Current Psychology

https://doi.org/10.1007/s12144-018-9914-7

Effect of cognitive - behavioral play therapy on working memory,

short-term memory and sustained attention among school-aged
children with specific learning disorder: a preliminary randomized
controlled clinical trial
Amir Azizi 1 & Fazlollah Mir Drikvand 1 & Mohamad Ali Sepahvandi 1

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
It has been shown by several studies that cognitive behavioral play therapy (CBPT) can ameliorate the condition in children
diagnosed with specific learning disorder (SLD). However, there is still need for randomized controlled clinical trials, in order to
evaluate this line of action as a standard option. The essence of this preliminary study was to assess the effect of CBPT on
working memory (WM), short-term memory (STM) and the sustained attention (SA) of school-aged children with SLD using a
randomized controlled clinical trial (RCT). In the present study, 35 eligible children with a DSM-5 SLD diagnosis, aged 7–9,
were randomly allocated in CBPT (n = 18) and control groups (n = 17). Evaluation of all participants was conducted for WM,
STM and SA using the digit span subscale of WISC-III, Wechsler memory scale-4th edition (WMS-IV) test and visual contin-
uous attention test (DAUF), respectively, both at the time of inclusion to the project and one month later. The intervention group
participated in 8 group sessions of CBPT and the control group was evaluated without any intervention. The study was completed
by a total of 16 boys and 14 girls (n = 15 per group). The mean ± S.D. of participants’ age were 8.29 ± 1.12 years and 8.20 ±
1.28 years in the CBPT and control groups, respectively. The treatment was effective on variables of the DAUF test (p = 0.001).
In addition, there was no significant improvement in any variables of WMS-IV and the digit span subscale of WISC-III tests
between two groups (p < 0.05). In this work, it was found that CBPT is effective on SA improvement among children with SLD,
but this intervention lacked effect on WM and STM in children with SLD. This study recommends more RCTs with large sample
sizes, more individual therapeutic sessions, longer time of follow-up and different protocols.

Keywords Cognitive - behavioral play therapy . Working memory . Short-term memory . Sustained attention . Specific learning
disorder

Introduction and Cornoldi 2015). The diagnosis of SLD in children, is

Despite the fact that children of school-age suffering from
SLD (specific learning disorders) show an average intelli-
gence in the early days of school, it is very tasking for them
to acquire the basic social and academic skills including read-
ing, writing, and arithmetic skills (DuPaul et al. 2013; Giofrè
* Fazlollah Mir Drikvand
Fazlolah2020@gmail.com
Amir Azizi
amir28144@gmail.com
1
Department of Psychology, Lorestan University, Khoram Abad, Iran
regarded as important when the inability of the person is con-
sidered not the result of sensory disabilities such as vision,
hearing and when it is not the result of illiteracy or lack of
education (American Psychiatric Association 2013). Records
show that students with SLD are more likely to drop out of
school (Vogel and Reder 1989), remain unemployed (Shapiro
and Lentz 1991) or even have suicidal thoughts compared to
other students (Daniel et al. 2006).
Working memory (WM) impairments have been greatly
discussed and identified as being associated with SLD
(Maehler and Schuchardt 2016). Based on the model of
Baddeley (1986), WM is comprised of three components:
the modality-free central executive, and two slave systems,
the phonological loop as well as the visual-spatial sketchpad

