Children and Youth Services Review 57 (2015) 127–133

Contents lists available at ScienceDirect

Children and Youth Services Review

journal homepage: www.elsevier.com/locate/childyouth

Child-centered play therapy with young children who are anxious: A

controlled trial
Hayley L. Stulmaker a,⁎, Dee C. Ray b
a
Sam Houston State University, United States
b
University of North Texas, United States

a r t i c l e i n f o a b s t r a c t

Article history: Traditional methods of treating anxiety have been less effective with young children. The researchers sought to
Received 15 June 2015 explore effects of child-centered play therapy (CCPT) on young children with anxiety symptoms. Fifty-three
Received in revised form 11 August 2015 participants between 6 and 8 years old were randomly assigned to the experimental or active control group.
Accepted 11 August 2015
Children who received CCPT significantly decreased their overall levels of anxiety and worry. Overall, CCPT
Available online 14 August 2015
may be considered a developmentally appropriate treatment for young children who are anxious.
Keywords:
Published by Elsevier Ltd.
Anxiety
Children
Play therapy
Treatment

1. Introduction
Children experience anxiety and fear as a normal part of develop-
ment. However, intervention is necessary when a child's anxiety re-
sponse exceeds the level of threat in reality and surpasses what is
developmentally expected. Clinical levels of anxiety that are intensely
experienced, impair children's ability to master developmentally ap-
propriate tasks, and prevent the ability to self-regulate when the anx-
iety provoking event is not occurring (Knell & Dasari, 2006). When
anxiety manifests in the ways stated above, it has outgrown develop-
mental appropriateness and may have surpassed the normal threshold
(Lyness-Richard, 1997; Muris, 2007; Ollendick, Grills & Alexander,
2001). Anxiety becomes an issue of concern when the level of severity
begins to impact the child or the family system (Kendall et al., 1992).
Between 10 and 20% of children experience heightened levels of
anxiety, resulting in anxiety as the most prevalent childhood disorder
(Costello, Egger & Angold, 2004; Kendall, Furr & Podell, 2010). The
National Institute of Mental Health (NIMH, 2013) estimated that 25% of
13 to 18 year olds experience an anxiety disorder, with 5.9% experiencing
severe anxiety disorders. The mean prevalence of any anxiety disorder
or ages 6 to 12 is 12.3% and 11% for 13 to 18 year olds (Costello, Egger,
Copeland, Erklani & Angold, 2011). Unfortunately, prevalence of anxiety
for young children below the age of 6 is not specifically available. These
high levels of anxiety that are intensely experienced impair children's
ability to master developmentally appropriate tasks, and prevent their
⁎ Corresponding author at: Department of Counselor Education, Sam Houston State
University, Box 2119, Huntsville, TX 77341, United States.
E-mail address: hxs018@shsu.edu (H.L. Stulmaker).
ability to self-regulate when the anxiety provoking event is not occurring
(Knell & Dasari, 2006). Children diagnosed with anxiety disorders dis-
play deeper negative emotions and struggle to regulate their emotions,
leading to overall functional impairment (Carthy, Horesch, Apter &
Gross, 2010).
Anxiety symptoms cause impairment when manifesting as exces-
sive avoidance of everyday activities, interactions, and possible onset
of panic attacks. If left untreated, children with anxiety disorders are
at high risk for challenges to development because of the high level of
comorbidity and low levels of remission (Kendall et al., 2010). Children
who have anxiety disorders struggle with academic achievement, sleep,
family cohesion, general happiness, self-esteem, and social and peer re-
lationships (Kendall et al., 2010; Weiner, Elkins, Pincus & Comer, 2015).
These children typically have an increased risk for future psychiatric
disorders, substance abuse, and conduct problems (Levin-Decanini,
Connolly, Simpson, Suarez & Jacob, 2013; Oldehinkel & Ormel, 2014).
1.1. Mental health intervention
When anxiety symptoms, such as worry, inability to regulate emo-
tions, and pervasive negative experiences, lead to functional impair-
ment, mental health intervention is recommended. Silverman, Pina,
and Viswesvaran (2008) reviewed psychosocial treatments for children
and adolescents with anxiety disorders and found that no current treat-
ments meet standards for well-established treatment. Although they
concluded that no treatments are supported by multiple randomized
controlled trials with rigorous guidelines, they listed various forms of
cognitive behavioral therapy (CBT) as probably efficacious and other be-
havioral interventions as possibly efficacious. The articles used to

