducting a series of factorial ANOVAs
the intervention, parents in both the experimental and wait-list with time (preintervention vs. postintervention) as the within-
control groups were asked to complete the SRS-2 and CBCL. group variable and group (CCPT vs. wait-list control) as the
After posttesting was completed, children in the wait-list control between-group variable (see Table 1). We inspected data for
group received 6 weeks of CCPT. assumptions regarding normal distribution, homogeneity of
intercorrelations, and homogeneity of variance. Normal dis-
Data Analysis tribution was slightly skewed, as would be expected for the
Preliminary data analysis included independent-samples t small sample size. However, ANOVA techniques are typically
tests to identify statistically significant differences between robust to slight abnormalities in distribution (Pallant, 2016).
the treatment group and control group. To determine the effect All other assumptions were met. Although random assign-
of CCPT on social skills and problem behaviors, we conducted ment was used in procedures, we visually noted differences
a mixed-model repeated analysis of variance (ANOVA). in pretest scores between groups. Independent-samples t
Within-subject levels included time from pretest to posttest tests were run on predata for each factorial ANOVA prior to
(k = 2). Levels of the between-subjects variables included analysis. In all cases, there were no statistically significant
child treatment (CCPT) and a wait-list control group (k = 2). differences between groups at pretest.
Through this approach, we examined statistical significance
and effect size outcomes between groups and across time. Social Responsiveness
We conducted post hoc, paired-samples t tests following dis- A 2 (CCPT vs. control) × 2 (time; preintervention vs.
covery of statistically significant differences (α = .05) and a postintervention) factorial ANOVA was conducted to

TABLE 1
Analysis of Variance Results for Outcome Variables

CCPT Group Control Group Effects

Pretest Posttest Pretest Posttest Time Time × Group
Outcome Variable M SD M SD M SD M SD F h p2 F h p2
SRS-2 total score 78.83 7.7 70.58 9.2 73.64 7.84 77.91 7.99 1.88 .08 18.60 .47
CBCL
Attention Problems 72.33 11.73 64.50 9.25 66.00 8.76 67.55 7.95 6.38 .23 14.20 .40
Aggressive Behavior 68.42 11.97 62.83 9.27 69.55 13.10 70.36 11.25 2.87 .12 5.19 .20
Externalizing Problems 68.67 9.35 63.08 7.90 65.36 9.54 67.27 8.72 2.60 .11 10.81 .34

Note. CCPT = child-centered play therapy; SRS-2 = Social Responsiveness Scale–2nd Edition; CBCL = Child Behavior Checklist.

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 Schottelkorb, Swan, & Ogawa

