Received 12/02/18

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

Intensive Child-Centered Play Therapy

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

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

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

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

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

Journal of Counseling & Development ■ January 2020 ■ Volume 98 63

that target both core ASD symptoms and comorbid behaviors
are needed.
Interventions for Childhood ASD
Across the literature, psychosocial treatments for improving
emotional and behavioral outcomes for children with ASD
are classified into two categories: focused or comprehensive.
In focused approaches, children with ASD are taught to dis-
criminate between appropriate and inappropriate behaviors, to
monitor and record their behaviors, and to use reinforcement
strategies for maintaining appropriate behavioral responses
(Lopata et al., 2012; National Autism Center [NAC], 2015).
Focused approaches may include applied behavior analysis,
pivotal response training, discrete trial training, functional
communication training, and antecedent-based intervention
(Odom, Collet-Klingenberg, Rogers, & Hatton, 2010; Stah-
met, Ingersoll, & Carter, 2003). Whereas focused approaches
demonstrate decreases in core ASD symptoms following
intervention, evidence shows that children with ASD do not
always generalize or maintain treatment effects (Lopata et
al., 2012; Strain & Schwartz, 2001). Additionally, evidence
shows that focused approaches are more appropriate for older
children and adolescents with relatively high-functioning
ASD than for younger children or adolescents with more
severe forms of ASD (NAC, 2015).
Conversely, comprehensive treatments are typically manu-
alized, provided over a span of months or years, and designed
to impact developmental growth and broad strands of pro-
social behaviors and social-emotional assets (Odom, Boyd,
Hall, & Hume, 2010; Odom, Collet-Klingenberg, et al., 2010).
Comprehensive interventions include the Denver model, the
Lovaas model, the Princeton Child Development Institute
program, and the Treatment and Evaluation of Autistic and
Communication Handicapped Children program (Odom,
Collet-Klingenberg, et al., 2010). Although there are relatively
few comprehensive interventions for improving core features
of ASD, there is a growing body of evidence demonstrating
that comprehensive, developmentally oriented interventions
increase IQ test scores, joint attention, and reciprocal com-
munication for children with ASD (Magiati, Moss, Charman,
& Howlin, 2011). Although these results are promising, there
remains a need to explore treatments that will reduce ASD
symptoms and comorbid behavioral problems.
In recent years, some researchers have cast doubt on
the use of current treatments for treating ASD symptoms,
highlighting that said approaches treat a person with ASD
as “a problem to be solved rather than an individual to be
understood” (Prizant, 2015, p. 17). Additionally, qualita-
tive interviews of individuals with autism have revealed a
need for approaches that affect self-esteem, well-being, and
quality-of-life indicators (Crane, Adams, Harper, Welch, &
Pellicano, 2019). In one study, Crane et al. (2019) discovered
64 Journal of Counseling & Development
Schottelkorb, Swan, & Ogawa
through in-depth interviews that young adults with autism
face immense pressure to act normal in a neurotypical world
(Prizant, 2015). Similar results from a grounded theory study
indicated that parents desire collaborative approaches that
foster their children’s independence, self-regulation, and sense
of happiness (Pfeiffer, Piller, Giazzoni-Fialko, & Chainani,
2017). Because ASD core symptoms may serve as strategies
for coping with dysregulation, there is a need to explore
comprehensive interventions that promote attachment; self-
regulation; choice; and natural, unsolicited play (Morgan
et al., 2018). One approach that is important to consider is
