International Journal of Play Therapy © 2016 Association for Play Therapy

2016, Vol. 25, No. 2, 78 –90 1555-6824/16/$12.00 http://dx.doi.org/10.1037/pla0000012

The Effects of Child-Centered Play Therapy (CCPT) on the Social

and Emotional Growth
of Young Australian Children With Autism

Kerri Salter, Wendi Beamish, and Mike Davies

Griffith University

This rural Australian study explored the effects of child-centered play therapy
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

(CCPT) on the social and emotional growth of 3 young children with autism ages
This document is copyrighted by the American Psychological Association or one of its allied publishers.

4⫺6 years. Parents sought private therapy for the emotional and behavioral diffi-
culties these children were experiencing at home and in educational settings. All
children participated in 10 weekly, individual therapy sessions, which focused on
targeted goals set by parents. Two instruments, the Adaptive Behavior Assessment
System, Second Edition, and the Developmental Behavior Checklist, were used to
formally measure social and emotional growth pre- and postintervention. Informal
data were also gathered on each child’s targeted goal using Goal Attainment
Scaling and weekly parent reflections. Data from both formal and informal mea-
sures showed positive improvements for all children in several areas of social and
emotional functioning. Results indicated that CCPT was an effective intervention
for this small sample of young children with autism. Limitations, implications, and
recommendations are discussed.

Keywords: child-centered play therapy, autism, social and emotional competence

Child-centered play therapy (CCPT) is a (Wilson & Ryan, 2005). Overall, the therapy
form of therapy that involves children engag- process is aimed to improve self-concept and
ing in enjoyable activities of their choice, support children to realign themselves, psy-
which symbolically and metaphorically al- chologically and behaviorally (Guerney,
lows them to address their emotional and be- 2001).
havioral distress (Guerney, 2001). While the The structure of CCPT draws on develop-
term child-centered play therapy is used in mental foundations to understand the child’s
the United States, therapy with the same core actions in relation to a normal developmental
elements is referred to as nondirective play trajectory (Cicchetti & Beeghly, 1987), with an
therapy (NDPT) in the United Kingdom emphasis on progress of the total child, not on
(Ryan & Courtney, 2009). This therapy draws specific symptoms (McGuire & McGuire, 2001;
on Axline’s (1969) early work and is based on Ryan, 1999; Wilson & Ryan, 2005). Addition-
the Rogerian principles of unconditional pos- ally, attachment is a crucial part of therapy,
itive regard, empathy, congruence, and self- ensuring that secure relationships exist to sup-
actualization (Rogers, 1976). When applied port the child’s development of a positive self-
by the astute therapist, these principles pro- concept and a healthy relationship script (Ain-
vide a climate that enables the child’s innate sworth & Bell, 1970). It is these positive
drive toward optimal functioning to unfold attachment behaviors that the therapist strives to
establish in the play room to empower the child
to work toward a healthy sense of self (Fall,
2010; Wilson & Ryan, 2005). This strong sense
Kerri Salter, Wendi Beamish, and Mike Davies, Griffith of self allows children to link their skills and
Institute for Educational Research, Griffith University. knowledge to current actions (Bandura, 1977),
Correspondence concerning this article should be ad- supporting the formation of new behavior sche-
dressed to Kerri Salter, Griffith University Mount Gravatt
Campus, 176 Messines Ridge Road, Mount Gravatt, mas necessary for social and emotional growth.
Queensland, Australia 4122. E-mail: kerri1@bigpond An accepting environment provides opportuni-
.net.au ties for the child to use play to relate to the
78
 CCPT AND CHILDREN WITH AUTISM 79

therapist and, through secure attachment, to Warreyn, 2012; Tomasello, 2014). Within the
process “inter and intrapersonal conflicts” CCPT framework, joint attention is explored as
(Cochran, Cochran, Nordling, McAdam, & the child shares his or her interest areas with the
Miller, 2010, p. 131). therapist. These circumstances create a safe
CCPT has proven an effective intervention platform where the child can be free from inhi-
for children across a broad spectrum of social, bitions. Over time, as the child feels more se-
emotional, and behavioral challenges. To date, cure, this platform typically broadens, allowing
studies have demonstrated that CCPT interven- the child to engage in a wider range of activities
tions result in desirable social behaviors in- and increased interactions with the therapist.
creasing conjointly with improved self-concept The repertoire of social behaviors emerging in
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