(Pickering et al. 2001).Studies have revealed that children
suffering from specific reading disabilities/dyslexia and spell-
ing disabilities are incapable of properly conducting phono-
logical processing (Schuchardt et al. 2008; Brandenburg et al.
2015). Also, it was found that their storage and central exec-
utive functioning is inhibited (Landerl et al. 2004). It has been
exposed that people with dyscalculia, experience hindrance in
the visual-spatial sketchpad and the central executive
(Passolunghi 2006). However, results in respect to the phono-
logical loop, have been inconsistent (see Geary et al. 2000 vs.
Landerl et al. 2004).
SLD has been linked with short-term memory (STM) prob-
lems (Narimoto et al. 2013). STM serves the purpose of tem-
porary storage and retaining of information for a limited peri-
od of time. There is temporary availability of information
when it is not yet stored for long-term retention (Cowan
2008; Baddeley 2012). Evidences show that children facing
the risk of non-verbal learning disabilities (NLD), find it dif-
ficult to encode relational information between spatial items.
This difficulty causes their impaired spatial short-term mem-
ory (Narimoto et al. 2013). Also, NLD involves difficulties
with graphomotor aspects of writing, language comprehen-
sion (Mammarella et al. 2009; Mammarella et al. 2015), social
interaction, (Semrud-Clikeman et al. 2010), tactile and visual
perception, visuospatial reasoning and memory, as well as
psychomotor coordination (Rourke 1989).
The ability to hinder executive functions like sustained
attention (SA), is among the important characteristics of
SLD (Sterr 2004). The psychological construct ‘SA’ describes
a basic aspect of attention which is characterized by the sub-
ject’s readiness to discover rarely and unpredictably occurring
signals over prolonged periods of time without being distract-
ed (Sarter et al. 2001; Bergera and Cassutob 2014). Studies on
children experiencing specific reading disabilities have shown
that cognitive functions such as SA is hindered (Duncan et al.
1994). In visual continuous attention test, it was found that
children with dyslexia disorder required more resolution time
(Facoetti et al. 2010). Generally, few researchers are of the
opinion that it is difficult for dyslexic children to focus their
attention on a given text (Facoetti and Molteni 2000).
Moreover, it has been shown that the slow attentional capture
and increased reaction time makes it difficult to process a
rapid sequence of stimuli in all sensory modalities (Hari and
Renvall 2001; Facoetti et al. 2010).
CBPT is a widely known therapy method with its own
special structure and goal. The use of CBPT among school-
aged children has been fully justified. The use of CBPT for
school-age children, offers a relatively unique adaptation of
cognitive behavioral therapy as it was originally developed for
adults. This approach utilizes a play therapy paradigm, as well
as a combination of the cognitive and behavioral interven-
tions. In the CBPT therapy method, problems are settled
through play activities including the application of verbal
Curr Psychol
and nonverbal forms of communication (Knell 2009). It has
been reported that CBPT can be successfully used with diverse
populations. For instance, it has been used to treat children
having selective mutism disorder, (Knell 1993) encopresis
disorder, (Knell and Moore 1990) as well as people who have
experienced unpleasant events in life, such as sexual abuse
(Springer et al. 2012). There is scarcity of data on the standard
treatment protocol using CBPT. A randomized controlled clin-
ical trial should be conducted to nominate CBPT for the treat-
ment of school-aged children with SLD in terms of the three
functions of cognitive status namely working memory (WM),
short-term memory (STM) and sustained attention (SA).
The effects of CBPT on WM, STM, and SA of school-aged
children suffering from SLD, was investigated using a ran-
domized controlled clinical trial.
Methods
Study Design and Subjects
In this RCT, thirty-five children aged 7–9, diagnosed with a
DSM-5 SLD and attending the Learning Disability Center
(Tabriz, IR Iran), were randomly allocated in two groups:
CBPT (n = 18) and control group (n = 17).
For eligibility assessment, a psychiatrist was employed to
evaluate the children prior to their participation in the study.
The inclusion criteria are as follows: (a) being between 7 and
9 years old, (b(having educational grade (grade 1 to 3), (c)
having at least 1 year of education, (d) showing no evidence of
mental retardation or neurodevelopmental disorders such as
attention deficit/hyperactivity disorder (ADHD), communica-
tion disorder (CD), developmental coordination disorder
(DCD) and autism spectrum disorder (ASD) or other mental
disorders such as anxiety disorders (AD), depression disorders
(DD) and bipolar disorders (BD) according to the participants’
parents and recorded in the psychiatric cases in school, (e)