http://dx.doi.org/10.1016/j.childyouth.2015.08.005
0190-7409/Published by Elsevier Ltd.
128 H.L. Stulmaker, D.C. Ray / Children and Youth Services Review 57 (2015) 127–133
support these titles of probably and possibly efficacious included chil-
dren ranging in age from 6 to 18, with many of the studies including pri-
marily older children or adolescents in their sample. However, results of
children, specifically on the younger end of the spectrum, were not
discussed as a unique or separate population. Historical meta-analyses
and systematic reviews explored the use of CBT as an intervention
for childhood anxiety with positive results (Compton et al., 2004;
In-Albon & Schneider, 2007; Silverman et al., 2008). In-Albon and
Schneider (2007) found an overall effect size of .86 when examining
24 published studies using CBT as the primary treatment modality for
childhood anxiety, with results maintaining over years after treatment.
Moreover, early intervention for anxiety disorders prevents symptoms
from increasing or intensifying (Huberty, 2012).
However, many gaps in the literature still exist, specifically in regard
to intervening directly with young children. CBT studies that include
parent or family components have demonstrated effectiveness for
young children (Cartwright-Hatton et al., 2011; Hirshfeld-Becker et al.,
2010; Jongerden & Bogels, 2015; Lyneham & Rapee, 2006; Wehry,
Beesdo-Baum, Hennelly, Connolly & Strawn, 2015). However, most
CBT studies exploring services delivered directly to the child have
been conducted with children older than school age children and have
strong results. Studies that intervene directly with children younger
than eight years old lack information to calculate effect sizes, and there-
fore interpretation of impact of intervention with young children is
limited (Compton et al., 2004; McKay & Storch, 2009; Silverman et al.,
2008). Although CBT seems to be effective when working with parents
or families of children who are anxious, the results are inconclusive re-
garding direct interventions with young children.
CBT may be limited in effectiveness with young children due to
the advanced cognitive processes involved in the treatment (Grave &
Blissett, 2004). Self-reflection, perspective taking, understanding cau-
sality, and reasoning are skills that are necessary to identify irrational
beliefs, thoughts, and attitudes, which is the foundation of CBT (Grave
& Blissett, 2004). Young children tend to be egocentric, inhibiting the
ability to take another person's perspective. In addition to developmen-
tal considerations, Rey, Marin, and Silverman (2011) stated that CBT is
less likely to be effective when children exhibit many symptoms, have
negative self-statements, have multiple diagnoses, have difficult family
dynamics, are not willing to participate in treatment, and have weaker
relationships with their therapists. Therefore, exploring other ap-
proaches to anxiety with young children appears warranted.
1.2. Person-centered approach to anxiety
Person-centered theorists believe that a person's self-structure is
their total way of being, incorporating thoughts, behaviors, and experi-
ences. Anxiety is conceptualized as a result of incongruence between
experience and self-structure that ultimately forces a change in the
self-structure (Bryant-Jefferies, 2012; Wilkins, 2010). More specifically,
anxiety occurs as the person's self-structure feels threatened. Threat
occurs “when an experience is perceived or anticipated (subceived)
as incongruent with the structure of the self” (Rogers, 1959, p. 204).
Self-structure is developed in childhood and can become rigid through
interactions with environments that lack empathy, acceptance, and
genuineness. When people operate out of a rigid self-structure, personal
experiences may not match their sense of self; hence they will feel
threatened, creating anxiety or incongruence. The level of anxiety is
dependent upon the level of threat experienced to the self-structure
(Rogers, 1959).
Person-centered theory proposes the therapeutic relationship as the
curative factor in counseling. Within the therapeutic relationship are the
environmental conditions necessary for change including empathic un-
derstanding, unconditional positive regard, and genuineness (Rogers,
1957). Child-centered play therapy (CCPT) was created as a develop-
mentally appropriate application of person-centered theory to working
with children (Axline, 1947). For children who exhibit symptoms of
anxiety, CCPT is a proposed intervention based on the theoretical as-
sumption that the relationship between counselor and child is the
change factor that helps reduce anxiety, specifically when the interven-
tion is delivered to children in their developmentally appropriate lan-
guage of play. CCPT provides a direct intervention for children, which
may increase the effectiveness of the intervention due to the internaliz-
ing nature of anxiety. Children participate in CCPT in a room filled with
selected toys that allow expression of diverse emotions and thoughts
while a play therapist facilitates the expression of the child's beliefs,
emotions, and behaviors. CCPT is identified as the most popular theoret-
ical approach to play therapy (Lambert et al., 2005). Additionally, meta-
analyses have reported positive and meaningful effects for children who
participate in CCPT (Bratton, Ray, Rhine & Jones, 2005; Lin & Bratton,
2015; Ray, Armstrong, Balkin & Jayne, 2015).
Theoretically, CCPT may be an effective modality in helping lessen
anxiety as it allows children to be self-directed, based on the belief
that children are the most knowledgeable experts on what they need
for emotional and behavioral growth (Landreth, 2012; Ray, 2011).
With a complete absence of threat to the self-structure through environ-
mental conditions of empathic understanding, unconditional positive
regard, and genuineness provided by the play therapist, children will
be more likely to move toward integrating experiences (i.e., anxiety
stimulant) into a consistent view of self. CCPT helps foster a greater
sense of self with a more integrated self-structure. The diminished in-
congruence resulting from a more integrated sense of self is inherently
a lessened state of anxiety and discomfort. Theoretically, children who
are in a secure relationship with the play therapist, characterized by
congruence, empathy, and unconditional positive regard, will be able
to accept parts of themselves and their experiences that they have de-
nied, including fears and anxiety. This greater self-acceptance will lead
to self-understanding, self-integration, and congruence within the child.
Individual CCPT studies have examined anxiety as an outcome in
relationship to main presenting issues with mixed results. Post (1999)
explored the impact of CCPT with children identified as academically
at-risk and found no change in anxiety levels. Shen (2002) found reduc-
tions in physiological anxiety and worry for Chinese earthquake victims
who participated in CCPT group sessions. In researching the effects of
CCPT with homeless children, Baggerly (2004) found that children
who participated in CCPT group sessions demonstrated a reduction in
total and physiological anxiety. However, the presented studies did
not focus solely on children who experience elevated levels of anxiety.
Although CCPT seems to be promising in the reduction of anxiety symp-
toms associated with other presenting issues, there appears to be a void
in the literature regarding the impact of play therapy with children who
are seeking treatment specifically for anxiety.
2. Purpose
The purpose of the present study was to explore the effects of CCPT
with young children experiencing anxiety. Due to high prevalence rates
of anxiety in the child population and the lack of developmentally
appropriate interventions for young children, there is a need to explore
effective interventions that best meet the needs of young anxious
children. This study sought to determine if participation in CCPT results
in substantial positive outcomes for children demonstrating anxiety
symptoms. The examined research question was: What impact does
CCPT have on young children with reported elevated levels of anxiety
symptoms?
3. Methods
3.1. Participants
Participants were recruited from four elementary schools in the
southwest United States. All four elementary schools were federally
categorized as having a high percentage of children from low-income
 H.L. Stulmaker, D.C. Ray / Children and Youth Services Review 57 (2015) 127–133
families. Criteria for inclusion in this study included the following:
1) Children were between 6 and 8 years old; 2) Children's scores on
any subscale of the Revised Children's Manifest Anxiety Scale (RCMAS)
fell in elevated range with a T-score above 50 or fell in the Clinical or
Borderline range on the Anxious/Depressed subscale on the Teacher
Report Form (TRF) with T-scores above 65; 3) Children understood
and spoke English; 4) Parents were willing to give consent; 5) Teachers
of children were willing to complete instruments. Fifty-five partici-
pants were recruited who met criteria for anxiety threshold. Two were
dropped from the study from the intervention group due to lack of pro-
tocol adherence. Participant demographics and design flow are reported
in Fig. 1.
3.2. Measures
3.2.1. Revised Children's Manifest Anxiety Scale
The Revised Children's Manifest Anxiety Scale, Second Edition
(RCMAS-2; Reynolds & Richmond, 2008) is a 49-item self-report measure
of anxiety for children 6 to 19 years old and was the primary measure of
change for this study. Each question is answered by circling either “yes” or
“no” in response to a statement. The validity scales of the RCMAS-2 are In-
consistent Responding Index and Defensiveness. The anxiety scales are
Total Anxiety, Physiological Anxiety, Worry, and Social Anxiety. The
Total Anxiety score encompasses all questions related to physiological
anxiety, worry, and social anxiety. Physiological Anxiety assesses physio-