and emotional regulation (Cochran et al., 2010; the therapy room can then be generalized to
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Fall, 2010; Garza, 2010; Packman & Lebeauf, other supportive environments, such as the
2010; Ray, 2010; Wilson & Ryan, 2005). More- home (Axline, 1969; Josefi & Ryan, 2004;
over, CCPT has been found to support children Mittledorf, Hendricks, & Landreth, 2001).
with behavioral concerns, including reductions Imitation has been found to be important in
in aggressive occurrences (Ray, Blanco, Sulli- developing reciprocal social skills, including
van, & Holliman, 2009; Schumann, 2010), at- social responses and verbal communication
tention problems (Bratton et al., 2013; Ray, (Doepke, Mulderink, D’Santiago, & Karlen,
Schottelkorb, & Tsai, 2007; Schottelkorb, 2014). CCPT interventions help develop imita-
2010), and undesirable social behaviors (Coch- tion skills through the therapist modeling be-
ran et al., 2010). haviors that occur naturally in social interaction.
Child-initiated role play, where the therapist
Autism and CCPT portrays different personas and emotions (e.g.,
“You are my friend now”; “You are really angry
Autism is a neurodevelopmental disorder now”) within the CCPT framework, invites the
with a diagnosis based on the presence of re- modeling of more complex social interactions.
petitive behaviors and impairment in the critical Because these interactions are child led, chil-
areas of communication, flexibility, and the de- dren tend to be receptive to this form of social
velopment of reciprocal social relations (Amer- learning (Wilson & Ryan, 2005; VanFleet, Sy-
ican Psychiatric Association, 2013). As a result, wulak, Sniscak, & Guerney, 2011).
children with autism struggle to develop and Theory of mind—the ability to acknowledge
grow socially and emotionally in a pattern sim- that others have distinct thoughts and beliefs
ilar to their typically developing peers. They separate from one’s own—is seen as central to
frequently have difficulties initiating and join- social deficits in autism, particularly the devel-
ing in play, understanding turn taking, building opment of perspective and empathy (Boucher,
friendships, and in general enjoying reciprocal 2009; Frith & Happé, 1994). CCPT interven-
social interactions (Ashwell, 2009; Barton & tions can strengthen theory of mind concepts as
Harn, 2012; Fun, 2009). Areas of input have the child works through developmental stages
been identified that support broader develop- in which awareness is developed with the sup-
ment in social and emotional domains (Lai, port and modeling of an empathetic, accepting
Lombardo, & Baron-Cohen, 2014). Josefi and therapist. The secure connection with the ther-
Ryan (2004) have specifically identified four apist “holds” the child, supporting him/her to
pivotal areas that CCPT interventions address: move through this process. To support this con-
joint attention, imitation response, theory of nection and understand the child’s perspective,
mind, and symbolic and functional play skills. the therapist uses developmental frameworks
Skills involved in joint attention have been that draw on Piaget’s cognitive theories (Piaget,
found to be connected to language formation 1962), Erikson’s psychosocial stages (Erikson,
and social development (Baldwin, 2014; Delini- 1968), and Ainsworth’s attachment theories
colas & Young, 2007). Recent research has (Ainsworth & Bell, 1970) within the context of
suggested that advances in response to joint the child’s history.
attention are closely linked to the development Play is commonly recognized to have a cog-
of social cognition, a predecessor for building nitive organizational function, reflecting differ-
social competency (Schietecatte, Roeyers, & ing stages of development (Piaget, 1962; Wil-
 80 SALTER, BEAMISH, AND DAVIES

son & Ryan, 2005). Within this framework, the bathroom and use the toilet, as well as sponta-
progression from functional to symbolic play is neously engaging in attachment behaviors with
viewed as a complex process. It involves the the therapist with whom he sought physical
child consolidating information from thoughts, closeness. It was also noted that Brad gained a
imagination, and mental pictures (mental imag- physical sense of himself and was increasingly
ery), together with current life experiences in independent in his play repertoire. Moreover,
order to work toward the integration of cogni- Brad experienced some level of academic and
tive and personal schemas (Piaget, 1962; Wil- social success in a mainstream behavior disor-
son & Ryan, 2005). This developmental step is der classroom.
supported in CCPT interventions that are recep- A third study, by Josefi and Ryan (2004)
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

tive to the child exploring and integrating these from the United Kingdom, involved “John,” a
This document is copyrighted by the American Psychological Association or one of its allied publishers.