having no history of brain injury. The exclusion criteria are
as follows: (a) receiving CBPT prior to entering the research
and (b) failure to cooperate.
Intervention
Cognitive - Behavioral Play Therapy (CBPT)
Eight (8) group sessions of CBPT occurred twice a week.
Each training session lasted between 60 to 90 min (min).
Behavior therapy (BT), cognitive therapy (CT), and cognitive
behavioral therapy (CBT) formed the basis of the concepts
and theoretical grounds for CBPT (Drewes 2009). The basic
therapeutic tools of CBPT include the use of developmentally
appropriate games, and a play therapy method (Knell 1998;
Knell 2009).
Curr Psychol
A CBPT program was completed by the subjects (see
Table 1). The CBPT training was supervised by a certified
CBPT training coach, who was completely independent from
the study team.
Measurements
The Digit Span Subscale of WISC-III
For WM assessment, the digit span subscale of WISC-III was
utilized. A part of the WISC-III subscale was used to evaluate
WM for verbal material (Figueiredo 2002). Previous studies
used this measure as an index of WM (Gathercole et al. 2004).
The WISC-III had sufficient reliability and validity in Iranian
children (Mosanezhad Jeddi and Nazari 2013). In this study,
reliability was estimated through the use of Cronbach’s alpha
coefficient for WISC-III 0.90.
Wechsler Memory Scale-4th Edition (WMS-IV)
The Wechsler memory scale-4th edition (WMS-IV) was used
for STM evaluation. The following eight subtests were eval-
uated in this scale: general information, memory quotient,
orientation, mind control, learning associations, logical mem-
ory, visual memory and repeat numbers. There are studies
which support the acceptable validity of WMS-IV (Soble et
al. 2018). Reliability was estimated through the use of
Cronbach’s alpha coefficient for WMS-IV 0.77.
Visual Continuous Attention Test (DAUF)
We used the Visual continuous attention test (DAUF), In a bid
to determine SA, the Visual continuous attention test (DAUF)
was applied. This is a computer-based test which uses the
sustained attention procedure. The DAUF test uses rows of
triangles on the computer screen by the subjects; this is done
Table 1 CBPT program overview
Session number Intervention component
1 Encourage and strengthen relationships
2 Training, identification and separation of feelings
(sadness, anger, happiness and fear)
3 Distinguishing thoughts and feelings (Magic circle)
4 Identifying the relationship of behavior, thoughts and feelings
5 Training and identification automatic thoughts and
thinking errors (negative look, labels, or zooming)
6 Cognitive retraining techniques
7 Relaxation training and breathing relaxation training
8 Training in problem solving
under critical time conditions. It is possible for the top of each
triangle to be either upwards or downwards. After watching a
previously determined downward triangle, the reaction button
should be pressed by the subject. The basis of SA assessment is
determined by the number of correct and incorrect responses as
well as the mean reaction time. In terms of the research goals,
the acceptable validity of DAUF was supported by some stud-
ies (Rostami et al. 2017). The Cronbach’s alpha coefficient for
DAUF 0.72 was used to estimate reliability.
Outcome Assessment
The members of the different groups were evaluated for WM
using WISC-III, STM using WMS-IV and SA using DAUF.
WM, STM, and SA were applied twice: at the baseline and a
month afterwards. Prior to and after 8 sessions of CBPT, par-
ticipants in the experimental group underwent evaluation.
Prior to receiving any treatments, participants in the control
group were evaluated at the baseline and a month after enter-
ing the research in the respective order.
Statistical Analysis
Quantitative variables were shown as mean (M), standard de-
viation (S.D) and frequency (percentage), respectively. Using a
multivariate analysis of covariance (MANCOVA), the differ-
ences between groups in terms of WM, STM and SA variables
and also before and after the interventions were evaluated. The
following categorical variables (sex, age and grade) were also
analyzed by x2 test. The effect of sizes (estimated as Cohen’s d)
was also presented. The effect of sizes were rated as small,
medium and large for d of 0.02, 0.15, and 0.35, respectively
(Cohen 1992). All statistical analyses were performed in IBM
SPSS Statistics, version 20.0 (IBM Corp 2011). P values less
than 0.05 were regarded as statistically significant.
Examples of games and techniques
Reading the story of little rabbit, playing and pencil drawing.
Play dough, musical chairs, pantomime, pictures and color your
own world
Water colors, finger paint and Listen to the story
Detective game, missing ring and spider trap games and also,
positive emphasis
Traffic signals and detective game
Painting, finger puppets and modeling
Rock jelly game, bubbles, flowers and candles making games
News reading game, role playing and Game animal power
 Curr Psychol