child-centered play therapy (CCPT).
CCPT
CCPT is a comprehensive, relational counseling approach
based on Virginia Axline’s (1947) developmental construction
of person-centered therapy. According to Landreth (2012),
play therapy is “a dynamic interpersonal relationship between
a child (or person of any age) and a therapist trained in play
therapy procedures who provides selected play materials
and facilitates the development of a safe relationship for the
child (or person of any age) to fully express and explore self
(feelings, thoughts, experiences, and behaviors) through play,
the child’s natural medium of communication, for optimal
growth and development” (p. 11). CCPT is grounded in the
belief that an attuned and therapeutic relationship, expressed
in terms of unqualified acceptance of the child and empathic
resonance, is curative (Axline, 1947; Landreth, 2012; Ray,
2011). Through the CCPT process, children engage in self-
directed play, exploring their experiences and emotions and,
as a result, gaining a sense of mastery and control over their
world and, ultimately, becoming more integrated human be-
ings (Landreth, 2012; Ray, 2011).
For children on the autism spectrum, some researchers
maintain that the play experience and core relational tenets
lead to increased joint attention, environmental exploration,
and self-regulation (Kasari, Freeman, & Paparella, 2006;
Kasari, Paparella, Freeman, & Jahromi, 2008; Prizant, 2015).
Ray, Sullivan, and Carlson (2012) reasoned that the experienc-
ing of an accepting, genuine, and empathic relationship in a
nondirective play environment may contribute to improved
relational engagement and communication. Similarly, Porges
(2011) argued that in relational experiences such as CCPT,
which create a soothed autonomic nervous system and secure
attachment, children may experience what neuroscientists
refer to as neuroception of safety. Thus, the process of CCPT
allows children with ASD to experience safety in a relation-
ship, express affective arousal and dysregulation, and practice
self-regulatory skills and varying forms of self-expression
(Porges, 2011; Schore, 2001).
As an intervention, CCPT has been used for more than
60 years in the successful treatment of a variety of present-
■ January 2020 ■ Volume 98
Child-Centered Play Therapy for Children on the Autism Spectrum
ing problems and diagnoses (Bratton, Ray, Rhine, & Jones,
2005; Jensen, Biesen, & Graham, 2017; Leblanc & Ritchie,
2001; Lin & Bratton, 2015; Pester, Lenz, & Dell’Aquila,
2019). Studies suggest that CCPT reduces attention prob-
lems (Ray, Schottelkorb, & Tsai, 2007; Robinson, Simp-
son, & Hott, 2017; Schottelkorb & Ray, 2009; Swank &
Smith-Adcock, 2018); decreases internalizing problems as
well as symptoms of anxiety (Gholamalizadeh, Asghari, &
Farhangi, 2018; Mosavi & Koolaee, 2016; Stulmaker & Ray,
2015); improves externalizing problems, including aggres-
sion and conduct problems (Garza & Bratton, 2005; Ray,
Blanco, Sullivan, & Holliman, 2009; Swan & Ray, 2014;
Wilson & Ray, 2018); and decreases symptoms relating
to trauma and adverse childhood experiences (Patterson,
Stutey, & Dorsey, 2018; Schottelkorb, Doumas, & Garcia,
2012). Despite these promising results, limited research ex-
ists on the effectiveness of CCPT for children with ASD. In
a recent investigation, Salter, Beamish, and Davies (2016)
investigated the effect of CCPT on social and emotional
growth for three children with ASD. Through analysis of
single-case research data, these researchers found that all
participants demonstrated increases in social skills, com-
munication, and prosocial behaviors (Salter et al., 2016).
In another single-case design, Balch and Ray (2015) found
improvement for children with mild to moderate levels of
ASD in ratings of empathy, social competence, and self-
regulation. Beyond the highlighted studies, there are no
randomized controlled trials examining the effectiveness
of CCPT for children with ASD.
Purpose of the Current Study