constructs at his or her own pace. 6.5-year-old boy with autism, who had 16 indi-
Hence, CCPT interventions can provide the vidual 1-hr sessions of NDPT over a 5-month
child with developmentally appropriate self- period. Results indicated that John demon-
paced input across these four pivotal areas using strated an increase in autonomy and initiative,
the support of a skilled therapist. However, de- which the researchers related to the successful
spite the general growth in CCPT intervention, reworking of the relevant Erikson stage. John
the area of individual therapy with CCPT and also increased his initiation of attachment be-
children with autism has been poorly re- haviors; he was more emotionally responsive
searched. A comprehensive search of the liter- and developed a secure attachment with the
ature revealed that only four CCPT intervention therapist. In regard to play, John was able to
studies have been conducted to date. play for longer periods of time and increase his
The first study was undertaken in the United repertoire of play activities. These new behav-
States by Kenny and Winick (2000). Therapy iors were associated with a decrease in ritualis-
involved 11 sessions of CCPT with “Judy,” an tic behavior. Toward the end of the intervention,
11-year-old girl with autism, who presented improvements in joint attention and social in-
with aggressive and oppositional behavior. This teraction with the therapist, together with the
intervention not only used nondirective play development of symbolic play, were also noted.
and parental support as a major modality, but A fourth study, also in the United Kingdom,
also included directive interventions in the areas was undertaken by Carden (2009), who reported
of personal hygiene and social skills. Results on the progress of “Lisa,” a 10-year-old girl
indicated that Judy benefited only from the non- with autism. Lisa had weekly sessions of indi-
directive component of therapy. Judy’s mother vidual CCPT followed by filial therapy and a
reported fewer child⫺parent arguments and a story-making narrative over a 1-year period.
reduction in Judy’s irritability. On the other She presented with self-harming behaviors and
hand, Judy’s teacher reported positive behav- what appeared to be stress-related symptoms.
ioral changes, with increased compliance to re- The researcher reported that Lisa’s self-harming
quests and fewer tantrums and anger outbursts. behaviors reduced substantially once she was
The therapist reported an increase in interactive able to communicate triggers for her anxieties
play together with the development of other during sessions. The documentation of the pro-
attachment behaviors in sessions, which was cess revealed that Lisa progressed to developing
recognized as a foundation for the development trust in the therapist, while also increasing her
of relationship skills. ability and willingness to communicate. Other
A second U.S. study (Mittledorf et al., 2001) reported positive changes included her develop-
reported an intervention of individual biweekly ment of a sense of self and others, an under-
CCPT sessions over approximately 18 months standing of perspective, and an increased ability
with “Brad,” a 5-year-old boy with autism. Prior to cope.
to intervention, Brad presented with a lack of In summary, all studies used a single-case
language development, toileting issues, a reluc- design, and all reported improvements in attach-
tance to connect with others, a lack of aware- ment behaviors and social interactions, together
ness of his body and objects in space, and a with progression in play skills. These positive
limited sense of self. Following intervention, outcomes indicated that CCPT could be a suc-
Brad was seen to be willing to go into the cessful intervention in supporting the social and
 CCPT AND CHILDREN WITH AUTISM 81

emotional growth of young children with au- to his frequent tantrums and physical expression
tism. of anger, which was mostly directed at his
mother and siblings. These behaviors were most
Purpose of the Study common at times of transition (e.g., going to
school or bed), meal times (eating refusal), and
This Australian CCPT study used a single- when he was told “no.” Peter’s parents identi-
case design to investigate the effects of CCPT fied his hitting as a priority, and his goal for
on a number of young children with autism in therapy was to decrease physical demonstra-
relation to their social and emotional growth. tions of frustration and anger.
The first research question explored the impact John, a 6.5-year-old, was a tall child who
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

of CCPT on the social and emotional growth of demonstrated heightened anxiety by flicking
This document is copyrighted by the American Psychological Association or one of its allied publishers.

participating children. The second research and blowing on his fingers. The main concerns
question examined parental perspective on identified by John’s parents were related to his
changes in their child’s behavior following the difficulties in separating from his mother. He
CCPT intervention. was unable to play independently or with others
for any period of time, and frequently checked
Method on his mother whereabouts. He also had diffi-
culties following instructions at school and in
Participants interpreting social cues. John’s parents identi-
fied the priority of not feeling anxious about his
A convenience sample of three children was mother’s whereabouts, and his goal for therapy
obtained from referrals to an established inde- was that he be able to calmly play for short
pendent practice in rural Queensland, Australia. periods without seeking out his mother.
This rural area is 400 km from a major provin-
cial city and generates its economy from mining Instruments
and agriculture. The three participating boys,
under the pseudonyms of “Sean”, “Peter,” and In the present study, two formal measures
“John,” were between 5.5 and 6.5 years of age, were used to obtain quantitative data and three
and each had a verified diagnosis of autism informal measures were used to collect qualita-
spectrum disorder (ASD). All boys lived with tive data. The Adaptive Behavior Assessment
both parents, attended formal schooling, and System, Second Edition, Parent Form (ABAS-
had fluent expressive and receptive language II; Harrison & Oakland, 2003) and the Devel-
skills. All parents had identified problems, both opmental Behavior Checklist⫺Parent/Carer
at home and at school, as causing them to seek (DBC-P; Einfield & Tonge, 2002) were used
therapeutic support. pre- and postintervention. The ABAS-II mea-
Sean, a 5.5-year-old with a twin, was a thin sures practical independent functioning, to-
pale boy who was anxious most of the time. He gether with the effectiveness of interactions
constantly sought reassurance through being with others both at home and in community
close to adults and asked repeated questions. settings (Harrison & Oakland, 2003). Skills are
Sean also had secondary diagnoses comprising assessed in 10 areas: communication, functional
attention-deficient/hyperactivity disorder and academics, self-direction, social, leisure, self-
epilepsy. Key parental concerns were related to care, home living, community use, health and
Sean not completing tasks he was capable of safety, and motor. These areas can be used
(e.g., dressing, eating), his restricted diet, and independently or combined to form four domain
frequent temper tantrums. In addition, Sean composites scores and an overall score, General
sought continuous physical contact with his Adaptive Composite. By comparison, the
mother, and did not allow his dad to assist him DBC-P is an Australian scale designed to assess
with everyday tasks. His parents identified mas- a broad range of behavioral and emotional dif-
tery of everyday tasks as a priority, and his goal ficulties in children ages 4⫺18 years with de-
for therapy was that he would attempt tasks at velopmental disabilities (O’Brien, Pearson,
home of which he was capable. Berney, & Barnard, 2001). This 96-item ques-
Peter, a 5.5-year-old, was a freckled, ener- tionnaire has five subscales: Disruptive/
getic child. His parents’ main concerns related Antisocial, Self-Absorbed, Communication
 82 SALTER, BEAMISH, AND DAVIES