logical responses that often accompany anxiety. The Worry scale assesses
children's level of fear, nervousness, or oversensitivity to environmental
pressures. The Social Anxiety scale measures concern about self in relation
Fig. 1. Participant flow diagram.
129
to others. All of the scales were used as qualifying criteria for this research
study, including defensiveness as children who are responding defensive-
ly may be more anxious than they are reporting (Reynolds & Richmond,
2008).
When scoring the RCMAS-2, raw scores are calculated then trans-
lated into T scores. T scores above 60 fall in the significant range, sug-
gesting that the respondent has difficulties with anxiety. T scores that
are 71 or higher are categorized as extremely problematic while T
scores from 61 to 70 are considered moderately problematic. T scores
above 50 indicate elevated levels of anxiety. T scores below 40 indicate
that respondents are unusually anxiety free.
Reliability estimates for the RCMAS-2 are considered strong.
Reynolds and Richmond (2008) reported a Cronbach's alpha of .92 for
Total score of the RCMAS-2, with subscale scores ranging from .75 to
.86. When examining test–retest reliability, they reported Total score at
.75, with ranges from .64 to .73 for the subscale scores. Reynolds and
Richmond reported that validity of the RCMAS-2 has been thoroughly
examined through theoretical considerations in creation and careful
construction of items.
3.2.2. Teacher Report Form
The Teacher Report Form (TRF; Achenbach & Rescorla, 2001) as-
sesses level of functioning in children between 6 and 18 years old as
reported by teachers. For the purpose of this research, the Anxious/
Depressed subscale was used as a screening for inclusion criteria. The
Anxious/Depressed subscale measures children's behaviors that may
be indicative of anxiety or depression if displayed in excess of that ob-
served with other children. For the Anxiety/Depressed subscale, T scores
130 H.L. Stulmaker, D.C. Ray / Children and Youth Services Review 57 (2015) 127–133
below 64 are considered normal. T scores between 65 and 69 are in the
borderline range. T scores 70 and above are considered to fall in the
clinical range.
The TRF reports strong psychometric properties. The TRF has inter-
nal consistency ratings from .54 to .96 on subscales and test retest reli-
ability ranging from .86 to .89. Achenbach and Rescorla (2001) reported
test–retest reliability estimate for the Anxious/Depressed subscale at
r = .68.
3.3. Procedures
Following university institutional review board approval, school
personnel were asked to identify children who seemed anxious and ex-
hibited problems in school such as picking their skin, having frequent
headaches, or crying, items under the Anxious/Depressed subscale
of the TRF. Following informed consent and assent, teacher and child
measures were completed to determine eligibility for the study. The
RCMAS-2 was administered individually and directly to the children
and the TRF was administered to teachers of identified children. An a
priori power analyses was conducted for the planned ANOVA analysis.
Results indicated that in order to have a power of .95 with a medium
effect size for a factorial ANOVA, 36 participants were needed. Addition-
ally, post hoc power analyses were conducted to determine power
of statistically significant results. Recruitment procedures began in
September and post-intervention testing was conducted in December
of the same year.
This factorial design followed randomized controlled trial proce-
dures; children who met criteria were randomly assigned into a treat-
ment or active control group by school (Anderson & McLean, 1974).
We set an allocation ratio of 1 to ensure equal groups. We utilized
block randomization to account for differences in time for when consent
forms were received. Participants were randomized per school to
ensure equal amounts of participants in each group. Children in the
experimental group received two 30 minute individual CCPT sessions
per week for a period of eight weeks. Participants in the active control
group participated in 30 min of weekly small activity groups over
eight weeks. Teachers and parents were not informed of group assign-
ment for participants.
The study was designed to provide 16 CCPT sessions for the experi-
mental group and eight activity sessions for the active control group
over eight weeks. Due to student and counselor absences and inclement
weather, children in CCPT received between 12 and 16 sessions of play
therapy with a mean of 15.32 sessions. To control for attention, children
in the active control group participated in an activity group once a week
over the eight-week period. Due to student and counselor absences and
inclement weather, children in the control group received between six
and eight groups with a mean of 7.32.
At the completion of the eight-week period, the RCMAS-2 was ad-
ministered as a post-test measure. Additionally, children in the active
control group were provided play therapy services at the conclusion of
the eight weeks.
3.3.1. Experimental group procedures
Children assigned to the treatment group participated in 12 to 16
30-minute sessions of individual CCPT over eight weeks. CCPT uses
children's natural language of play to provide a therapeutic environ-
ment that is developmentally appropriate for young children. Treat-
ment was provided according to the protocol as outlined in CCPT
treatment manual (Ray, 2011). Counselors responded with verbal and
nonverbal communication to develop the therapeutic relationship in-
cluding empathic responses, limit setting, returning responsibility, and
facilitating emotional expression. Counselors used these skills to facili-
tate a warm, empathic, and non-judgmental environment.
Playrooms were assembled and materials chosen based on recom-
mendations by Landreth (2012) and Ray (2011). The toys in the
playrooms were selected to match the developmental age of children
and to allow for maximum communication potential. Toys were repre-
sentative of many categories, such as nurturing, mastery, aggression,
imaginary, and creative expression to facilitate a wide range of emotional
expression. Protocol adherence was assessed through fidelity checks of
video-recorded sessions utilizing the Play Therapy Skills Checklist
(PTSC; Ray, 2011). One session per counselor was randomly selected
and reviewed in its entirety by the researcher. Sessions adhered to CCPT
protocol over 90% of the time with an average of 96.64% adherence to pro-
tocol per session.
The counselors were doctoral level counseling students and one
faculty member trained and experienced in play therapy procedures.
All participating counselors had a minimum of a master's degree in
counseling and had conducted play therapy for at least one year prior
to participating in the study. Each counselor completed at least two
play therapy courses and a counseling practicum with an emphasis
on play therapy. Counselors included 10 females who identified as
Caucasian (n = 7), Asian (n = 2), and African American (n = 1). Coun-
selors participated in a two hour training prior to delivering play thera-
py services to explain the protocol for conducting play therapy in
the schools and emphasizing the use of CCPT skills and attitudes. Addi-
tionally, counselors received weekly supervision by advanced CCPT
trained play therapists.
3.3.2. Active control group procedures
Children assigned to the active control group received a coloring
based weekly activity group facilitated by doctoral level counselors.
Students participated in groups of two to four students with one coun-
selor. The purpose of the active control group was to address the inter-
nal validity threat of attention provided to children in the experimental
group. Hence, the active control group participated in a task-oriented
relationship with the counselor. Groups were designed to simulate
typically conducted activities in schools; groups were not intended to
provide intervention for anxiety and were only intended to provide
extra attention to children in the study.
The counselors for the small activity groups were doctoral level
counselors with training and experience in school guidance. Guidance
training consisted of a university course on school counseling, including
guidance delivery. Further, group counselors were required to attend
training conducted by the investigator on coloring activity protocol.
These counselors received supervision throughout the duration of the
study to ensure that activity procedures were being followed.
4. Results
In order to address effectiveness of play therapy on children's anxi-
ety, we conducted a factorial ANOVA using the Total Anxiety score on
the RCMAS-2 as the dependent variable and treatment group as the in-
dependent variable. We decided that if a statistically significant and
practical effect was found on total anxiety, we would conduct post hoc
analyses using the subscales of the RCMAS-S to gather more information
regarding the change in anxiety scores. Statistically significant differ-
ences between the means across time were tested at the .05 alpha
level for Total Anxiety on the RCMAS-2. The alpha level for the post
hoc RCMAS-2 subscale analyses was lowered to .025 to control for
Type 1 error. Mean scores for pre and post RCMAS-2 total and subscale
scores for experimental groups are provided in Table 1. ANOVA results
are provided in Table 2. Practical significance was calculated through
Cohen's d, a group difference effect size used to compare standard devi-
ations between the two groups.
4.1. Total anxiety on the RCMAS-2
The first ANOVA assessed the impact of play therapy and an active
control group on participants' total scores on the RCMAS-2 across pre
and post tests. The assumptions for level of measurement, random sam-
pling, independence of observations, homogeneity of variance, normal
 H.L. Stulmaker, D.C. Ray / Children and Youth Services Review 57 (2015) 127–133 131

