FEATURED RESEARCH
E
EFFECTIVENESS
OF A PLAY
THERAPY
INTERVENTION
ON CHILDREN’S
EXTERNALIZING
AND OFF-TASK
BEHAVIORS
Children’s externalizing and off-task behaviors
are deemed a major concern for elementary
teachers and interfere with the classroom learning
environment (Abidin & Robinson, 2002;
Shillingford-Butler & Theodore, 2013). Children
with these behaviors are at risk of falling behind
academically and experiencing ongoing behavioral
problems throughout their development. This
single-case research design investigates the
effectiveness of Adlerian play therapy on the
behaviors of two elementary-aged children
who have externalizing and off-task classroom
behaviors. Results for this intervention suggest
Adlerian play therapy may show promise as an
effective intervention for school counselors and
school-based counselors.
stimates indicate that 20% of
children experience distress-
ing emotional problems and less
than one third of those children will
receive mental health services (Mental
Health America; MHA, 2009), largely
due to inaccessibility of services to
children and a lack of counseling
interventions that are responsive to
these needs. Distressing emotional
concerns are often expressed through
externalizing behavioral problems
(Abidin & Robinson, 2002) such
as aggression, impulsivity, property
or personal destruction, off-task
behaviors, and verbal insult, which
are symptoms consistent with atten-
tion deficit hyperactivity disorder
(ADHD). These behaviors interfere
with the rights and dignity of other
people such as peers, teachers, and
family members. Because schools are
responsible for maintaining an emo-
tionally and physically safe environ-
ment and one that is conducive to all
students’ learning, as is outlined in the
California Education Code, Section
48900-48927 (2011), schools have an
interest in attending to these children’s
behavioral needs.
School tends to be especially difficult
for children with externalizing and off-
task behaviors because these behaviors
are in opposition to the expectations of
students’ classroom and school behav-
iors (Shillingford-Butler & Theodore,
2013). Regardless of their intelligence,
children with these behaviors are more
likely to perform poorly academically
because they are less likely to retain
information. They may receive ad-
ditional diagnoses, such as learning
Kristin K. Meany-Walen, Ph.D., is an
assistant professor at the University of
Northern Iowa in Cedar Falls. E-mail:
Kristin.meany-walen@uni.edu Sunny
Teeling, Aubrey Davis, George Artley,
and Andrea Vignovich are graduate
students at the University of Northern
Iowa.
doi: 10.5330/1096-2409-20.1.89
VOLUME 20, NUMBER 1 (2016-2017) | ASCA 89
 disabilities, because externalizing
behaviors can exacerbate such difficul-
ties (DuPaul, Stoner, & O’Reilly, 2008).
Children with these types of behaviors
also tend to have strained relationships
with others because of their tendency to
be loud, disruptive, argumentative, or
stubborn (Kats-Gold, Besser, & Priel,
2007). They may be socially awk-
ward and lack skills in demonstrating
empathy (Cordier, Bundy, Hocking, &
Einfeld, 2009; Wilkes, Cordier, Bundy,
Docking, & Munro, 2011). They are
more likely to build relationships with
peers who have similar behaviors,
reducing their opportunity to learn and
practice socially constructive behaviors.
Because of the significant amount of
time early-elementary-aged children
spend with a single teacher, teachers
can be first responders for recogniz-
ing changes in children’s behaviors or
disruptive behaviors that signal the
need for intervention. Schools and
school personnel are in an extraordi-
nary position to identify children who
suffer from emotional and behavioral
difficulties and provide accessible early
intervention that can prevent the onset
of more severe problems (Abidin &
Robinson, 2002).
SCHOOLS AND SCHOOL PERSONNEL ARE IN AN
EXTRAORDINARY POSITION TO IDENTIFY CHILDREN WHO
SUFFER FROM EMOTIONAL AND BEHAVIORAL DIFFICULTIES
AND PROVIDE ACCESSIBLE EARLY INTERVENTION.
When children in need do not
receive mental health services, their
externalizing behaviors persist over
time (Barkley, 2007; MHA, 2009).