Disturbance, Anxiety, and Social Relating. sions with the same trained therapist in accor-
Scores across all subscales contribute to a Total dance with the structural and procedural pro-
Behavior Problem Score (TBPS), with higher cesses outlined by Wilson and Ryan (2005). A
scores indicating areas of greater difficulties. 10-week block was chosen as the intervention
According to Einfield and Tonge (2002), period to align with the school term and to fit
DBC-P scores can be interpreted using the in- with the maximum financial support allowable
dividual item scores, subscales, or the overall to families by Medicare. Each child had ses-
TBPS. sions at the same time each week to encourage
Both formal measures were used to provide a stability. Face-to-face parental feedback meet-
broad assessment of global functioning and to ings occurred after the sixth and 10th session
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capture changes in behavior related to social (i.e., at the midpoint and conclusion of therapy).
This document is copyrighted by the American Psychological Association or one of its allied publishers.

and emotional growth connected to the parent’s Parents also accessed informal support from the
therapy goal for their child. Three informal therapist via telephone and email. At postinter-
measures were used to augment data obtained vention, parents again completed the two formal
from the ABAS-II and the DBC-P. First, data measures (i.e., ABAS-II and DBC-P).
were collected from parents on perceived child
behavior changes in relation to the goal they set Data Analysis
for their child in the form of a numerical rating
using a Goal Attainment Scale (GAS). GAS Following completion of the intervention,
offers a criterion-referenced method to measure scores from the ABAS-II and the DBC-P pre-
child achievements toward functional goals us- and postassessment were used to create child
ing a simple form of documentation, and has profiles to measure change related to the inter-
been used frequently in early intervention vention. In addition, the specific skill area
(Roach & Elliott, 2005). The GAS was format- (ABAS-II) or subscale (DBC-P) that related
ted as a 5-point Likert scale, with ⫺2 represent- directly to the targeted goal for the child was
ing the child’s behavior level in the goal area identified and pre and post comparisons were
prior to intervention and ⫹2 representing full made. The informal data, in the form of the
attainment of the parent therapy goal. Second, parent weekly GAS ratings associated with the
written parent reflections on the general behav- child’s goals and parental reflections, were as-
ioral status of their child were collected. Third, sessed. The GAS results were graphed (see Fig-
ongoing therapy notes were recorded by the ure 1), with parent reflections providing an ad-
therapist. ditional perspective (see summaries in Tables 2,
4, & 6).
Procedure
Results
Prior to the intervention, parents completed
the ABAS-II and the DBC-P. During the intake Data from both formal and informal mea-
session, parents identified a meaningful therapy sures indicated positive improvement for all
goal for their child. The goal was documented children following the CCPT intervention. In
using the GAS and this preformatted scale was terms of the impact of CCPT on the social and
completed weekly by the parents. Parent reflec- emotional growth in young children with autism
tions were also recorded weekly on this form, (Research Question 1), results on the formal
providing an outline of the child’s general prog- measures indicated that all children demon-
ress and contextual family happenings. These strated measureable behavior change, with
data were collected following each weekly ses- strong improvements being evident for Sean
sion to capture behaviors indicative of the and Peter. Improvements for these cases were
change process. Additionally, for each session, realized across both scales in the specific areas
the therapist documented the child’s behavior that correlated with respective parental therapy
and interactions, the development and progres- goals. Formal data are presented separately for
sion of themes, the stage of therapy of the child, each child in sections that follow (see Tables 1,
and reflections on change. The CCPT interven- 3, 5). In terms of parental perception of im-
tion was undertaken over 10 weeks, with each provement in their child’s behavior following
child attending individual, weekly 50-min ses- CCPT (Research Question 2), there was differ-
 CCPT AND CHILDREN WITH AUTISM 83
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This document is copyrighted by the American Psychological Association or one of its allied publishers.

Figure 1. Parental Goal Attainment Scale (GAS) ratings of the therapy goal from intake to
the end of intervention for the three participating boys.