Table 1 4.2. RCMAS-2 subscales

Mean scores on dependent variables for each group.

RCMAS-2 Play therapy group (n = 25) Control group (n = 28) 4.2.1. Physiological anxiety
M SD M SD
There was no significant interaction between treatment group and
time, F (1, 51) = 3.276, p = .076, with a moderate effect size (Cohen's
Total subscale⁎
d = .506). There was no significant effect for time, F (1, 51) = .292,
Pre-test 53.40 9.77 54.54 11.79
Post-test 49.36 10.52 56.54 11.29 p = .592, with a small effect (Cohen's d = .146). The main effect com-
paring the two groups was not significant, F (1, 51) = 2.505, p = .120,
Defensiveness
with a moderate effect size (Cohen's d = .445).
Pre-test 53.00 9.52 52.79 9.00
Post-test 53.36 10.09 52.36 8.62
4.2.2. Worry
Physiological
There was a statistically significant interaction between treatment
Pre-test 53.28 9.72 54.57 10.59
Post-test 50.24 9.71 56.21 8.13 group and time, F (1, 51) = 8.318, p = .006, with a large effect size
(Cohen's d = .795) and power of .81, indicating that children who re-
Worry⁎
ceived play therapy decreased in their worry compared to children
Pre-test 52.52 9.40 53.68 11.64
Post-test 47.68 10.24 55.50 12.53 who were in the active control group. There was no significant effect
for time, F (1, 51) = 1.708, p = .197, with a small effect (Cohen's
Social anxiety
d = .340). The main effect comparing the two groups was not signifi-
Pre-test 53.00 10.26 53.61 11.73
Post-test 51.16 10.01 55.93 11.93 cant, F (1, 51) = 2.527, p = .118, with a moderate effect size (Cohen's
d = .445).
⁎ Statistically significant at p b .05.