Our preliminary search of the literature revealed that
comprehensive psychotherapy-based approaches for treat-
ing core autism symptoms and comorbid behaviors are
scarce. A need thus exists to explore the efficacy of CCPT
in improving both core ASD symptoms and externalizing
behaviors, such as attention and aggression problems. In
this study, we examined the behavioral effects of CCPT
for children with ASD. We primarily aimed to (a) test the
efficacy of CCPT using validated rating scales to measure
core autism symptoms, attention problems, aggression
problems, and externalizing problems; (b) examine the
feasibility of implementing CCPT in school settings for
children with ASD; and (c) implement an intense CCPT
intervention with sessions occurring four times per week
over a period of 6 weeks.
We designed a randomized controlled trial to include two
conditions: (a) CCPT intervention and (b) wait-list control.
At the outset, we hypothesized that children with ASD in the
CCPT condition would show improved core ASD symptoms
and decreased behavioral problems when compared with
the control group.
Journal of Counseling & Development ■ January 2020 ■ Volume 98
Method
Participants
Research participants were recruited from five elementary
schools in the northwestern United States. The first author
contacted the school counselor from each school to explain
the study parameters. The school’s counselor then identi-
fied and contacted all parents of children in their respective
schools with diagnoses of ASD to determine their interest in
participating in this study. Next, the first author met with all
interested parents from each school in individual meetings
to review informed consent and participation requirements.
If parents provided consent for participation, the first author
continued with intake and initial assessment to determine
whether all qualifications for participation were met.
Children were included in the study if they met the follow-
ing criteria: (a) had a diagnosis of ASD either by a medical
professional or school psychologist, (b) were between 3 and
12 years of age, (c) scored on the Social Responsiveness
Scale–2nd Edition (SRS-2; Constantino, 2012) in the mod-
erate to severe impairment of functioning for ASD, and (d)
were not participating in counseling services. Twenty-five
children’s parents agreed to participate and completed pre-
test assessments; however, two participants did not qualify
with clinical levels of ASD on the SRS-2 and thus were not
included in the study.
Participants included 23 children (ages 4–10) diagnosed
with ASD and having moderate or severe levels of symptoms
as reported on the SRS-2. As CCPT is typically used for
children ages 3 to 10 (Ray, 2011), our participants’ age range
of 4 to 10 was appropriate. Of the 23 children enrolled in the
study, 19 (83%) were male and four (17%) were female; 22
children were White, and one child was Black. Five (22%)
children attended half-day, public developmental preschools,
and 18 (78%) attended full-day public elementary schools.
In the initial meeting, we asked parents about their children’s
diagnoses and services received. Of the children included in
the study, many had co-occurring diagnoses of ADHD (n =
13), OCD (n = 3), GAD (n = 2), pica (n = 1), or ODD (n =
1) as reported by parents.
No children were participating in counseling services at the
time of the study. Depending on their individualized education
plans, the children received varying supports at school, with
speech and occupational therapy (OT) services most typically
provided. More narrowly, as per their parents’ report at pretest
assessment, children participated in supports such as speech
services inside and/or outside school (n = 16), OT services
inside and/or outside school (n = 11), medication manage-
ment for their symptoms (n = 7), one-on-one assistance in
the regular classroom setting from a paraprofessional (n = 3),
and/or feeding therapy outside school (n = 3); three students
received no services. The first author asked all parents at
65