Without intervention, these children
are at an increased risk for a host of
ongoing problems throughout life
(Reef, Diamantopoulou, van Meurs,
Verhulst, & van der Ende, 2011).
Problems can include emotional diag-
noses such as anxiety and depression
(Reef et al., 2011), and social issues
such as teenage pregnancy, substance
abuse, legal problems, and academic
failure (Barkley, 2007; Brinkmeyer
90 ASCA | PROFESSIONAL SCHOOL COUNSELING
& Eyeberg, 2003; MHA, 2009). Due
to the negative trajectory of external-
izing behaviors in children, counseling
interventions such as play therapy and
teacher consultation that respond to
the cognitive, emotional, physical, and
social development of children would
be invaluable services to have available
in elementary schools and could be a
part of students’ individualized educa-
tion plans, in the event that one is in
place or in process.
The American School Counselor
Association (ASCA) suggests school
counselors spend 80% of their time
delivering counseling services (ASCA,
2016). Two responsibilities of school
counselors are responsive services and
indirect student services. Responsive
services are individualized or group
activities designed to meet specific
needs of students and delivered by
the school counselor. Indirect student
services are activities or interventions
delivered by other professionals or
stakeholders such as parents, teach-
ers, or community organizations.
However, school counselors are often
overburdened with responsibilities
outside of their assigned role (e.g.,
clerical work) and have steep ratios
of students to school counselors
that are outside of ASCA’s recom-
mendations. Counselors need to find
innovative ways to provide responsive
services that meet the needs of their
diverse students (Brown, Dahlbeck, &
Sparkman-Barnes, 2006).
PLAY THERAPY
RESEARCH
Play therapy is “the systematic use of
a theoretical model to establish the
interpersonal process wherein trained
play therapists use the therapeutic
powers of play to help clients prevent
or resolve psychosocial difficulties
and achieve optimal growth and
development” (Association for Play
Therapy [APT], 2014, para. 3). Play
therapy is developmentally responsive
to children’s social, emotional, and
cognitive development. A rich history
of research demonstrates the effec-
tiveness of play therapy with children
who present a variety of concerns
(Bratton, Ray, Rhines, & Jones,
2005; Lin & Bratton, 2015; Ray,
Armstrong, Balkin, & Jayne, 2015).
Child-centered play therapy (CCPT)
has the largest body of published
research that informs practitioners
of its effectiveness with children
(e.g., Blanco & Ray, 2011; Bratton,
2010; Schottelkorb & Ray, 2009).
Researchers also found promising re-
sults using cognitive-behavioral play
therapy with children’s school adjust-
ment (Pearson, 2008), symptoms of
attention and hyperactive behaviors
(Kaduson & Finnerty, 1995), and
encopresis (Knell & Moore, 1990).
Bromfield (1989) published a case
study in which he successfully used
psychodynamic play therapy with a
child diagnosed with autism.
One of the more popular ap-
proaches used by play therapists is
Adlerian play therapy (Lambert et
al., 2007). To date, we are aware
of only one randomized controlled
trial using Adlerian play therapy
(Meany-Walen, Bratton, & Kottman,
2014) and four single-case designs
(e.g. Dillman Taylor & Meany-
Walen, 2015; Meany-Walen, Bullis,
Kottman, & Dillman Taylor, 2015;
Meany-Walen, Kottman, Bullis, &
Dillman Taylor, 2015; Meany-Walen
& Teeling, 2016). Researchers found
promising results for Adlerian play
therapy with reducing teaching
stress and students’ externalizing
behaviors, and increasing children’s
on-task behaviors. The current trend
of using evidence-based treatments
creates an ethical necessity to assess
interventions for their efficacy with
different populations.