4.2.3. Social anxiety

distribution, and homogeneity of intercorrelations were all reasonably
met. There was a statistically significant interaction between treatment
group and time, F (1, 51) = 6.569, p = .013, with a large effect size
(Cohen's d = .715), and power of .71, indicating that the children in the
play therapy group had lower anxiety scores than the children in the ac-
tive control group after treatment. There was no significant effect for time,
F (1, 51) = .749, p = .391, with a small effect size (Cohen's d = .230). The
main effect comparing the two groups was not significant, F (1, 51) =
2.265, p = .139, with a moderate effect size (Cohen's d = .424). Based
on visual inspection of the means of the groups over time there is a
trend in which total scores of the play therapy experimental group de-
creased (marking improvement) and scores of the active control group
increased (marking deterioration). Because statistically significant and
meaningful effect sizes were found, we further explored the subscales of
the RCMAS-2.
Table 2
ANOVAs for RMCAS-2 Total, RCMAS-2 Defensiveness, RCMAS-2 Physiological, RCMAS-2
Worry, and RCMAS-2 Social Anxiety as a function of group and time.
There was no significant interaction between treatment group
and time, F (1, 51) = 2.018, p = .162, with a small to medium ef-
fect size (Cohen's d = .398). There was no significant effect for time,
F (1, 51) = .027, p = .870, with a small effect (Cohen's d = .045). The
main effect comparing the two groups was not significant, F (1, 51) =
1.014, p = .319, with a small effect size (Cohen's d = .279).
5. Discussion
The current study sought to determine the effectiveness of CCPT
with young children who are anxious. To date, there has been no play
therapy study found in review specifically designed to identify and
treat children with elevated levels of anxiety. Results of the current
study indicated that play therapy was an effective intervention in reduc-
ing self-reported anxiety symptoms for young children. This finding
provides evidentiary support for the use of CCPT as prevention and
intervention with anxious children, specifically regarding the worry
construct contributing to anxiety.