Results Table 2 Participant demographics

CBPT group Control group P

Demographic Data (n = 15) (n = 15)
M ± S.D M ± S.D
In this study, 42 children with SLD were recruited and
Sex 0.45
assessed for eligibility (Fig. 1). Of these, 7 did not
Boys, n (%) 16 (60)
meet the eligibility criteria: 4 revealed the presence of
Girls, n (%) 14 (40)
ADHD and 1 showed the presence of CD using the
Age, years 8.29 ± 1.12 8.20 ± 1.28 0.72
parents and recorded in the psychiatric cases while 1
Grade 0.50
received CBPT before entering the study, 1 was over
11 years of age. The remaining 35 children were ran- First grade 7.13 ± 1.25 7.20 ± 0.92
domized to one of the two groups. During CBPT, three Second grade 8.42 ± 0.89 8.37 ± 1.34
children dropped out at the pre-test and two children Third grade 9.33 ± 1.23 9.04 ± 1.59
dropped out at the post-test in the control group. The M, mean; S.D., standard deviation; P values refer to the χ2 test
study was completed by 35 children: CBPT (n = 15)
and Control group (n = 15).
Table 2 shows that the final sample is comprised as Descriptive Findings
follows: 16 (60%) boys and 14 (40%) girls; first grade,
2 boys and 3 girls, mean ± S.D. of age 7.13 ± 1.25 years Table 3 presents each variable of the digit span subscale of
in CBPT groups, 2 boys and 2 girls, mean ± S.D. of age WISC-III, WMS-IV and DAUF evaluated at the baseline and
7.20 ± 0.92 years in the Control group; second grade,3 after one month of inclusion between the two groups.
boys and 2 girls, mean ± S.D. of age 8.42 ± 0.89 years There was an improvement in the number of correct an-
in the CBPT group, 4 boys and 3 girls, mean ± S.D. of swers, reaction time and number of incorrect answers from
age 8.37 ± 1.34 years in the Control group; and third pre to post for the intervention group but not for the control
grade, 4 boys and 1 girl, mean ± S.D. of age 9.33 ± group (Table 3).
1.23 years in the CBPT group, 1 boy and 3 girls, mean
± S.D. of age 9.04 ± 1.59 years in the Control group. Inferential Findings
The mean ± S.D. of participants’ age were 8.29 ±
1.12 years, 8.20 ± 1.28 years and 8.53 ± 1.63 years in The intergroup comparison of the WISC-III, WMS-IV, and
CBPT and the control groups, respectively. Considering DAUF variables at the baseline and one month after com-
the demographic variables (sex, age and grade) (p < mencing the research are presented in Table 4.
0.05), no statistically significant differences were found At the baseline and one month after entering into the re-
between both groups. search, the intergroup evaluation of each variable of DAUF

Fig. 1 Distribution of study Children 7-9 years old with SLD

children (screening) Did not meet criteria (n = 7):
(n = 42) Comorbid ADHD, CD (n = 5)
Age > 11 years (n = 1)
Receiving CBPT (n = 1)

Incorporated into the study

(n = 35)

Randomization (n = 35)

Experimental Control group

group (n=18) (n=17)

Pre- test n=15 n=15

Dropped out (n Dropped out (n

= 3) = 2)
Post- test Reason: not Reason: not
cooperating cooperating
n=15 n=15
Curr Psychol