ADLERIAN PLAY
THERAPY
Adlerian play therapy was developed
by Kottman in the late 1980s (Kott-
man & Meany-Walen, 2016) based
on the theoretical tenets of Adler’s
Individual Psychology. Adlerian theory
holds that people are creative and
unique, strive for belonging, and are
goal directed (Adler, 1927/1954). Ad-
lerian play therapists use play therapy
skills such as tracking, reflecting
feelings, encouraging, setting limits,
restating content, and metacommu-
nicating. They also employ directed
activities such as creating metaphors
and telling stories, playing games,
using puppets, and cleaning the room
together (Kottman, 2009; Kottman &
Meany-Walen, 2016). Moving through
the four phases of Adlerian theory, the
Adlerian play therapist (a) builds an
egalitarian relationship with the child;
(b) investigates the child’s lifestyle; (c)
helps the child gain insight; and (d)
reorients/re-educates the child to new
ways of feeling, thinking, and behav-
ing.
Building an egalitarian relation-
ship. During this phase, the Adlerian
play therapist works with the client to
build a shared partnership in which
the child feels respected and a part of
the process, rather than feeling as a
recipient of interventions (Kottman &
Meany-Walen, 2016). To do this, the
play therapist enlists play ideas from
the child, takes turns making decisions
with the child, plays actively with the
child, asks and answers questions of
the child, and communicates respect to
the child.
Investigating the lifestyle. The goal
of this phase is for the Adlerian play
therapist to gain an understanding of
the child’s lifestyle. The play therapist
is concerned with learning about how
the child makes sense of his or her
world and finds significance—specifi-
cally considering the child’s personal-
ity priorities (Kfir, 2011), goals of
misbehavior (Dreikurs & Soltz, 1964),
life tasks (Mosak & Maniacci, 2008),
Crucial Cs (Lew & Bettner, 1998,
2000), and assets (Kottman, 2009).
Personality priorities are a pattern of
beliefs and behaviors that help the
child to control and predict life. The
four personality priorities are pleasing,
control, superiority, and comfort (Kfir,
2011). Counselors can become aware
of the child’s personality priorities by
observing the child’s behaviors with
other children, adults, and the coun-
selor, as well as by observing how the
child approaches stressful situations.
When counselors know the child’s
personality priority, they can help the
child understand and capitalize on the
COUNSELING INTERVENTIONS SUCH AS PLAY THERAPY
AND TEACHER CONSULTATION … WOULD BE
INVALUABLE SERVICES IN ELEMENTARY SCHOOLS.
assets of the priority and reduce the
liabilities. The four goals of misbehav-
ior are attention, power, revenge, and
proving inadequacy (Dreikurs & Soltz,
1964). The counselor can determine
the child’s goals of misbehavior by
answering the question, “What is
this child trying to gain from this
behavior and how do I feel when the
child engages with me in these ways?”
Children use misbehavior because they
feel discouraged and have decided that
socially constructive behavior is no
longer meeting their needs. Life tasks
are the challenges of life that every
person addresses and includes family,
love/friendships, work/school, self,
and spirituality (Mosak & Maniacci,
2008). To different degrees of suc-
cess, people are able to attend to these
tasks. Crucial Cs are qualities that
people must possess in order to handle
the challenges of life (Lew & Bettner,
1998, 2000). The child must believe
that he or she counts in the world,
is able to connect, has courage to be
imperfect, and is capable of handling
life’s challenges. Assets and talents are
also explored by the play therapist and
used to help encourage the client.
Nondirected play, sandtray, sto-
rytelling, doll play, puppets, dance
or movement, and art, among other
interventions, can be used to help the
Adlerian play therapist learn about
the child (Kottman & Meany-Walen,
2016). As play therapists develop a
conceptualization of each child, they
are able to create a treatment plan that
responds to the individual needs of
each child. Counselors use what they
have learned about the child’s person-
ality priorities, goals of misbehavior,
functioning at life tasks, Crucial Cs,
and assets to create interventions that
help the child to gain insight into his
or her lifestyle (Kottman & Meany-
Walen, 2016).
Gaining insight. When the coun-
seling processes is in this phase, the
Adlerian play therapist uses directed
activities that are intentionally geared
toward helping the child become
aware of lifestyle characteristics (Mo-
sak & Maniacci, 2008). As children
become more aware of their typical
patterns of emotions, thoughts, and
behaviors, they are more informed to
make decisions about what areas to
change and how to go about mak-
ing those changes. The play therapist
uses skills of self-disclosure, reflection
of feeling, and metacommunication
as ways of helping the child develop
insight (Kottman & Meany-Walen,
2016).