Source df MS F p Cohen's d
5.1. Effectiveness of CCPT with children who are anxious
RCMAS-2 total anxiety
Group 1 456.118 2.265 .139 .424 Over the course of the present study, children who participated in
Time 1 27.482 .749 .391 .230
Group ∗ Time 1 240.916 6.569 .013⁎ .715
play therapy demonstrated statistically significant improvement over
Error 51 36.676 children who participated in the active control group on Total Anxiety
and the Worry subscale of the self-reported RCMAS-2. Statistical, prac-
RCMAS-2 defensiveness
Group 1 9.783 .068 .795 .063
tical, and clinical significance found for total anxiety speaks to the
Time 1 .031 .001 .974 .009 level of effectiveness of CCPT for young children who were identified
Group ∗ Time 1 4.107 .140 .710 .110 as anxious. Mean differences on all subscales of the RCMAS-2 indicated
Error 51 29.300 that children who participated in play therapy demonstrated a trend of
RCMAS-2 physiological anxiety improvement while children in the active control group demonstrated
Group 1 348.617 2.505 .120 .445 deterioration of symptoms. Although no previous studies concentrated
Time 1 12.891 .292 .592 .146 solely on anxiety and play therapy, these results are consistent with
Group ∗ Time 1 144.815 3.276 .076 .506
group play therapy studies with young children who were homeless
Error 51 36.676
(Baggerly, 2004) and children who experienced trauma (Shen, 2002)
RCMAS-2 worry that showed statistically significant reductions in anxiety after partici-
Group 1 532.362 2.527 .118 .445
pating in child-centered group play therapy.
Time 1 60.172 1.708 .197 .340
Group ∗ Time 1 293.040 8.318 .006⁎ .795 Reynolds and Richmond (2008) described the Worry subscale of
Error 51 35.230 the RCMAS-2 in the following way: “A high WOR score suggests that
the respondent is afraid, nervous, or in some manner oversensitive to
RCMAS-2 social anxiety
Group 1 190.838 1.014 .319 .279 environmental pressures. A high score on this scale may indicate a
Time 1 1.531 .027 .870 .045 child or adolescent who internalizes much of the anxiety he or she ex-
Group ∗ Time 1 114.361 2.018 .162 .398 periences and who may thus get overburdened with trying to relieve
Error 51 56.681 this anxiety” (p. 18). Richmond and Reynold's conceptualization of
⁎ Statistically significant at p b .05. the worry scale as an indicator of oversensitivity to environmental
132 H.L. Stulmaker, D.C. Ray / Children and Youth Services Review 57 (2015) 127–133
pressures supports the person-centered conceptualization of anxiety
as an outcome of incongruence between person and environment.
Hence, CCPT offers an intervention that provides an environment
that supports the child's ability to explore, change, or strengthen the
self in connection to the perceived environment. Theoretically, as chil-
dren are in a warm, understanding, and accepting environment, their
developmental capabilities are released, allowing for greater self-
exploration and expression (Landreth, 2012). Prior to play therapy,
children's behavior may be rigid in an attempt to defend the self-
concept. Rigidity through worry and general anxiety may be one de-
fense to protect the self-concept. Through the process of play therapy,
and specifically in the presence of the attitudes provided by the play
therapist, children are able to experience a reduced level of threat
and begin to assimilate experiences into the self-concept (Landreth,
2012; Ray, 2011). Children begin to try out new behaviors and express
new feelings, including taking risks, within the safety of the therapeu-
tic relationship. Children may experience their own strengths and mis-
takes and accept themselves more fully in the presence of a play
therapist who is providing this acceptance as well for them. The accep-
tance provided from a play therapist may allow a child to develop
greater inner strength and security within the self. Children develop
a greater valuing of themselves as they reduce their fears and negative
sense of self-worth. They begin to live more in the present, reducing
levels of worry and anxiety for the future. Additionally, they begin to
experience more of a feeling of control through experiencing the atti-
tudinal conditions from their play therapists. Through the therapeutic
relationship, children become more integrated in their self-structures
and develop skills to function effectively within their environments,
freeing children of the burden of internalization of anxiety (Landreth,
2012; Ray, 2011).
Consistent with the anxiety literature (Albano, Chorpita & Barlow,
2003; Kendall et al., 2010; Pollock, Rosenbaum, Marrs, Miller &
Biederman, 2006; Seligman & Ollendick, 1998), children in the current
study who did not receive mental health intervention began to show
trends of further decline through reported levels of increased anxiety.
Previous researchers have found that anxiety symptoms that begin in
childhood and are left untreated are more likely to continue and be ex-
acerbated in adulthood, culminating in other psychopathology and co-
morbidity (Albano et al., 2003; Kendall et al., 2010). Due to the early
onset of anxiety and the high risks associated with untreated anxiety,
early-intervention programs are crucial to change the trajectory for
anxious children (Pollock et al., 2006).
Prior to this study, CBT had been deemed the most appropriate in-
tervention for children with anxiety (Compton et al., 2004; McClellan
& Werry, 2003; Silverman et al., 2008), despite the reported flaws
and potential developmental inappropriateness for young children in
addition to the high percentages of children who do not improve as
a result of successfully completing treatment (McKay & Storch, 2009;
Rey et al., 2011; Silverman et al., 2008). The prevalence rates of anxiety
in children and the adverse effects of not intervening early further
increase the importance of utilizing an intervention that meets the
developmental needs of young children and can effectively improve
symptoms of anxiety. CCPT intervention is substantially different
from CBT, the traditional method of treating childhood anxiety. CBT
may be contraindicated for young children with anxiety due to the co-
existence of worry, which tends to restrict children's limited cognitive
abilities and thwart further emotional processing. The cognitive ability
to simultaneously hold negative emotions and examine problematic
thoughts is a higher order ability and may be limited in young children.
Typically, in CBT, children are exposed to an anxiety-provoking stimulus
and taught to cognitively work through their anxious thoughts; how-
ever, this approach may be difficult with young children (Silverman
et al., 1995). CCPT provides an intervention directed toward a child's
developmental level, providing an emotional process outlet through
the use of play and relationship, as opposed to cognitively working
through thoughts.
5.2. Limitations
Although participants were selected for the study based on teacher
and self-reports of elevated anxiety, inclusion criteria did not require
that each child meet diagnostic criteria for an anxiety disorder and