ential individual progress. Figure 1 shows that omous behavior for Sean. Taken together, formal
progress was nonlinear, with Sean making the and informal data showed strong, progressive, and
most improvement. These data also reveal Pe- positive change for Sean after the CCPT interven-
ter’s progress was intermittent, with consistent tion and supported both research questions.
“ups” and “downs,” while John’s parents re- Sean’s response to play therapy reflected these
ported no progress using GAS ratings. Addi- changes. In early play sessions, Sean continuously
tionally, parental reflections provided a final sought direction and validation while engaging in
snapshot of each child’s progress within the short bursts of chaotic play. In the middle stages,
family context, with all parents reporting some he engaged with messy sensory materials (that he
positive changes. Results for the three children avidly avoided earlier) and progressed to be able
across all measures will now be discussed to- to verbalize his emotions and to demonstrate in-
gether, with a brief therapeutic summary. creasing autonomy. For example, after Sean inde-
Sean pendently reconstructed a toy truck, he announced
proudly “I figured it out.” This was in stark con-
As presented in Table 1, the ABAS-II and the trast to “I can’t do it, you do it” that Sean repeated
DBC-P data strongly supported improvement for in earlier sessions. Sean also started to direct the
Sean postintervention in the targeted goal area, therapist into roles rather than trying to please her.
attempting home tasks, as well as improvement in At home, he had started to feed himself, eating
the areas of communication, leisure and social some family dinners, was starting to dress himself,
interaction, and motor functioning. Anxiety levels and was letting dad put him to bed, with his
also appeared to decrease. Moreover, parental data parents commenting that he appeared happier (see
on the targeted goal showed that Sean gradually Table 2). In the later stages of therapy, Sean
moved toward his goal, increasing three incre- moved into structured play with longer sequences,
ments on the GAS. Documented parental reflec- with a noticeable decrease in female persona
tions, for example, “trying to do more for himself” dress-ups and an increase in the use of male power
and “feeling more confident in himself, not so icons as he continued work on his identity, mas-
clingy to me,” also supported increases in auton- tery, and self-esteem.
 84 SALTER, BEAMISH, AND DAVIES

Table 1
ABAS-II and DBC-P Pre- and Postdata for Sean
Highest Pre Post
Comparison of possible
Measures ABAS-II Skill areas Pre Post DBC subscales score Score Percentile Score Percentile
ⴱ ⴱⴱ
Communication 1 4 Disruptive/ 54 49 100th 30 94th
Antisocial
Community use 2ⴱ 3ⴱ Self-Absorbed 62 44 98th 33 94th
Functional academics 4ⴱⴱ 8† Communication/ 26 19 98th 20 98th
Disturbance
Home living 1ⴱ 3ⴱ Anxiety 18 14 98th 8 86th
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Health and Safety 1ⴱ 4ⴱⴱ Social Relating 20 4 58th 3 48th

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Leisure 1ⴱ 8†
Self-care 1ⴱ 3ⴱ
Self-direction 1ⴱ 1ⴱ
Social 1ⴱ 6ⴱⴱⴱ
Motor 1ⴱ 8†
Overall score GAC 14ⴱ 48ⴱ TBPS 180 139 100th 96 98th
ⴱ
Note. Boldface denotes child therapy goal. ABAS classification of skill areas: 1–3 (extremely low; denoted ); 4 –5
(borderline; denotedⴱⴱ); 6 –7 (below average; denotedⴱⴱⴱ); 8 –12 (average; denoted†). DBC is reverse-scored: Higher scores
and higher percentiles indicate lower function. Raw scores are used. Range for subscales vary and is indicated, with 0 being
lowest score possible. Percentiles indicate the percentage of children in the Australian normative sample who functioned
higher than this child on each scale. Classification of Goal Attainment Scale and domain composites: ⱕ70 ⫽ extremely low.
All scores are scaled. Scores for skill areas are out of possible 19. Scores for GAC and domain areas are out of possible
160. ABAS-II ⫽ Adaptive Behavior Assessment System, Second Edition, Parent/Primary Caregiver; DBC-P ⫽ Develop-
mental Behavior Checklist⫺Parent; GAC ⫽ General Adaptive Composite; TBPS ⫽ Total Behavior Problem Score.

Peter progressive and positive change due to the

CCPT intervention and, in doing so, supported
Data from both the ABAS-II and the DBC-P
both research questions.
strongly indicated that Peter improved in his
Peter’s early sessions were dominated by in-
targeted goal area (see Table 3) and in following
routines and interactions, while decreasing his tense sword fighting games, which could be
anger and physical frustration. In addition, pa- interpreted as a need for power, control, and
rental data demonstrated that Peter gradually expression of anger. In the middle stages of
moved toward his goal, increasing one incre- therapy, Peter participated in some nonphysical
ment on the GAS, while parental reflections play, placing the therapist in roles that required
tracked Peter’s decreasing acts of physical ag- working together to “solve” the problem. As
gression and improvements in verbal communi- Peter progressed in therapy, he engaged in
cation, for example, Peter “has been using his fewer fighting games while increasingly using
words to voice his anger” and “had a good week play that explored nurturing and social interac-
at school, happy to go off once there without the tion. Toward the end of therapy, Peter’s primary
usual drama.” Hence, all data pointed to Peter’s mode of interaction with the therapist was play

Table 2
Parental Reflection Summary for Sean
Session Reflections
1 Lots of meltdowns about school/bedtime along
3 Has been calmer and adjusting to new routines (Mum returned to full-time work); only got upset leaving me
on Thursday (for school), but Mrs. J (usual teacher) was absent; even tried a few of our meals
5 Trying to do more for himself
7 Feeling more confident in himself, not so clingy to me
8 Is accepting change more easily; he loves going to school at the moment
10 Calmer, settled; doing things for himself again; happy to be on holidays
 CCPT AND CHILDREN WITH AUTISM 85

