Play for Life

2009 Review of PTI/PTUK Outcomes a small number of cases is that the results may be
Research used to predict future outcomes with a high degree of
certainty. This should be very comforting for commis-
sioners of services. It shows that an investment in
Introduction
play therapy is not a leap into the unknown and that
there are strong guidelines for performance expecta-

R
esearch data boring? I don't think so. It's one of
our main ways of creating and sustaining your em-
ployment in the play therapy profession and another
method for reflecting on practice. So we suggest that
you read this review from two perspectives:
• How can you use the data to promote play
therapy and defend the funding for your services?
• How does your practice compare to that of the
overall guidelines?
This is the third annual review of the research data
drawn from our database of clinical outcomes. It
confirms that overall 70% of all children receiving play
and creative arts therapies, for social, emotional, be-
haviour and mental health problems show a positive
change. This overall figure is derived from the SDQ
Total Difficulties domain data provided by referrers.
The consistency of play therapy’s effectiveness, when
the PTI/PTUK standards of practice are used, is shown
by the results of positive change for the last 4 years:
69.48%, 63.20%, 70.06%, 69.91%.
There are now many combinations of variables by
which the data may be analysed. In order to keep this
paper to a reasonable length we have chosen the
referrer’s SDQ total difficulties domain as the princi-
ple one. Referrers normally work for an organisation
funding the service and total difficulties includes the
four ‘problem’ sub domains.
One of the main advantages of our large scale practice
based research, unlike that of ad hoc studies based on
tions. Emphasise this point in your presentations and
proposals.
Other advantages are the detailed findings that are
possible through the use of our database design and
software to analyse sub sets of the data. Examples are
given in this article. The continuity of the programme
enables sub sets of the data to grow towards
‘statistical maturity’.
However a very minor disadvantage of large scale,
continuous, practice based research is that unlike
‘laboratory’ conditions or a small number of case stud-
ies, some of the data items are incomplete. This is
why the Ns vary from analysis to analysis. For exam-
ple out of a total of 5167 client records we only have
gender data for 4968 of them.
Last year we conducted a preliminary analysis of the
children’s activities in the playroom. This year we
have a much greater number of records and the pic-
ture looks rather different, so please use these up to
date figures when talking about this aspect. Although
PTUK has the world’s most comprehensive and usable
database of quantitative play therapy research there
are many ways in which it can be improved. For exam-
ple, see the separate article soon to follow in the ‘Play
for Life’Journal on ‘Proposed Taxonomy of Condi-
tions’.
Our sincere thanks to all of our members who have
contributed the SDQ measures and to Mike, Valerie,
Lyn and Brenda for their considerable data input
efforts.

Data base Content: As at the end of August 2009 the database contains data for:

N Comments

Practitioners 549 A mix of trainees, therapeutic play practitioners and play therapists

Locations 577 Some practitioners work in more than one iocation.

Clients total 5 167 Some have incomplete attribute data

Clients ages 5 - 11 3498 Age data was not collected in the earlier years

Referrers Pre and Post SDQs 3326 Most analyses are based on these numbers - a total of over 6000
questionnaires
Parents Pre / Post SDQs 2977

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 Play for Life
This review may be considered a a meta -analysis of Client Profile
549 separate practices.
Clients By Gender
Referrals Profile
The overall composition of the database is:
No Clients Per Practitioner

Clients N Practitioners N % Girls 1685 34%

Boys 3238 65%

Not recorded 45 1%
50 + 3 1%
4968

20 to 49 28 5%
This proportion has been unchanged over
10 to 19 129 23% the past 5
years.
5 to 9 249 45%
Clients By Age and Gender
Under 5 140 26% N=4340

549 100%
Primary School age 77%

The average (mean) number of clients per Secondary School age 19%
practitioner by year.
Infants 3%
Practitioners N
Average No
Post secondary school 1%
Clients

2006 129 9.81

in the following table those aged under 5 and
2007 177 7.09 over 16 have been excluded.

2008 218 6.30

109 6.19
2009 Age at Referral Girls Boys Ratio Boys:Girls
(8 months)
5 75 135 1.80

This shows that, so far, as the number of practitioners 6 148 264 1.78
contributing data has increased, the average number 7 204 369 1.81
of clients has decreased. 436 2.40
8 182
9 193 399 2.07
Geographical Distribution of Referrals 10 192 369 1.92

90% of the practitioners work in the UK spread over 11 202 323 1.60
52 counties. 12 145 247 1.70
13 67 150 2.24
14 44 74 1.68
15 29 47 1.62
16 21 25 1.19
1502 2838 1.90

11
Play for Life
This is the first time we have analysed the proportion Interventions
of boys to girls by age. The results are very interest- Planned Interventions By Type
ing as best shown by the chart below.
The proportion does not remain constant. Most play therapy is conducted on a one to one basis
At age 8 there are 2.4 times the number of boys than which is divided equally into short (up to 12 sessions)
girls. and long term work.