many children did not score in the highest level of anxiety on the assess-
ments. Thus, generalizability of results is limited due to utilizing a
screening measure as opposed to a diagnostic interview. Additionally,
a single-informant self-report measure was utilized to determine effec-
tiveness as opposed to a multi-informant assessment of anxiety. Finally,
participants who were in the play therapy group received twice as
much time with counselors over children in the active control group,
weakening the comparability of the two groups in attention received.
5.3. Implications for practice
CCPT is a developmentally appropriate direct intervention for young
children, and results from the current study appear to support its effec-
tiveness with children who are anxious. The current study brings hope
and promise for the application of person-centered counseling to the
treatment of anxiety, specifically with children. CCPT may also serve
as a preventative measure for further emotional and behavioral decline
in children who are exhibiting symptoms of anxiety. Additionally, CCPT
may help improve or relieve anxiety symptoms, specifically overall
levels of anxiety and worry.
5.4. Implications for research
As this was the first study designed to specifically examine CCPT
with children who are anxious, further studies with this population
are needed to demonstrate that results can be replicated. Furthermore,
effectiveness research with children who are anxious should be ex-
tended into long-term research, examining the lasting effects of CCPT
on anxiety. Determining the effectiveness of CCPT immediately after
treatment is a positive finding; however, demonstrating long-term
maintenance of the effects would strengthen the supporting evidence
for CCPT as an effective intervention.
To further expand on the knowledge of CCPT effectiveness with chil-
dren who are anxious, it would be important to examine mediating and
moderating effects of CCPT. Historically, Baron and Kenny's (1986)
model has been used to investigate mediation; however, Preacher and
Hayes (2008) multiple mediator model may be more appropriate to in-
vestigate the complex nature of the therapeutic process. The research
base and therefore knowledge of educators, supervisors, and practi-
tioners could be enhanced by truly understanding the mechanisms of
change that are operating in CCPT. Additionally, moderators, or inherent
characteristics that affect responsiveness to interventions, could be
investigated to determine if CCPT is more effective with certain types
of children.
6. Conclusion
This study sought to explore the effects of child-centered play ther-
apy (CCPT) on young children with symptoms of anxiety. Theoretically,
CCPT could be an intervention to intervene effectively with young chil-
dren who are anxious. Anxiety is considered one of the most current
and pervasive childhood disorders, with a poor prognosis if left un-
treated. Furthermore, traditional methods of treating anxiety have de-
velopmentally questionable with young children. This study examined
the effect of CCPT on 53 children who were anxious compared to chil-
dren participating in an active control group. Statistically significant dif-
ferences were found in total anxiety and worry, suggesting that children
who received play therapy decreased their overall levels of anxiety and
worry while children who were in the active control group increased
their levels of anxiety and worry. Overall, children seemed to benefit
from CCPT and it may be considered a viable treatment for children
 H.L. Stulmaker, D.C. Ray / Children and Youth Services Review 57 (2015) 127–133
who are anxious. Further research is encouraged to consider mediating
and/or moderating effects of CCPT with children who are anxious.
Acknowledgments
This research was funded by the University of North Texas College of
Education Grant and the Dan E. Homeyer Research Grant.
References
Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA school-age forms and
profiles; Child Behavior Checklist for Ages 6–18, Teacher's Report Form, Youth Self Report:
An integrated system of multi-informant assessment. Burlington, VT: ASEBA.
Albano, A. M., Chorpita, B. F., & Barlow, D. H. (2003). In E. J. Mash, & R. A. Barkley (Eds.),
Child psychopathology (pp. 279–329) (2nd Edition ). New York, NY: Guilford Press.
Anderson, V. L., & McLean, R. A. (1974). Design of experiments: A realistic approach.
New York, NY: Marcel Dekker, Inc.
Axline, V. (1947). Play therapy. New York, NY: Ballantine.
Baggerly, J. (2004). The effects of child-centered group play therapy on self-concept,
depression, and anxiety of children who are homeless. International Journal of Play
Therapy, 13(2), 31–51. http://dx.doi.org/10.1037/h0088889.
Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social
psychological research: Conceptual, strategic, and statistical considerations. Journal of
Personality and Social Psychology, 51(6), 1173–1182.
Bratton, S. C., Ray, D., Rhine, T., & Jones, L. (2005). The efficacy of play therapy with chil-
dren: A meta-analytic review of treatment outcomes. Professional Psychology, 36(4),
376–390. http://dx.doi.org/10.1037/0735-7028.36.4.376.
Bryant-Jefferies, R. (2012). In J. Tolan, & P. Wilkins (Eds.), Client issues in counseling and
psychotherapy (pp. 81–96). Thousand Oaks, CA: Sage.
Carthy, T., Horesch, N., Apter, A., & Gross, J. (2010). Patterns of emotional reactivity and
regulation in children with anxiety disorders. Journal of Psychopathology and
Behavioral Assessment, 32, 23–36. http://dx.doi.org/10.1007/s10862-009-9167-8.
Cartwright-Hatton, S., McNally, D., Field, A. P., Rust, S., Laskey, B., et al. (2011). A
new parenting-based group intervention for young anxious children: Results of a
randomized controlled trial. Journal of the American Academy of Child and Adolescent
Psychiatry, 50, 242–251.
Compton, S., March, J. S., Brent, D., Albano, A. M., Weersing, R., & Curry, J. (2004). Cogni-
tive–behavioral psychotherapy for anxiety and depressive disorders in children and
adolescents: An evidence-based medicine review. Journal of the American Academy
of Child and Adolescent Psychiatry, 43, 930–950.
Costello, E. J., Egger, H. L., & Angold, A. (2004). Developmental epidemiology of anxiety
disorders. In T. H. Ollendick, & J. S. March (Eds.), Phobic and anxiety disorders in children
and adolescents: A clinician's guide to effective psychosocial and pharmacological
interventions (pp. 61–91). New York, NY: Oxford University Press.
Costello, E. J., Egger, H., Copeland, W., Erklani, A., & Angold, A. (2011). The developmental
epidemiology of anxiety disorders: Phenomenology, prevalence, and comorbidity.
In W. Silverman, & A. Fields (Eds.), Anxiety disorders in children and adolescents
(pp. 56–75) (2nd Edition ). New York, NY: Cambridge University Press.
Grave, J., & Blissett, J. (2004). Is cognitive behavior therapy developmentally appropriate
for young children: A critical review of the evidence. Clinical Psychology Review, 24,
399–420. http://dx.doi.org/10.1016/j.cpr.2004.03.002.