posttest assessment about any changes in services received
during the 6-week experimental period of the study, and all
parents denied any changes in interventions provided to or
medications used by the participants.
Counselors and Treatment Integrity
The CCPT intervention was provided by three graduate-level
counseling students and two licensed counselors who held
professional credentials in the northwestern United States.
All of the therapists were trained in using CCPT and in
implementing procedures outlined in the CCPT treatment
manual (Ray, 2011). To ensure treatment fidelity, counselors
received weekly supervision from the first author and at the
conclusion of the study, the research team (the authors) exam-
ined treatment adherence. One member of the research team
observed one full session from each therapist and used the
Child Centered Play Therapy–Research Integrity Checklist
(CCPT-RIC) to conduct fidelity, as recommended by Ray,
Purswell, Haas, and Aldrete (2017). In their examination,
Ray et al. (2017) found that the CCPT-RIC had a high level of
interrater reliability (.95) in defining verbal CCPT responses
among a panel of CCPT experts. Ray (2011) reported that over
90% adherence to CCPT indicates good treatment fidelity.
In this study, we found that the therapists used verbal CCPT
responses in their sessions 96% of the time, demonstrating
good adherence to CCPT.
Treatment
CCPT was provided initially to the 12 children in the in-
tervention group across 6 weeks, with each child attending
four (30-minute) individual sessions weekly for a total of 24
sessions at their school. Play therapy rooms were established
at each participant’s school, and the rooms were furnished in
accordance with materials recommended by Landreth (2012).
Additionally, all playrooms were equipped with cameras so
that therapists could record all play sessions to assist with
supervision of skills and treatment integrity. Therapists in
the study were asked to complete a play therapy session sum-
mary after each session, documenting each child’s significant
verbalizations, play behaviors, play themes, and changes
across sessions. Additionally, therapists conducted in-person
parent-consultation sessions weekly for a total of six sessions.
Because parent consultation is typically considered part of
CCPT treatment, as recommended in the CCPT treatment
manual (Ray, 2011), we desired to include that component
in this investigation. For this study, therapists followed a
specific parent-consultation protocol established by the first
author, which required that each therapist share play therapy
themes and behaviors noted in session to parents, and that
therapists solicit any behavioral changes noticed by parents
at home. Although other parent-consultation models affiliated
with CCPT have been described in the literature (e.g., Schot-
telkorb, Swan, & Ogawa, 2015), our study did not use any of
66 Journal of Counseling & Development
Schottelkorb, Swan, & Ogawa
those specific models, as many would have required parent
education and training components. For this investigation,
we wished to determine the effectiveness of CCPT without
the interference of parent training and education and, thus,
simply reported play themes and solicited parent feedback
about changes noted at home. All parent information was
documented in parent-consultation session notes, which were
later used in social validity reported in the Results section.
Instruments
SRS-2. To assess the effectiveness of CCPT for children
with ASD, we had parents complete the SRS-2 (Constantino,
2012) at preintervention and postintervention periods. The
SRS-2 is a 65-item rating scale that measures and quanti-
fies the severity of symptoms of social impairment relating
to ASD. In our study, parents rated the items on the SRS-2
on a 4-point Likert-type scale ranging from 1 (not true) to 4
(almost always true). The SRS-2 is well regarded for helping
identify ASD core symptoms in school-age children and is
also recommended for use in assessing intervention impact on
social behavior, communication, and stereotypic behaviors of
children with ASD (Bruni, 2014). The SRS-2 provides a total
score as well as scores for subscales of Social Awareness, So-
cial Cognition, Social Communication, Social Motivation, and
Restricted Interests and Repetitive Behavior. The total SRS-2
score is the most reliable score (Bruni, 2014) and thus was
used for determining overall change in core ASD symptoms
in this study. More specifically, an SRS-2 total score of 76
or higher indicates severe impairment of social functioning,
scores from 75 to 66 indicate moderate impairment, scores
from 65 to 60 indicate mild impairment, and scores under 60
indicate a lack of social difficulties associated with an ASD
diagnosis (Bruni, 2014). The SRS-2 is a strongly reliable
instrument (with a total reliability coefficient of .95) and
valid for identifying individuals with ASD, particularly with
the school-age form (Bruni, 2014).
Child Behavior Checklist (CBCL). In addition to the SRS-
2, parents also completed the CBCL (Achenbach & Rescorla,
2001). The CBCLs for children ages 1½ to 5 and 6 to 18 are
instruments of the Achenbach System of Empirically Based
Assessment. Both measures are used for examining emotional
and behavioral problems as well as adaptive functioning of
children as rated by parents/guardians. In our study, parents
rated the items on the CBCL on a 3-point Likert-type scale
ranging from 0 (not true) to 2 (very true or often true).
The instruments are designed to evaluate child behaviors
across three domains—externalizing, internalizing, and
total behavior problems—using various subscales. Due to
the varied ages of participants in this study, the two different
CBCL versions were used. Because the two versions offer
differing subscales, we focused on comparing pre-post
data from those subscales that were consistent across the
two types: Attention Problems, Aggressive Behavior, and
■ January 2020 ■ Volume 98
Child-Centered Play Therapy for Children on the Autism Spectrum