Table 3
ABAS-II and DBC-P Pre- and Postdata for Peter
Highest Pre Post
Comparison of possible
Measures ABAS-II skill areas Pre Post DBC subscales score Score Percentile Score Percentile
ⴱⴱⴱ ⴱⴱⴱ
Communication 7 6 Disruptive/ 54 36 98th 36 98th
Antisocial
Community use 3ⴱ 4ⴱⴱ Self-Absorbed 62 37 96th 29 90th
Functional academics 7ⴱⴱⴱ 9† Communication/ 26 15 96th 13 94th
Disturbance
Home living 4ⴱⴱ 3ⴱ Anxiety 18 13 98th 10 96th
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Health and Safety 1ⴱ 3ⴱ Social Relating 20 9 90th 8 86th

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Leisure 1ⴱ 3ⴱ
Self-care 1ⴱ 1ⴱ
Self-direction 2ⴱ 3ⴱ
Social 3ⴱ 5ⴱⴱ
Motor 3ⴱ 5ⴱⴱ
Overall score GAC 32ⴱ 42ⴱ TBPS 180 126 100th 112 98th
ⴱ
Note. Boldface denotes child therapy goal. ABAS classification of skill areas: 1–3 (extremely low; denoted ); 4 –5
(borderline; denotedⴱⴱ); 6 –7 (below average; denotedⴱⴱⴱ); 8 –12 (average; denoted†). DBC is reverse-scored: Higher scores
and higher percentiles indicate lower function. Raw scores are used. Range for subscales vary and is indicated, with 0 being
lowest score possible. Percentiles indicate the percentage of children in the Australian normative sample who functioned
higher than this child on each scale. Classification of Goal Attainment Scale and domain composites: ⱕ70 ⫽ extremely low.
All scores are scaled. Scores for skill areas are out of possible 19. Scores for GAC and domain areas are out of possible
160. ABAS-II ⫽ Adaptive Behavior Assessment System, Second Edition, Parent/Primary Caregiver; DBC-P ⫽ Develop-
mental Behavior Checklist⫺Parent; GAC ⫽ General Adaptive Composite; TBPS ⫽ Total Behavior Problem Score.

in which he was able to openly express his that he was playing with others, verbalizing
needs. For example, in the seventh session, he emotions, and happily going to school.
requested “let’s eat, come and sit next to me and
we will eat” (see Table 4). This simple gesture John
was reflective of Peter’s progress in relationship
building and trust, and was in stark contrast to Data from the ABAS-II and DBC-P (see Table
his behavior in early sessions where he moved 5) revealed that John improved in his targeted goal
rapidly, frequently approached the therapist area: His separation anxiety decreased while his
with a weapon, and chose not to touch food or ability to play independently increased. These data
drink when offered. At this stage, improve- provided some support for behavioral change due
ments at therapy were accompanied by im- to the CCPT intervention. By comparison, the
provements at home, with his parent reporting GAS data on the targeted goal across the interven-

Table 4
Parental Reflection Summary for Peter
Session Reflections
1 Has been angry this week; has been looking forward to coming
2 Has been using his words to voice his anger; has been playing with other children a bit better this week
4 Is upset and angry a lot at home; is teary at times and demanding of my time; wanting me to play with him
lots; has been very affectionate and starting to want to play with dad
6 Has played well for short periods of time this week; has been good at verbalizing his feelings
7 Played well with neighbors young children; got angry and hit and pushed then left the room to calm himself
(FIRST) told me he was tired; went better at Kindy; didn’t challenge as much; has no problem telling us
how much he hates things and that he is very angry at us
9 Had good week at school, very happy to go off without the usual drama; still having outburst of anger for
about 20 min; very keen to invade your space when angry, did have some good days though
 86 SALTER, BEAMISH, AND DAVIES

Table 5
ABAS-II and DBC-P Pre- and Postdata for John
Highest Pre Post
Comparison of possible
Measures ABAS-II skill areas Pre Post DBC subscales score Score Percentile Score Percentile
† ⴱⴱ
Communication 14 5 Disruptive/ 54 18 74th 21 78th
Antisocial
Community use 8† 5ⴱⴱ Self-Absorbed 62 9 38th 12 52nd
Functional academics 11† 5ⴱⴱ Communication/ 26 6 66th 3 38th
Disturbance
Home living 8† 5ⴱⴱ Anxiety 18 7 86th 8 90th
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Health and safety 5ⴱⴱ 10† Social Relating 20 5 76th 4 58th