Hirshfeld-Becker, D. R., Masek, B., Henin, A., Blakely, L. R., Pollock-Wurman, R. A., et al.
(2010). Cognitive behavioral therapy for 4- to 7-year-old children with anxiety
disorders: A randomized clinical trial. Journal of Consulting and Clinical Psychology,
78, 498–510.
Huberty, T. (2012). Anxiety and depression in children and adolescents: Assessment,
intervention, and prevention. New York, NY: Springer.
In-Albon, T., & Schneider, S. (2007). Psychotherapy of childhood anxiety disorders:
A meta-analysis. Psychotherapy and Psychosomatics, 76, 15–24. http://dx.doi.org/10.
1159/000096361.
Jongerden, L., & Bogels, S. M. (2015). Parenting, family functioning and anxiety-
disordered children: Comparisons to controls, changes after family versus child
CBT. Journal of Child and Family Studies, 24(7), 2046–2059. http://dx.doi.org/10.
1007/s10826-014-005-6.
Kendall, P. C., Chansky, T. E., Kane, M. T., Kim, R. S., Kortlander, E., Ronan, K. R., Sessa, F. M.,
& Siqueland, L. (1992). The nature of anxiety and its disorders in youth. Anxiety
disorders in youth, cognitive–behavioral interventions (pp. 1–11). Needham Heights,
MA: Allyn and Bacon.
Kendall, P. C., Furr, J. M., & Podell, J. L. (2010). Child-focused treatment of anxiety. In J. R.
Weisz, & A. E. Kazdin (Eds.), Evidence-based psychotherapies for children and adoles-
cents (pp. 45–60) (2nd Edition ). New York, NY: The Guilford Press.
Knell, S. M., & Dasari, M. (2006). Cognitive–behavioral play therapy for children with
anxiety and phobias. In H. G. Kaduson (Ed.), Individual play therapy (pp. 22–50).
New York, NY: Guilford Press.
133
Lambert, S., Leblanc, M., Mullen, J., Ray, D., Baggerly, J., White, J., & Kaplan, D. (2005).
Learning more about those who play in session: The national play therapy in counsel-
ing practices project. Journal of Counseling and Development, 85, 42–46.
Landreth, G. (2012). Play therapy: The art of the relationship (3rd Edition ). New York, NY:
Routledge.
Levin-Decanini, T., Connolly, S., Simpson, D., Suarez, L., & Jacob, S. (2013). Comparison of be-
havioral profiles for anxiety-related comorbidities including ADHD and selective mutism
in children. Depression and Anxiety, 30, 857–864. http://dx.doi.org/10.1002/da.22094.
Lin, D., & Bratton, S. (2015). A meta-analytic review of child-centered play therapy ap-
proaches. Journal of Counseling and Development, 93, 45–58. http://dx.doi.org/10.
1002/j.1556-6676.2015.00180.x.
Lyneham, H. J., & Rapee, R. M. (2006). Evaluation of therapist-supported parent-
implemented CBT for anxiety disorders in rural children. Behaviour Research and
Therapy, 44, 1287–1300.
Lyness-Richard, D. (1997). Play therapy for children with fears and phobias. In H.
Kaduson, & D. Cangelosi (Eds.), The playing cure: Individualized play therapy for specific
childhood problems. Child therapy series (pp. 29–59). Northvale, NJ: Jason Aronson, Inc.
McClellan, J., & Werry, J. (2003). Evidence-based treatments in child and adolescent
psychiatry. Journal of the American Academy of Child and Adolescent Psychiatry, 42,
1388–1400.
McKay, D., & Storch, E. A. (2009). Cognitive-behavior therapy for children: Treating complex
and refractory cases. New York, NY: Springer.
Muris, P. (2007). Normal and abnormal fear and anxiety in children and adolescents.
Burlington, MA: Elsevier.
National Institute of Mental Health (2013). Anxiety disorders. Retrieved from http://www.
nimh.nih.gov/health/topics/anxiety-disorders/index.shtml.
Oldehinkel, A. J., & Ormel, J. (2014). A longitudinal perspective on childhood adversities
and onset risk of various psychiatric disorders. European Child and Adolescent Psychi-
atry, 24(6), 641–650. http://dx.doi.org/10.1007/s00787-014-0540-0.
Ollendick, T. H., Grills, A. E., & Alexander, K. L. (2001). Fears, worries, and anxiety in
children and adolescents. In C. A. Essau, & F. Petermann (Eds.), Anxiety disorders in
children and adolescents: Epidemiology, risk factors, and treatment (pp. 1–35). East
Sussex: Brunner-Routledge.
Pollock, R. A., Rosenbaum, J. F., Marrs, A., Miller, B. S., & Biederman, J. (2006). Anxiety
disorders of childhood: Implications for adult psychopathology. Psychiatric Clinics of
North America, 18, 745–766. http://dx.doi.org/10.1016/0010-440X(92)90002-8.
Post, P. (1999). Impact of child-centered play therapy on the self-esteem, locus of control,
and anxiety of at-risk 4th, 5th, and 6th grade students. International Journal of Play
Therapy, 8(2), 1–18. http://dx.doi.org/10.1037/h0089428.
Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing
and comparing indirect effects in multiple mediator models. Behavior Research
Methods, 40(3), 879–891. http://dx.doi.org/10.3758/BRM.40.3.879.
Ray, D. C. (2011). Advanced play therapy: Essential conditions, knowledge, and skills for child
practice. New York, NY: Routledge.
Ray, D., Armstrong, S., Balkin, R., & Jayne, K. (2015). Child centered play therapy in
the schools: Review and meta-analysis. Psychology in the Schools, 52, 107–123.
http://dx.doi.org/10.1002/pits.21798.
Rey, Y., Marin, C. E., & Silverman, W. K. (2011). Failures in cognitive-behavior therapy for
children. Journal of Clinical Psychology: In Session, 67(11), 1140–1150. http://dx.doi.
org/10.1002/jclp.20848.
Reynolds, C. R., & Richmond, B. O. (2008). Revised children's manifest anxiety scale, second
edition: Manual. Los Angeles, CA: Western Psychological Services.
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality
change. Journal of Consulting Psychology, 21(2), 95–103.
Rogers, C. R. (1959). A theory of therapy, personality and interpersonal relationships, as
developed in the client-centered framework. In S. Koch (Ed.), Psychology: A study of
science. Vol. 3. (pp. 184–256). New York, NY: McGraw Hill.
Seligman, L. D., & Ollendick, T. H. (1998). Comorbidity of anxiety and depression in chil-
dren and adolescents: An integrative review. Clinical Child and Family Psychology
Review, 1, 125–144.
Shen, Y. (2002). Short-term group play therapy with Chinese earthquake victims: Effects
on anxiety, depression, and adjustment. International Journal of Play Therapy, 11(1),
43–63. http://dx.doi.org/10.1037/h0088856.
Silverman, W. K., La Greca, A. M., & Wasserstein, S. (1995). What do children worry
about? Worries and their relation to anxiety. Child Development, 66, 671–686.
Silverman, W. K., Pina, A. A., & Viswesvaran, C. (2008). Evidence-based psychosocial
treatments for phobic and anxiety disorders in children and adolescents. Journal of
Clinical Child and Adolescent Psychology, 37, 62–104. http://dx.doi.org/10.1080/
15374410701817907.
Wehry, A. M., Beesdo-Baum, K., Hennelly, M. M., Connolly, S. D., & Strawn, J. R. (2015).
Assessment and treatment of anxiety disorders in children and adolescents. Current
Psychiatry Reports, 17(52), 1–11. http://dx.doi.org/10.1007/s11920-015-0591-z.
Weiner, C. L., Elkins, R. M., Pincus, D., & Comer, J. (2015). Anxiety sensitivity and sleep-
related problems in anxious youth. Journal of Anxiety Disorders, 32, 66–72. http://dx.
doi.org/10.1016/j/janxdis.2015.03.009.
Wilkins, P. (2010). Person-centered therapy: 100 key points. London, England: Routledge.