Reorienting/Re-educating. During
this phase, the goals of the child and
the play therapist are to replace de-
structive behaviors and thoughts with
constructive behaviors and thoughts,
and to foster the Crucial Cs (Kott-
man & Meany-Walen, 2016). The
therapist uses the assets of the child
to help teach and practice new skills.
Some children need specific instruc-
tion and repeated opportunities to try
new ways of being. Other children
naturally begin to implement new
patterns of emotions, thoughts, and
VOLUME 20, NUMBER 1 (2016-2017) | ASCA 91
 behaviors in and out of the counseling
sessions, such as with peers, teachers,
and families.
Group Adlerian play therapy. Group
play therapy is a pragmatic approach
for Adlerian play therapists because
Adlerian theory holds that people are
socially embedded. Sweeney, Baggerly,
and Ray (2014) suggested that group
play therapy can include as few as
two children. Group sessions might
be particularly ideal in school settings.
Group services can allow for more
students to be served while taking
advantage of limited resources such
as time and the number of profession-
als trained in providing counseling
interventions to children (Hess, Post,
& Flowers, 2005). Another benefit of
group counseling is the opportunity
for children to develop or refine social
skills, build interpersonal relation-
ships, gain insight, and be provided
with immediate feedback from fellow
group members and the group leader
(Meany-Walen, Bullis, et al., 2015;
Sweeney, Baggerly, & Ray, 2014).
RESEARCHERS FOUND PROMISING RESULTS FOR
ADLERIAN PLAY THERAPY WITH REDUCING TEACHING
STRESS AND STUDENTS’ EXTERNALIZING BEHAVIORS,
AND INCREASING CHILDREN’S ON-TASK BEHAVIORS.
A limitation with group-only
intervention is the lack of one-on-one
time that might be advantageous for
children who have significant underly-
ing emotional difficulties. Children
who only participate in group sessions
might miss out on the valuable op-
portunity to individually process their
emotions, thoughts, attitudes, and
experiences that is a typical part of
individual play therapy sessions (Kott-
man & Meany-Walen, 2016).
The purpose of this study was to
evaluate the effectiveness of Adlerian
play therapy as a responsive service for
children identified by classroom teach-
ers as being disruptive in the class-
room. Our research questions were
the following: According to results on
92 ASCA | PROFESSIONAL SCHOOL COUNSELING
the Direct Observation Form: (a) Is
Adlerian play therapy effective in in-
creasing children’s on-task behaviors?
(b) Is Adlerian play therapy effective in
decreasing total problems? (c) Is Adle-
rian play therapy effective in reducing
children’s symptoms of ADHD?
METHOD
We used a single-case research design
(SCRD) for this study. SCRDs al-
low for participants to serve as their
own control (Ray, 2015; Rubin,
2008). During the baseline phase,
several points of assessment are used
to determine a participant’s typical
functioning. After establishing the
baseline, we implemented a targeted
intervention. Assessments continued
on a regular basis throughout the
intervention period. The changes from
baseline to intervention phase suggest
change (if any) is attributed to the
intervention. In this design, we also
included a follow-up phase in which
the treatment was removed. Routine
assessments continued during this time
period to assess sustainability of the
changed behaviors.
Experts in the field of counsel-
ing have encouraged researchers and
practitioners to use SCRD because
of challenges in providing services
to multiple participants in designs
such as randomized controlled trials
(Foster, 2010; Lundervold & Belwood,
2000; Ray, 2015; Ray, Barrio Minton,
Schottelkorb, & Garofano Brown,
2010). We integrated design recom-
mendations from several researchers
to ensure a rigorous study design. We
used a treatment protocol (Lundervold
& Belwood, 2000), multiple base lines
(Lundervold & Belwood, 2000; Mor-
gan & Morgan, 2003; Rubin, 2008),
multiple treatment phases (Lundervold
& Belwood, 2000; Ray, 2015; Rubin,
2008), and at least three data points
within a given phase (Lundervold &
Belwood, 2000; Rubin, 2008). Ob-
servers, blinded to the details of the
treatment and start dates, were used
to complete the observations, which
increased the objectivity of the results
(Ray, 2015; Volpe, DiPerna, Hintze, &
Shapiro, 2009).