Clients N %

Group 646 14%

1:1 LT 2076 44%

(Over 12 sessions)

2033 43%
1:1 ST
(12 or under
sessions)

No. Sessions Clients N %

By Number of Sessions 40 and over 5 1

We have improved the recording of sessions in the 30 -39 27 4
last two years. The overall average (mean) number
of sessions is 15.25 with a range from I to 70. 20-29 122 I8
This has decreased slightly from 15.8 in 2008 14.9 in
2009 10 to I9 365 53

I to 9 168 24

687 100

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 Play for Life
The effect of a recommended number of 12 sessions, for mild to moderate problems is clearly shown by the
spike in the chart below.

Clients By Number of Sessions

Clients N

Number of Sessions

Pre Therapy Assessment By Severity of Problem

Overall - Total Difficulties This table is based on Referrer’s Total Difficulties

SDQ scores for ail clients aged 5 - 11
There has been little change in the Total Difficulties
Referrer pre-therapy SDQ scores over the past
four years. Remembering that 16 is the SDQ cut
off score for ‘abnormal/at risk’ this shows that the
state of children’s mental health is not improving N %
and the need for play therapy is not diminishing.
Normal/no risk 573 22
Borderline/low 525
risk 20
17.1
2006
154 58
2007 Abnormal/high
16.6
2998 17.0 risk

16.9 2639 100.00

2008

Referrer's Total Difficulties By Severity of Problem

22%

□ Normal
□ Borderline
□ Abnormal
58%

13
Play for Life
This data could be used as a standard profile against
Pro-social score % Clients
which a location’s own profile of referrals could be
used.
10 23
The main question is why there is a relatively high
number of referrals for normal/low risk clients? The 9 14
hypothetical answer is that one or more sub domains 8 14
have high scores or that there is another issue not
7 13
revealed by the SDQ measure.
6 12
Conduct % 5 13
Sub Emotional Hyper Peer %
Domain % activity % Problems 4 7
3 2
9 0 1
2 2
8 1 2 1 0
7 3 3 1
100
6 4 1 6 1 Overall Pro-social
5 9 2 15 3
Similarly to total difficulties, there has been little
4 15 9 14 8 change in the Pro-social Referrer pre-therapy SDQ
scores over the past four years. Remember that 5 is
3 17 12 19 17
the SDQ cut off score for ‘borderline and the lower
27 32 the score the worse the issues. Our data shows that
2 22 21
on average children referred are on the cusp of
1 28 49 21 37 borderline/normal and do not have pro-social issues
The shaded figures indicate the percentage of scores to the same extent as total difficulties.
that are above the SDQ borderline cut off. So 17% of
this sub population need attention to their emotional
problems, 24% to conduct problems, 12% to hyperac- Pre Therapy Pro-Social Average Score
tivity and 13% to peer problems. It is concluded that
75% of the referrals classified as normal are also nor- N=3432 Ages 5-11 Scale I-10
ma! in their sub domains and on this basis cannot be a 2006 5.67
good use of play therapy resources. Consequently
2007 5.58
some 16% of the total referrals for play therapy can-
not be justified on the basis of their Goodman’s total 2008 5.45
difficulties scores, although of course there may be 2009 5.48
other reasons. As a result of this conclusion it is rec-
ommended that the case summary forms include a By severity of Problem
field for an explanation of the reasons for proceeding This table is based on the referrer’s Pro-social SDQ
with the client. score for all clients aged 5-11. The fourth column
So 17% of this sub population need attention to their shows the comparison with the total difficulties
emotional problems, 24% to conduct problems, 12% to domain.
hyperactivity and 13% to peer problems. It is conclud-
ed that 75% of the referrals classified as normal are N % Tot Diffs %
also normal in their sub domains and on this basis can-
not be a good use of play therapy resources. Conse- Normal 1575 46 22
quently some of the 16% of the total referrals for play /no risk
therapy cannot be justified on the basis of their
Goodman’s total difficulties scores, although of course
there may be other reasons. As a result of this conclu- 582 17
sion it is recommended that the case summary forms Borderline/
20
include a field for an explanation of the reasons for low risk
proceeding with the client. We have also investigated
the pro-social assessment scores, where the total diffi- Abnormal/ 1275 37 5
culties scores are under 11 ie. Normal. As in the fol- High risk
8
lowing table below only 24% of the clients require
attention. 3432 100 100.00

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 Play for Life

Outcomes
Now we come to the most interesting part for commissioners of services - the effectiveness of play therapy,
as delivered to PTI/PTUK standards. We first consider the overall changes - where clients’ scores change
from pre therapy to post therapy. Then we look at the clinically reliable changes, where clients have moved
from one SDQ band to another.