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

TABLE 1
Analysis of Variance Results for Outcome Variables

CCPT Group Control Group Effects

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

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

Journal of Counseling & Development ■ January 2020 ■ Volume 98 67


examine the effect of the intervention on SRS-2 scores.
Results of the factorial ANOVA on the SRS-2 total score in-
dicated a statistically significant interaction effect between
group and time, Wilks’s Λ = .53, F(1, 21) = 18.60, p < .01,
hp2 = .47, with a large effect size. This result indicated that
participants in the play therapy group experienced a drop
in SRS-2 scores from preintervention (M = 78.83, SD =
7.71) to postintervention (M = 70.58, SD = 9.29), whereas
the control group participants were reported to increase
in symptomatology from pre- (M = 73.64, SD = 7.84) to
posttesting (M = 77.91, SD = 7.99).
Attention Problems
A 2 (CCPT vs. control) × 2 (Time; preintervention vs.
postintervention) factorial ANOVA was conducted to
examine the effect of the intervention on the Attention
Problems subscale scores of the CBCL. Results of the
factorial ANOVA on the Attention Problems score indicated
a statistically significant interaction effect between group
and time, Wilks’s Λ = .60, F(1, 21) = 14.20, p < .01, hp2
= .40, with a large effect size. This result indicated that
participants in the play therapy group experienced a decrease
in attention problems from preintervention (M = 72.33, SD =
11.73) to postintervention (M = 64.50, SD = 9.25), whereas
the control group participants were reported to increase
in symptomatology from pre- (M = 66.00, SD = 8.76) to
posttesting (M = 67.55, SD = 7.95).
Aggressive Behavior
A 2 (CCPT vs. control) × 2 (time; preintervention vs.
postintervention) factorial ANOVA was conducted to exam-
ine the effect of the intervention on the Aggressive Behavior
subscale scores of the CBCL. Results of the factorial ANOVA
on the Aggressive Behavior score indicated a statistically
significant interaction effect between group and time, Wilks’s
Λ = .80, F(1, 21) = 5.19, p = .03, hp2 = .20, with a large ef-
fect size. This result indicated that participants in the play
therapy group experienced a decrease in aggression problems
from pre- (M = 68.42, SD = 11.97) to postintervention (M
= 62.83, SD = 9.27), whereas the control group participants
were reported to increase in symptomatology from pre- (M
= 69.55, SD = 13.10) to posttesting (M = 70.36, SD = 11.25).
Externalizing Problems
Results of the factorial ANOVA on the Externalizing Problems
subscale scores revealed a statistically significant interaction
effect between group and time, Wilks’s Λ = .66, F(1, 21) =
10.81, p < .01, hp2 = .34, with a large effect size. Following
the same trend as previous analyses, participants in the play
therapy treatment group were reported to have decreased ex-
ternalizing symptoms from pre- to post-testing (M = 68.67, SD
= 9.35; M = 63.08, SD = 7.90), whereas control group scores
increased (M = 65.36, SD = 9.54; M = 67.27, SD = 8.72).
68 Journal of Counseling & Development
Schottelkorb, Swan, & Ogawa
Social Validity/Clinical Significance
At the end of the study, we completed interviews with partici-
pants’ parents in the CCPT group for the purpose of obtain-
ing social validity. Parents reported improved eye contact,
decreased tantrums, increased appropriate play behaviors,
and increased relational play with parents. Analysis of pre-
post data also revealed that half of the children in the CCPT
group (n = 6) changed in symptom severity by an entire cat-
egory (e.g., from severe to moderate ASD symptoms or from
moderate to mild ASD symptoms) on the SRS-2. Of the 12
treatment group participants, 11 were reported to have im-
proved ASD symptoms. By contrast, of the 11 control group
participants, six were reported to have worsening symptoms,
and the remaining five were reported to score the same as or
within 1 point of pretest.
Discussion
The goal of this study was to examine the effectiveness of
CCPT on the social functioning and externalizing problems
of children with ASD. We speculated that CCPT would be
effective in improving social responsiveness associated with
ASD and decreasing attention, aggression, and externalizing
problems of children with ASD, and these hypotheses were
supported in this study: Children in the CCPT treatment