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Leisure 6ⴱⴱⴱ 10†

Self-care 6ⴱⴱⴱ 4ⴱⴱ
Self-direction 6ⴱⴱⴱ 6ⴱⴱⴱ
Social 5ⴱⴱ 5ⴱⴱ
Motor Work Work
Overall score GAC 69ⴱ 55ⴱ TBPS 180 49 64th 53 70th
ⴱ
Note. Boldface denotes child therapy goal. ABAS classification of skill areas: 1–3 (extremely low; denoted ); 4 –5
(borderline; denotedⴱⴱ); 6 –7 (below average; denotedⴱⴱⴱ); 8 –12 (average; denoted†). DBC is reverse-scored: Higher scores
and higher percentiles indicate lower function. Raw scores are used. Range for subscales vary and is indicated, with 0 being
lowest score possible. Percentiles indicate the percentage of children in the Australian normative sample who functioned
higher than this child on each scale. Classification of Goal Attainment Scale and domain composites: ⱕ70 ⫽ extremely low.
All scores are scaled. Scores for skill areas are out of possible 19. Scores for GAC and domain areas are out of possible
160. Work replaces Motor on the 5–21 years form. ABAS-II ⫽ Adaptive Behavior Assessment System, Second Edition,
Parent/Primary Caregiver; DBC-P ⫽ Developmental Behavior Checklist⫺Parent; GAC ⫽ General Adaptive Composite;
TBPS ⫽ Total Behavior Problem Score.

tion period showed no improvement, and parental change and limited support to both research ques-
reflections did not indicate any change until half- tions.
way through the intervention. However, at that John’s early therapy sessions were character-
time, John’s mother reported that she could “go ized by his struggling to separate from his
downstairs now and he is ok” and that John was mother and beginning each session with repet-
“playing better with little brother,” “demonstrat- itive and physically aggressive play. This play
ing emotions,” and “he seems to be moving for- reflected John’s rapid emotional cycling: from
ward and main issues are now at school.” In being highly excited and animated to being very
summary, the formal data and informal parental still and quiet, to suddenly laughing out loud,
reflections pointed to some positive behavioral and then progressing to aggressive play, which

Table 6
Parental Reflection Summary for John
Sessions Reflections
2 Not really happy about going to school; says he has no friends; often gets very emotional telling me
3 Trying to include him in all day-to-day running of the house and routines; is not watching TV, but joining
in and playing with S (younger brother); lots of tickles and games that result in touching; seems to like
this though he is showing signs of jealousy with S
4 Enjoying school again, addressed issue of not wanting to go to the unit (teased by another student) hoping
that this week will be good
5 Relationship with his dad is much better; playing better with S, demonstrating emotions, showing jealousy
of S, this is just starting to happen; main issues are at school now
7 Made breakfast by himself, which we ate together; showing and asking for more affection; at school
behavior has been challenging
8 John says he is trying really hard, his teacher is seeing improvements too
 CCPT AND CHILDREN WITH AUTISM 87

involved hitting, stabbing, choking, and fighting Moreover, the three children in this study
with the bop bag. By the middle sessions, John also demonstrated other behavioral improve-
could calmly separate from his mother and did ments indicative of broader social emotional
not need to interrupt his session to visit her in growth outside of the targeted goal area. This
the waiting room (see Table 6). At home, his holistic change with simultaneous improvement
mother reported that he was more open and in more than one area of social and emotional
interactive with her. John then progressed to growth mimics the normal developmental tra-
commencing sessions with nonphysical play jectory (Fun, 2009; Stagnitti & Cooper, 2009;
such as cooking or dress up, and he engaged in Wilson & Ryan, 2005). As previously outlined,
longer play sequences with an emphasis on in- CCPT supports children to move through nor-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

teraction with the therapist who was alterna- mal growth stages (Landreth, 2002), and some
This document is copyrighted by the American Psychological Association or one of its allied publishers.

tively placed in roles of being powerful (and developmental progressions can lead to long-
restricting) and powerless. Another dimension term changes, with the child’s new skills and
of this period was that John noticeably re- awareness creating a positive cycle of reciprocal
gressed, using baby talk and inviting early nur- interaction with others and the environment
turing both at home and in sessions as he re- (Bratton et al., 2013; Fall, 2010).
worked earlier developmental stages. By the Developmental progressions in this study
final stage of therapy, John was showing empa- were monitored in various complementary
thy in his role plays of friendship with the ways. In CCPT autism-specific research, this is
therapist, together with some quiet individual the first published study to use formal develop-
play, which was connected to self-esteem and mental measures of social and emotional
role identity. At home, John was reported to be growth. As previously indicated, the ABAS-II
playing better with others, was able to separate and the DBC-P were used to formally measure
from his mother for short periods, was seeking changes in each child’s social and emotional
interaction with his father, and had reduced functioning. The ABAS-II provided compre-
periods of flicking or blowing on fingers. hensive information across a number of do-
mains so that a meaningful comparison could be
Discussion made between the pre- and postassessments of
each child. In fact, the information was so com-
Given the increasing prevalence of young prehensive that considerable time and reflection
children diagnosed with autism (Centers for were required to glean data pertinent to the
Disease Control and Prevention, Autism and targeted goal of each case. The DBC-P was
Developmental Disabilities Monitoring Net- relatively quick for parents to complete, and
work Surveillance, 2010) and the impact of was easy to score and interpret. Percentile rank-
this disorderba on developmental trajectories ings greatly assisted interpretation, providing a
(Boucher, 2009), this preliminary study offers comparative level of functioning within and
promising intervention results. Changes in across cases. Consistent with ASD norms
scores on the formal measures indicated that all (Thorson & Matson, 2012), children in the pres-
children improved in several areas of social and ent study scored at the very low end of scales in
emotional functioning and progressed in the both measures, making it difficult to capture
targeted goal areas identified by parents. Taken small changes that resulted over the 10-week
together, these data suggest that each CCPT intervention period. However, measuring the
intervention was effective in assisting partici- targeted goal area independently from the dif-
pating children to enhance their social and emo- ferent lenses of each measure provided a rich
tional skill sets. Overall findings from the pres- comparative analysis.
ent study are consistent with the literature On the other hand, GAS provided parents with
indicating that CCPT is an intervention that can an opportunity to benchmark targeted goals and
support the development of social and emo- related behavior. Additionally, this informal scal-
tional growth for children both with and without ing process provided an avenue for parents to have
autism (Bratton et al., 2013; Fall, 2010; Josefi & weekly input by recording behavior change nu-
Ryan, 2004; Landreth, 2002; Mittledorf et al., merically. As such, GAS graphing (see Figure 1)
2001; VanFleet et al., 2011; Wilson & Ryan, provided a useful visual reminder to both therapist
2005). and parent of the targeted goal and child progress.
 88 SALTER, BEAMISH, AND DAVIES