Overall Change - Total Difficulties

First we show the number and percentage of children by the type of change. This is based on a comparison
of the SDQ scores pre and post therapy. We have combined the referrer and parent/carer scores in one
table. The percentages for both groups is almost identical disproving the myth that parents might be motivat-
ed to keep the improvements marginal for social benefit payments or other reasons. It might apply to a few
cases but not to the majority.

Change in Total Difficulties - Combined Referrer and Parent

Number of clients by type of change

N = 6209 SDQ Questionnaires

Negative No Change Positive Total

N % N % N % N

Referrers 764 23 261 8 2250 69 3275

Parents 627 2I 227 8 2080 71 2934

Combined I39I 22 488 8 4330 70 6209

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Play for Life

Changes in Total Difficulties -By Gender

Next we explore the data to see if there Is any

change according to the gender of the client as
observed by the referrers. These confirm the
findings of last year's review that there are no
significant differences in total outcomes between
boys and girls.

Changes in Total difficulties-By Age

Boys Girls
The data appears to support in general terms
N % N % the hypothesis, based on brain plasticity, that the
Positive ISM 68% 717 69 younger the child the more effective therapy is in
achieving a positive change. This assertion needs
more detailed statistical analysis.
No Change 170 8% 90 9

Age N
Negative 533 24% 225 Posi- No Nega-
22 tive change tive

N % N % N %
2214 1032 100.00
100.0 5 101 78 77 8 8 15 15
0%
6 265 191 72 18 17 56 21

7 373 252 68 27 7 94 25

8 428 299 70 40 9 89 21

9 426 296 69 35 8 95 22

10 377 249 66 31 8 97 26

11 365 243 67 34 9 88 24

2335 1608 69 193 8 534 23

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 Play for Life

Posiitive Changes in Total Difficulties (Referrer) By Age

Overall Changes Pro-social

Combined Referrer and Parent Changes
The following table and charts show that 50% of the clients show a positive change in the pro-social domain.
This figure may also be used with confidence as a predictor and guide line, being based on over 5800
questionnaires. Unlike the total difficulties domain, there is a pronounced difference between referrers' and
parent/carers’ data. Although the ‘negative’ change proportions are very similar the parent/carers’ ‘no change’
is much higher and consequently the percentage of ‘positive change' is lower.

Number of clients by type of change

N = 5828 SDQ Questionnaires

Negative No Change Positive Total

N % N % N % N
Referrers 699 23 691 23 1623 54 3013

Parents 663 24 889 32 1263 45 2815

Combined 1362 23 1580 27 50 5828

2886

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Play for Life

Reliable Clinical Change

As well as showing the number of children who have shown a positive change, the Goodmans SDQ provides
a way of measuring clinically reliable change. This is achieved when a client changes bands. For example
moving from ‘abnormal’ to ‘normal’.

In this section clients who were initially assessed as ‘abnormal/at risk’ are included.

Positive Negative No change Total

1420 139
1262 2821

50.34% 4.93% 44.74%

Total Difficulties - Referrer - Clinically Reliable Change

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 Play for Life
Total Difficulties - Parent/Carers Clinically Total Difficulties - By Gender - Clinically
Reliable Change Reliable Change

A higher percentage of clients showing a positive- Although the overall amount of positive change is
clinicaliy reliable change as rated by parents/carers almost the same for boys and girls, as shown above,
as compared to referrers is shown in the next table. the degree of clinically reliable change is higher for
girls, as demonstrated in the next table:

Positive Negative No change Total Positive Negative N

No
Change

1398 73 906 2377 Boys 47% 5% 48% 1994

58.81% 30.7% 38.12% Girls 57% 5% 38%

802

Total Difficulties - Clinically Reliable Change - Boys -

Refeme rs

Total Difficulties - Clinically Reliable Change - Girls -

Referrers

Total Difficulties - Combined Referrers and

Parent/Carers - Clinically Reliable Change
The combined analyses of both referrer and parent
carer data based on 5198 measures gives a positive
reliable clinical change figure of 54%.T