group demonstrated significant improvements in social
behavior as measured by the SRS-2 and demonstrated
significant reductions in externalizing, attention problems,
and aggression as measured by the CBCL. These research
findings support the previous findings of Balch and Ray
(2015) and Salter et al. (2016), who found improvements
in social behaviors in single-case research for children with
ASD. These results, along with results of the present study,
indicate that CCPT may be an effective intervention to help
improve the social behaviors of children with ASD. Whereas
applied behavior analysis may be effective in eliminating
or reducing specific behaviors and reinforcing preferred
behaviors and is considered an “established” treatment
intervention, it is very time intensive, requiring 30–40
hours per week for 2 or more years (Granpeesheh, Tarbox,
& Dixon, 2009). In contrast, in our investigation, we found
that just 12 hours of CCPT with six parent-consultation
sessions improved social behaviors for children with ASD.
Thus, these preliminary results indicate that CCPT may
be a cost-effective intervention to help improve the social
functioning of children with ASD.
Children with ASD typically struggle with emotional
and behavioral self-regulation (Jahromi, Bryce, & Swanson,
2013; Laurent & Gorman, 2018). Poor self-regulation is
related to increased difficulties with social functioning and
adaptive behaviors (Uljarevic et al., 2018) and increased
aggressive and externalizing behaviors (White, Jarrett, &
Ollendick, 2012). In this study, we found that externalizing
■ January 2020 ■ Volume 98
Child-Centered Play Therapy for Children on the Autism Spectrum
behaviors, attention problems, and aggression as rated by
parents on the CBCL decreased significantly through partici-
pation in CCPT, which supports previous research (Bratton
et al., 2013; Ray et al., 2007, 2009; Ritzi, Ray, & Schumann,
2017; Schottelkorb & Ray, 2009). Thirteen children with
ASD in our study also had a comorbid diagnosis of ADHD,
similar to previous research wherein 30%–75% of children
with ASD had a comorbid ADHD diagnosis (Grzadzinski
et al., 2016; Johnston et al., 2013). Leitner (2014) reported
that there are no interventions that have been found effective
to treat deficits associated with both ASD and ADHD. In
addition, aggressive behaviors are a common co-occurring
behavior associated with autism (Kanne & Mazurek, 2011).
In this investigation, we found that CCPT improved social
functioning associated with ASD and decreased ADHD and
aggressive behaviors.
Ray et al. (2012) postulated that CCPT is an intervention
inherently designed to be effective for children with ASD
because it is relationship and communication focused—areas
that are core deficits for children with ASD. In CCPT, chil-
dren with ASD are accepted just as they are, which differs
significantly from typical behavioral interventions used for
children with ASD that are designed to target and change
specific behaviors. In our study, parents reported that social
behaviors and relational interactions with parents were im-
proved after participation in CCPT. We speculate that when
children with ASD experience full acceptance of themselves
through the CCPT relationship, they may feel safe in their
attempts to engage in a relationship with the play therapist.
Once acceptance is discovered in one relationship (the play
therapy relationship), we posit that children with ASD are
more likely to interact with others outside of the therapy room,
as confirmed by parents in this study, with parents reporting
improved social interactions with them through SRS-2 results
and parent feedback in parent-consultation sessions.
Results from this investigation indicate good clinical
significance for CCPT as parents reported positive changes
detected at home, including fewer tantrums, improved eye
contact, and improved relational play with parents. These
findings support other researchers’ findings that for interven-
tions to be implemented, good social validity from parents
and teachers is required (Callahan et al., 2017; Carter, 2010).
Thus, our findings indicate that parents perceived CCPT as
a helpful intervention.
Implications for Counseling
The findings of this investigation indicate that children who
have ASD along with co-occurring attention and aggression
problems may benefit from participation in intensive CCPT.
Thus, clinical counselors in private practice or in mental