Table 3 Mean and standard

deviation of the WISC-III, WMS- Variable Groups M ± S.D M ± S.D
IV and DAUF variables at the At the baseline At the one month
baseline and the one month of
inclusion between the two groups SA
Number of correct answers CBPT 46.54 ± 13.26 51.72 ± 14.56
Control 47.83 ± 13.05 48.00 ± 13.10
Reaction time CBPT 3.73 ± 0.22 1.44 ± 0.35
Control 3.65 ± 0.43 3.99 ± 1.17
Number of incorrect answers CBPT 16.92 ± 4.33 13.32 ± 4.14
Control 15.33 ± 4.25 15.02 ± 3.76
WM CBPT 13.26 ± 1.32 15. 28 ± 1.64
Control 13.05 ± 1.16 15.07 ± 1.03
STM
Memory quotient CBPT 80.32 ± 33.05 81.20 ± 32.10
Control 78.05 ± 24.11 80.60 ± 22.13
General information CBPT 3.18 ± 1.05 4.52 ± 1.45
Control 4.23 ± 0.89 4.72 ± 1.01
Orientation CBPT 3.51 ± 1.19 4.37 ± 2.03
Control 3.95 ± 1.32 4.26 ± 1.87
Learning association CBPT 11.66 ± 4.07 13.00 ± 3.75
Control 10.55 ± 3.95 12.91 ± 4.25
Mind control CBPT 3.74 ± 2.31 3.30 ± 2.68
Control 3.20 ± 2.84 4.09 ± 2.11
Logical memory CBPT 6.53 ± 2.77 5.54 ± 2.71
Control 6.43 ± 3.00 4.81 ± 1.62
Repeat numbers CBPT 7.84 ± 1.90 7.00 ± 2.15
Control 7.79 ± 0.33 7.02 ± 1.41
Visual memory CBPT 7.60 ± 3.46 6.86 ± 3.69
Control 8.25 ± 2.50 7.77 ± 2.10

M, mean; S.D., standard deviation; SA, sustained attention; WM, working memory; STM, short-term memory;
CBPT, cognitive behavioral play therapy
N = 30

was conducted twice. At p < 0.05, MANCOVA revealed a the number of incorrect answers and reaction time in DAUF
statistically significant difference for the groups in terms of test were reduced after CBPT training and there was an
the number of correct answers, F(1,18) = 47.91, p = 0.001, re-
action time, F(1,18) = 70.76, p = 0.001, and number of incorrect
Table 4 Comparison of the WISC-III, WMS-IVand DAUF variables at
answers, F(1,18) = 14.47, p = 0.001. A medium effect size, was the baseline and the one month of inclusion between the CBPT and
shown for the eta squared statistic for number of correct an- control groups
swers and reaction time scores of (0.12) and (0.19), respec-
F P d
tively. Also, a large effect size indicated the eta squared statis-
tic for the number of incorrect answers score (0.44). SA
In this study, intergroup evaluations of each parameter of Number of correct answers 47.91 0.001 0.12
WMS-IV and the digit span subscale of WISC-III were con- Reaction time 70.76 0.001 0.19
ducted twice: 1) at the baseline and 2) one month after enter- Number of incorrect answers 14.47 0.001 0.44
ing into the research. Within this period, calculation was done WM 3.52 0.077 0.16
for the inter and intragroup discrepancy of each variable
STM
(Table 4). It is shown in the table that the discrepancies were
Memory quotient 2.87 0.107 0.13
not statistically significant (p < 0.05).
General information 1.13 0.300 0.05
Orientation 0.77 0.390 0.04
Learning association 3.33 0.085 0.15
Discussion
Mind control 2.36 0.142 0.11
Logical memory 0.63 0.435 0.03
Through the use of the digit span subscale of WISC-III,
Visual memory 2.18 0.156 0.10
WMS-IV and DAUF tests in children with SLD, the objective
Repeat numbers 1.17 0.293 0.06
of this study was to determine the efficacy of CBPT on WM,
STM and SA. Regarding this objective, it can be finalized that P values refer to multivariate analysis of covariance, d = Cohen’s effect
CBPT were able to effect changes on DAUF test. Therefore, size