Nega-
Positive No change Total
tive
Combined 5198
2818 212 2168

54% 4% 42% 100%

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Play for Life
Pro-social - Clinically Reliable Change Is there a difference by gender? A bit. Overall boys
spend 30% of their time using the sand tray, whereas
The amount of clinically reliable change for the pro- girls use it only for 16%. Boys spend 18% drawing
social domain is 61%, which is higher than the 54% and painting - girls 28%. Talking - accounts for only
for total difficulties. 8% of what boys do, but 18% for girls! These are
overall average figures. How do they compare to
your experience?
Positive Negative No N Three media: therapeutic story telling, movement and
% % Change creative visualisation do not appear in the top eight.
% Is this because these are not ‘on the shelf so that the
children are not aware of them so don’t choose
them? Or is it due to practitioners’ lack of confi-
Referrer 59 4 37 1928 dence? One suggestion is that you create a colourful
4 30 856 box named ‘Stories’, but that it is empty, so when
Parent/ca your clients spontaneously open it you spontaneously
rers 66
tell them an appropriate one. After all you’ve been
trained to do this and we receive many stories for
Com- 61 4 34 2784
publication in ‘Play for Life’.
bined
Finally we carried out an analysis of the percentage of
time each medium has been used by the age of the
client.
Which Activities Produced These One of the fascinating aspects of research is when
Outcomes? the data is difficult to interpret and it does not con-
firm to accepted wisdom. This sub set of the data-
As well as researching outcomes, the programme has base is such an example. Just look at the chart. The
for the last two years been gathering data on the analysis then becomes provisional, because of the
activities that the children use in therapy. This area number of caveats, suggesting new lines of enquiry
is fundamental for driving future research and has not and changes in data collection methods.
been studied before on such a scale - 9972 sessions, However some patterns can be discerned:
667 clients, 23817 activities. It provides valuable guid-
• Sand - overall the most popular medium. After
ance for training standards, recruitment policies and
the age of 5 there is a trend for its use to decline
job descriptions.
as age increases, but there are peaks at ages I I
and 13 that are against the trend. Will a larger
The first point to note in the analysis of activities is
data set smooth these out?
that talking, as a main activity, only takes up
12% of the time. The second is that a variety of • Drawing and painting - the second most popular
media is required although the most popular eight medium. A similar trend to sand as its use
Use of Media - All Clients declines as age increases, but with only one
contra peak at the age of 12

% of Session time • Talking (as a sole activity) - this has a very

pronounced trend over time, increasing from 5%
Sand tray 25 to 15%. This also matches most of our
Drawing and painting 22 expectations. We can safely make the prediction
that talking becomes more popular over time
Talking 12
but only be comes a main activity (15%) at age 14.
Drama/Role Play/Dressing up. 11

Games
10
Clay 8
Music 5

Puppets 5

96

20
 Play for Life

• Role play/dressing up-tends to decline as age increases but more slowly between the ages of 6 and 12
• Games- a trend to increase with age but some out of trend values at ages 9 and I I for which there are no
explanations. An awkward series. Needs further investigation.
• Clay - a gradual increase up to the age of 12 - then a sharp decline
• Music and puppets - both show a minority use. Both with similar patterns peaking at age 13. Is the use of
these two media constrained by the lack of equipment?
• Other activities - a decline from the age of 5 and then a rapid increase age 13 onwards. This classification
also needs more investigation.

% session time AGES

Medium 5 6 7 8 9 I0 II I2 13 I4

Sand tray 22% 25% 24% 22% 2I% 23% 27% 16% 2I% 12%

Drawing and painting 19% 23% 22% 20% 20% 17% 16% 2I% 15% 8%

Talking 5% 5% 5% 8% 7% (0% I0% I l% II% 15%

Role Play/Dressing Up 17% I \% 12% I0% 12% I0% I0% 9% 2% 2%

Games 4% 3% 6% 7% 14% 9% 7% I l% 14% 19%

Clay 5% 6% 7% 7% 6% 7% 7% 9% 5% 5%

Music 3% 5% 4% 4% 4% 3% 5% 4% 7% 3%

Puppets 3% 3% 4% 4% 3% 4% 3% 4% 6% 3%

Other 22% 17% 17% 18% 14% 16% 15% 13% 18% 32%

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Play for Life
Implications for Policy
This research contradicts the findings of a damaging
report commissioned by the DCSF, published in
June of this year . Its findings were based on an
inadequate review of available evidence, omitting
any research from the play therapy profession in
the UK. PTUK contends that play therapy is
extremely effective and must be included in the
Department’s new policies for the emotional care
of primary school pupils.
Presentation Points
When you present this research please remember
to make it clear that:
This research project is a continuous programme
managed and financed entirely by Play Therapy UK
and international (PTUK & PTI) and is the largest of
its type world wide.
22
The interventions used by the practitioners are
homogenous. All have been trained using a common
set of competencies to PTUK/PT! standards. These
standards are far more specific than those used in
the training for other therapies, for example those
currently laid down by the Health Professions
Council.
The research has the same degree of independence
as that conducted by a University or Government
department. As professional organisations we abide
by ethical standards. The data is provided by
independent practitioners and the Goodman’s
SDQ, used for gathering the data is an independent
psychometric instrument used by a number of
other organisations.