health settings may consider using CCPT for children with
ASD and, more narrowly, may consider using a more inten-
sive model with multiple sessions in a week, rather than the
Journal of Counseling & Development ■ January 2020 ■ Volume 98
traditional once-per-week model. Because our study took
place in the school setting, we encourage school counselors
and school-based mental health practitioners to use CCPT
in their work with children with ASD. In such settings, it
is easier to access the children more frequently throughout
the week and thus implement an intensive CCPT model. In
addition, counselor educators who train school-based and
clinical counselors who plan to work with children ages 4
to 10 may encourage training and use of CCPT for their
students, particularly as CCPT has been found effective
for a multitude of presenting problems of childhood (Ray,
2011). Because ASD is the fastest growing neurodevelop-
mental disability in the United States (CDC, 2014, 2018), it
is imperative that child counselors know of evidence-based
interventions for children with ASD. Preliminary results
of our investigation, as well as previous research (Balch &
Ray, 2015; Salter et al., 2016), indicate that CCPT may be
effective for children with ASD.
Limitations
The present study was the first of its kind to use a randomized
controlled trial in exploring the effectiveness of CCPT for
children with ASD. However, several limitations exist, includ-
ing that our study used a small sample size, no follow-up was
performed to ensure changes persisted postintervention, and
there was limited diversity in the sample due to the study tak-
ing place within one area of the northwestern United States.
Another limitation of this investigation is that all evaluation
of change was done through parents’ reports of symptoms on
the SRS-2 and CBCL. Thus, it is possible that parents’ positive
experiences participating in this intervention impacted their
reporting at the postassessment period.
Future Research
Although we found significant improvement in social
behaviors and decreased attention and externalizing be-
havioral problems and aggressive behaviors for children
with ASD after participating in CCPT, no follow-up was
performed to determine sustained improved functioning
postintervention. Future researchers could consider a
1-year follow-up to ensure improvements were sustained.
As this study was a pilot study, future researchers could
use larger, more diverse samples and consider comparing
CCPT with evidence-based interventions for children with
ASD, such as applied behavior analysis. An additional
consideration is exploration of CCPT with and without
parent involvement to see if parent consultation impacts
treatment outcome. Future researchers could include a
direct observation assessment for examining change in
symptoms outside of parent report. Direct observation
methods in the classroom would provide information
regarding change occurring in other settings, such as the
classroom (Kasari & Smith, 2013). Because participants
69

in this study had moderate or severe levels of ASD as per
the SRS-2, researchers could explore the effectiveness of
CCPT for children with varying levels of ASD severity.
Finally, in this investigation, we explored an intensive
model of CCPT, rather than the more traditional once-
or twice-per-week model that is described in the CCPT
literature (Ray, Henson, Schottelkorb, Brown, & Muro,
2008). Thus, researchers could explore the effectiveness of
intensive models of CCPT compared with the traditional
once-weekly sessions that are commonplace in clinical
counseling settings.
Conclusion
ASD is a common neurodevelopmental disability for chil-
dren, and mental health and school counselors should be
informed of a variety of interventions that are effective with
this population. Although there is evidence to support be-
havioral interventions, our study shows that relational-based
counseling interventions may be effective alternatives for
meeting the varied needs of children with ASD. In this inves-
tigation, we found that an intensive CCPT intervention was
effective in improving social responsiveness and decreasing
externalizing problem behaviors of children diagnosed with
ASD. Thus, this pilot study provides preliminary evidence
that intensive CCPT may be a cost-effective intervention
for children with ASD.
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