examine the effect of the intervention on SRS-2 scores. Social Validity/Clinical Significance
Results of the factorial ANOVA on the SRS-2 total score in- At the end of the study, we completed interviews with partici-
dicated a statistically significant interaction effect between pants’ parents in the CCPT group for the purpose of obtain-
group and time, Wilks’s Λ = .53, F(1, 21) = 18.60, p < .01, ing social validity. Parents reported improved eye contact,
hp2 = .47, with a large effect size. This result indicated that decreased tantrums, increased appropriate play behaviors,
participants in the play therapy group experienced a drop and increased relational play with parents. Analysis of pre-
in SRS-2 scores from preintervention (M = 78.83, SD = post data also revealed that half of the children in the CCPT
7.71) to postintervention (M = 70.58, SD = 9.29), whereas group (n = 6) changed in symptom severity by an entire cat-
the control group participants were reported to increase egory (e.g., from severe to moderate ASD symptoms or from
in symptomatology from pre- (M = 73.64, SD = 7.84) to moderate to mild ASD symptoms) on the SRS-2. Of the 12
posttesting (M = 77.91, SD = 7.99). treatment group participants, 11 were reported to have im-
Attention Problems proved ASD symptoms. By contrast, of the 11 control group
participants, six were reported to have worsening symptoms,
A 2 (CCPT vs. control) × 2 (Time; preintervention vs. and the remaining five were reported to score the same as or
postintervention) factorial ANOVA was conducted to within 1 point of pretest.
examine the effect of the intervention on the Attention
Problems subscale scores of the CBCL. Results of the Discussion
factorial ANOVA on the Attention Problems score indicated
a statistically significant interaction effect between group The goal of this study was to examine the effectiveness of
and time, Wilks’s Λ = .60, F(1, 21) = 14.20, p < .01, hp2 CCPT on the social functioning and externalizing problems
= .40, with a large effect size. This result indicated that of children with ASD. We speculated that CCPT would be
participants in the play therapy group experienced a decrease effective in improving social responsiveness associated with
in attention problems from preintervention (M = 72.33, SD = ASD and decreasing attention, aggression, and externalizing
11.73) to postintervention (M = 64.50, SD = 9.25), whereas problems of children with ASD, and these hypotheses were
the control group participants were reported to increase supported in this study: Children in the CCPT treatment
in symptomatology from pre- (M = 66.00, SD = 8.76) to group demonstrated significant improvements in social
posttesting (M = 67.55, SD = 7.95). behavior as measured by the SRS-2 and demonstrated
significant reductions in externalizing, attention problems,
Aggressive Behavior and aggression as measured by the CBCL. These research
A 2 (CCPT vs. control) × 2 (time; preintervention vs. findings support the previous findings of Balch and Ray
postintervention) factorial ANOVA was conducted to exam- (2015) and Salter et al. (2016), who found improvements
ine the effect of the intervention on the Aggressive Behavior in social behaviors in single-case research for children with
subscale scores of the CBCL. Results of the factorial ANOVA ASD. These results, along with results of the present study,
on the Aggressive Behavior score indicated a statistically indicate that CCPT may be an effective intervention to help
significant interaction effect between group and time, Wilks’s improve the social behaviors of children with ASD. Whereas
Λ = .80, F(1, 21) = 5.19, p = .03, hp2 = .20, with a large ef- applied behavior analysis may be effective in eliminating
fect size. This result indicated that participants in the play or reducing specific behaviors and reinforcing preferred
therapy group experienced a decrease in aggression problems behaviors and is considered an “established” treatment
from pre- (M = 68.42, SD = 11.97) to postintervention (M intervention, it is very time intensive, requiring 30–40
= 62.83, SD = 9.27), whereas the control group participants hours per week for 2 or more years (Granpeesheh, Tarbox,
were reported to increase in symptomatology from pre- (M & Dixon, 2009). In contrast, in our investigation, we found
= 69.55, SD = 13.10) to posttesting (M = 70.36, SD = 11.25). that just 12 hours of CCPT with six parent-consultation
sessions improved social behaviors for children with ASD.
Externalizing Problems Thus, these preliminary results indicate that CCPT may
Results of the factorial ANOVA on the Externalizing Problems be a cost-effective intervention to help improve the social
subscale scores revealed a statistically significant interaction functioning of children with ASD.
effect between group and time, Wilks’s Λ = .66, F(1, 21) = Children with ASD typically struggle with emotional
10.81, p < .01, hp2 = .34, with a large effect size. Following and behavioral self-regulation (Jahromi, Bryce, & Swanson,
the same trend as previous analyses, participants in the play 2013; Laurent & Gorman, 2018). Poor self-regulation is
therapy treatment group were reported to have decreased ex- related to increased difficulties with social functioning and
ternalizing symptoms from pre- to post-testing (M = 68.67, SD adaptive behaviors (Uljarevic et al., 2018) and increased
= 9.35; M = 63.08, SD = 7.90), whereas control group scores aggressive and externalizing behaviors (White, Jarrett, &
increased (M = 65.36, SD = 9.54; M = 67.27, SD = 8.72). Ollendick, 2012). In this study, we found that externalizing

68 Journal of Counseling & Development ■ January 2020 ■ Volume 98

Child-Centered Play Therapy for Children on the Autism Spectrum

behaviors, attention problems, and aggression as rated by traditional once-per-week model. Because our study took
parents on the CBCL decreased significantly through partici- place in the school setting, we encourage school counselors
pation in CCPT, which supports previous research (Bratton and school-based mental health practitioners to use CCPT
et al., 2013; Ray et al., 2007, 2009; Ritzi, Ray, & Schumann, in their work with children with ASD. In such settings, it
2017; Schottelkorb & Ray, 2009). Thirteen children with is easier to access the children more frequently throughout
ASD in our study also had a comorbid diagnosis of ADHD, the week and thus implement an intensive CCPT model. In
similar to previous research wherein 30%–75% of children addition, counselor educators who train school-based and
with ASD had a comorbid ADHD diagnosis (Grzadzinski clinical counselors who plan to work with children ages 4
et al., 2016; Johnston et al., 2013). Leitner (2014) reported to 10 may encourage training and use of CCPT for their
that there are no interventions that have been found effective students, particularly as CCPT has been found effective
to treat deficits associated with both ASD and ADHD. In for a multitude of presenting problems of childhood (Ray,
addition, aggressive behaviors are a common co-occurring 2011). Because ASD is the fastest growing neurodevelop-
behavior associated with autism (Kanne & Mazurek, 2011). mental disability in the United States (CDC, 2014, 2018), it
In this investigation, we found that CCPT improved social is imperative that child counselors know of evidence-based
functioning associated with ASD and decreased ADHD and interventions for children with ASD. Preliminary results
aggressive behaviors. of our investigation, as well as previous research (Balch &
Ray et al. (2012) postulated that CCPT is an intervention Ray, 2015; Salter et al., 2016), indicate that CCPT may be
inherently designed to be effective for children with ASD effective for children with ASD.
because it is relationship and communication focused—areas
that are core deficits for children with ASD. In CCPT, chil- Limitations
dren with ASD are accepted just as they are, which differs The present study was the first of its kind to use a randomized
significantly from typical behavioral interventions used for controlled trial in exploring the effectiveness of CCPT for
children with ASD that are designed to target and change children with ASD. However, several limitations exist, includ-
specific behaviors. In our study, parents reported that social ing that our study used a small sample size, no follow-up was
behaviors and relational interactions with parents were im- performed to ensure changes persisted postintervention, and
proved after participation in CCPT. We speculate that when there was limited diversity in the sample due to the study tak-
children with ASD experience full acceptance of themselves ing place within one area of the northwestern United States.
through the CCPT relationship, they may feel safe in their Another limitation of this investigation is that all evaluation
attempts to engage in a relationship with the play therapist. of change was done through parents’ reports of symptoms on
Once acceptance is discovered in one relationship (the play the SRS-2 and CBCL. Thus, it is possible that parents’ positive
therapy relationship), we posit that children with ASD are experiences participating in this intervention impacted their
more likely to interact with others outside of the therapy room, reporting at the postassessment period.
as confirmed by parents in this study, with parents reporting
improved social interactions with them through SRS-2 results Future Research
and parent feedback in parent-consultation sessions. Although we found significant improvement in social
Results from this investigation indicate good clinical behaviors and decreased attention and externalizing be-
significance for CCPT as parents reported positive changes havioral problems and aggressive behaviors for children
detected at home, including fewer tantrums, improved eye with ASD after participating in CCPT, no follow-up was
contact, and improved relational play with parents. These performed to determine sustained improved functioning
findings support other researchers’ findings that for interven- postintervention. Future researchers could consider a
tions to be implemented, good social validity from parents 1-year follow-up to ensure improvements were sustained.
and teachers is required (Callahan et al., 2017; Carter, 2010). As this study was a pilot study, future researchers could
Thus, our findings indicate that parents perceived CCPT as use larger, more diverse samples and consider comparing
a helpful intervention. CCPT with evidence-based interventions for children with
ASD, such as applied behavior analysis. An additional
Implications for Counseling consideration is exploration of CCPT with and without
The findings of this investigation indicate that children who parent involvement to see if parent consultation impacts
have ASD along with co-occurring attention and aggression treatment outcome. Future researchers could include a
problems may benefit from participation in intensive CCPT. direct observation assessment for examining change in
Thus, clinical counselors in private practice or in mental symptoms outside of parent report. Direct observation
health settings may consider using CCPT for children with methods in the classroom would provide information
ASD and, more narrowly, may consider using a more inten- regarding change occurring in other settings, such as the
sive model with multiple sessions in a week, rather than the classroom (Kasari & Smith, 2013). Because participants