increase in the number of correct answers after this interven-
tion (p = 0.001,Table 2). Conversely, there was no improve-
ment in the WMS-IV variables, as well as the digit span sub-
scale of WISC-III tests between CBPT and the control groups
(p < 0.05, Table 4).
It has been reported in various studies that school-aged
children with SLD have deficits in SA. Also, there could be
improvement in academic skills such as reading, writing, and
math among people with LD (Swanson and Jerman 2007), as
a result of important correlates of cognitive functioning
(Willcutt et al. 2011) and improvement of abilities.
Conversely, WM problem have been associated with specific
reading disabilities/dyslexia and spelling disabilities
(Schuchardt et al. 2008; Brandenburg et al. 2015).
Furthermore, results have shown the resolution of the forward
and backward digit span in children suffering from dyslexia
and other specific learning difficulties is hindered (Jeffries and
Everatt 2004).
As revealed by the literature review, this is the only study
that investigated the effects of CBPT among school-aged chil-
dren diagnosed with SLD along with the control group, in
terms of the three functions of cognitive status (WM, STM,
and SA). Notwithstanding, there are reports on the useful ef-
fects of CBPT training on the reduction of challenges faced by
children diagnosed with selective mutism (Knell 1993),
encopresis (Knell and Moore 1990), as well as people who
have experienced unpleasant events in life, like sexual abuse
(Springer et al. 2012).
It has been found that in CBPT, children have improved
focus on maintaining constant and purposeful attention as a
result of the pleasant atmosphere of the game, the students’
activation and also collaboration with the therapist
(Schaefer 1993), because a wide range of toys, art supplies,
dolls, game demos and other materials are used to stimu-
late their attention (Drewes 2009). Moreover, the use of
diverse educational games along with a goal-oriented ap-
proach, encourage children with SLD to use the opportu-
nities created in the game to maintain focus on the game
without distraction (through modeling and role playing as a
critical component of CBPT, Knell 2009).
The advantages of CBPT on children with SLD have been
confirmed; however, the effect of CBPT to improve STM and
WM loss in SLD children is uncertain. The ineffectiveness of
the CBPT appears to be associated with the treatment protocol.
This is because the standard CBPT- protocol of Drewes
(2009), does not employ assignments adequate for the correc-
tion of memory defects despite sufficient empirical evidence.
It is the author’s opinion that the treatment protocol should be
re-evaluated and other researchers should utilize the modified
program of the memory-focused CBPT. In addition, it is very
likely that future studies will revise the proposed treatment
program for CBPT and its number of sessions (explained in
the method section). Also, after a longer interval (more
Curr Psychol
follow-up of school-aged children), it becomes easier to in-
vestigate the effects of CBPT. Therefore, it is suggested that
other researchers should study the children for a longer period
of time.
Limitations
This study has some limitations, since it was conducted only
on school-aged children with SLD and it cannot be considered
as intervention on other samples (such as high school-aged
children with SLD). Therefore, generalization of the results
on other individuals is not without failure. Other limitations
of this study include lack of follow-up of these RCTs as a
result of the limited access to children.
Conclusion
It was concluded that CBPT is effective on ameliorating SA
among school-aged children with SLD, but this treatment was
not effective on WM and STM in school-aged children with
SLD. However, it should be noted that more studies are re-
quired to confirm the effects of CBPT in children with SLD.
Future studies should be conducted with larger sample sizes
among various participants regarding educational levels; they
also should consist of more sessions that are therapeutic indi-
vidually, have longer follow-up interval, and follow different
protocols.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Ethical Approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institu-
tional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Informed Consent Informed consent was obtained from all individual
participants included in the study.
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