Moreover, GAS results generally were consistent develop social and emotional growth for children
with the parental reflections, which added rich with autism, some limitations need to be acknowl-
contextual insight into the child’s behavioral prog- edged. Recruitment using a routine intake process
ress at home. Furthermore, the general theme of in one regional area of Queensland resulted in
parental reflections was consistent with therapy only a small number of children with a verified
notes, which were documented after each CCPT diagnosis in the desired age range being available.
session. In the case of John, there were differences Although the data obtained were supportive of
between scores on the GAS and on the formal CCPT effectiveness, the small sample size and the
instruments. It was speculated that his parents restricted period of intervention limits the gener-
were slower than other parents in recognizing alizability of findings (Davis & Smith, 2004). Ad-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

behavior change. ditionally, all children accessed intervention at a

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Broadly speaking, CCPT sessions fostered de-

special education development unit, and some be-
velopment through joint attention, imitation re-
havior change could be attributed to this program.
sponse, theory of mind, and symbolic and func-
tional play skills. These pivotal areas identified by Replication with a larger cohort in therapy versus
Josefi and Ryan (2004) provided a guiding frame- a wait-list would address the issues of power and
work for intervening with these young children provide further evidence of the efficacy of CCPT.
with autism. Through the lens of joint attention, Moreover, it would be worthwhile investigating
each child improved his social interactions; mov- the impact of a more comprehensive intervention
ing from having an intense focus on an interest undertaken over an extended period (e.g., 18
area to having a more open view that enabled months).
greater responsiveness to the therapist and parents. To further increase generalizability, it would
This behavioral change, in turn, allowed the child be valuable to replicate the study in a different
to learn from imitation opportunities, which pro- geographical area and to also include girls with
gressed to explorations of daily life events (e.g., autism. Additionally, effectiveness of CCPT
getting into trouble, relationships) through child- with older children with more mature cognitive
initiated role plays. In relation to theory of mind, processing could also be explored. Finally, an-
each child moved from being very egocentric to other limitation of the present study was reli-
beginning to acknowledge the perspectives of oth- ance on a sole therapist. To investigate inter-
ers, thereby showing some evidence of empathy in vention integrity, it would be ideal to have a
therapy and at home. minimum of two therapists involved in the in-
Play stages progressed with decreasing amounts tervention, and to video record sessions to iden-
of functional play, and increased amounts of rich tify strategies that produce meaningful therapy
imaginative symbolic play, including sociodramatic outcomes.
play where the children directed the therapist to an
assigned role to explore different perspectives. It was
Conclusion
also noted that, although positive outcomes were
obtained after 10 sessions of therapy, most of the This small-scale Australian study demon-
research on CCPT and children with autism has strated that CCPT is an effective intervention to
investigated interventions involving more sessions.
support the social and emotional growth of
Intervention periods ranged from 16 sessions (Josefi
young children with autism. Findings demon-
& Ryan, 2004) to 18 months of therapy, with up to
two sessions a week (Mittledorf et al., 2001). It is strated that participating children were not only
likely, therefore, that, with an extended intervention able to meet targeted behavioral goals, but also
period, targeted behaviors of children in the present to show general developmental progress. More-
study would have generalized not only from therapy over, the guiding framework of joint attention,
to home, but also from therapy and home to school. imitation response, theory of mind, and sym-
bolic and functional play skills (Josefi & Ryan,
Limitations and Recommendations 2004) contributed to these specific and general
for Research outcomes. Taken together, these outcomes pro-
vide a launching pad for therapists and research-
Although this study contributes to research on ers to further extend our understandings of the
the effectiveness of CCPT as an intervention to impact of CCPT on children with autism.
 CCPT AND CHILDREN WITH AUTISM 89

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