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 Schottelkorb, Swan, & Ogawa

in this study had moderate or severe levels of ASD as per Bratton, S. C., Ray, D., Rhine, T., & Jones, L. (2005). The ef-
the SRS-2, researchers could explore the effectiveness of ficacy of play therapy with children: A meta-analytic review
CCPT for children with varying levels of ASD severity. of treatment outcomes. Professional Psychology, 36, 376–390.
Finally, in this investigation, we explored an intensive doi:10.1037/0735-7028.36.4.376
model of CCPT, rather than the more traditional once- Bruni, T. P. (2014). Test review. Journal of Psychoeducational As-
or twice-per-week model that is described in the CCPT sessment, 32, 365–369.
literature (Ray, Henson, Schottelkorb, Brown, & Muro, Callahan, K., Hughes, H. L., Mehta, S., Toussaint, K. A., Nichols, S.
2008). Thus, researchers could explore the effectiveness of M., Ma, P. S., . . . Wang, H. (2017). Social validity of evidence-
intensive models of CCPT compared with the traditional based practices and emerging interventions in autism. Focus
once-weekly sessions that are commonplace in clinical on Autism and Other Developmental Disabilities, 32, 188–197.
counseling settings. Carter, S. L. (2010). The social validity manual: A guide to sub-
jective evaluation of behavioral interventions. Boston, MA:
Conclusion Academic Press.
Centers for Disease Control and Prevention. (2014, March 28).
ASD is a common neurodevelopmental disability for chil-
Prevalence of autism spectrum disorder among children aged 8
dren, and mental health and school counselors should be
years—Autism and Developmental Disabilities Monitoring Net-
informed of a variety of interventions that are effective with
work, 11 sites, United States, 2010. Morbidity and Mortal Weekly
this population. Although there is evidence to support be-
Report: Surveillance Summaries, 63, 1–21. Retrieved from
havioral interventions, our study shows that relational-based
https://www.cdc.gov/mmwr/preview/mmwrhtml/ss6302a1.htm
counseling interventions may be effective alternatives for
Centers for Disease Control and Prevention. (2018, November
meeting the varied needs of children with ASD. In this inves-
16). Prevalence and characteristics of autism spectrum disorder
tigation, we found that an intensive CCPT intervention was
among children aged 8 years—Autism and Developmental
effective in improving social responsiveness and decreasing
Disabilities Monitoring Network, 11 sites, United States, 2012.
externalizing problem behaviors of children diagnosed with
Morbidity and Mortality Weekly Report: Surveillance Sum-
ASD. Thus, this pilot study provides preliminary evidence
maries, 65, 1–23. Retrieved from https://www.cdc.gov/mmwr/
that intensive CCPT may be a cost-effective intervention
volumes/65/ss/ss6513a1.htm?s_cid=ss6513a1_w
for children with ASD.
Cohen, J. (1988). Statistical power analysis for the behavioral sci-
ences. New York, NY: Routledge.
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