The use of a treatment protocol
ensures that treatment is being imple-
mented in the manner in which it was
designed and creates a mechanism
for replicability for future research
and clinical practice (Lundervold &
Belwood, 2000). Multiple baselines
help to strengthen the treatment design
as participants start the interventions
at staggered dates (Lundervold &
Belwood, 2000, Morgan & Morgan,
2003; Rubin, 2008). The staggering of
start times accounts for outside events
that might influence the dependent
variable. In each phase of treatment,
multiple data points are necessary
to establish levels of participants’
functioning. A data point is a point
in time in which an assessment is
facilitated and scores are obtained on
a given dependent variable. We used a
minimum of three data points (weekly)
within a given phase. The data points
provide information about patterns of
the dependent variable over the course
of the study (Lundervold & Belwood,
2000; Rubin, 2008). The plotted data
points allow for visual and statistical
analysis.
Participants
This study consisted of two elementary-
aged students from a public school in
the Midwest region of the United States.
The elementary school (K-6) in which
the study was conducted had approxi-
mately 275 students with the following
demographic makeup: 88% Caucasian,
6% multiracial, 3% Hispanic, 2% Afri-
can American, and less than 1% Native
American; 44% of students qualified for
free and reduced lunch.
Participant 1. Andrew was an eight-
year-old, second grade, Caucasian boy.
He was referred to the study because
of his disruptive classroom behaviors.
His teacher described him as inattentive
and hyperactive. She stated that he was
often impulsive, fidgety, and unable
to follow directions. She believed his
behaviors interfered with his ability to
build relationships with peers as he was
often aggressive and loud.
Andrew lived with his father,
mother, and teenage half-brother. His
brother and father had a history of
aggression in the home. The parents
had considered divorce the previous
year and were attempting to mend the
relationship at the time of this study.
The family atmosphere was described
as chaotic, unpredictable, and lonely
for Andrew. Andrew spent a consider-
able amount of time alone. Andrew
described having a good relationship
with his mother and avoided discus-
sions about his father and half-brother.
Participant 2. Grayson was a seven-
year-old, second grade, Caucasian
boy. He was referred to the study
because of his classroom behaviors
that interfered with his ability to learn
and interfered with the rights and
dignity of his peers. His teacher stated
that he did not sit still and could not
stay focused for any length of time.
She stated that he would roam around
the classroom, could be destructive
and aggressive, and was often im-
pulsive. She suggested that he was
a bright child who was capable of
understanding the academic content
but would soon not be able to keep up
with course work as it became more
challenging and demanding, requiring
more attention and focus.
Grayson lived with his mother,
father, third-grade sister, and two teen-
age half-brothers. There was a great
deal of instability in his home. For
example, his father was in and out of
jail (out of jail during the time of the
study), and his brothers were often in
legal trouble and had been in sub-
stance abuse treatment during the last
year. They were currently not main-
taining sobriety. Yelling and aggres-
sion were often used in the home with
the older children. Child protective
services have been involved with this
THE CHILD MUST BELIEVE THAT HE OR SHE COUNTS
IN THE WORLD, IS ABLE TO CONNECT, HAS COURAGE
TO BE IMPERFECT, AND IS CAPABLE OF HANDLING
LIFE’S CHALLENGES.
family due to allegations of abuse and
truancy on the part of the older broth-
ers. Grayson’s mother reported being
diagnosed with ADHD and was un-
able to maintain steady employment.
She was loving and caring toward
her young children and she lacked
appropriate boundaries and successful
discipline skills.
Instrument/Direct Observation Form
The Direct Observation Form (DOF;
McConaughy & Achenbach, 2009)
is an objective assessment to measure
children’s behaviors in natural settings
such as schools. In this study, we were
specifically focused on classroom be-
haviors. Thus, observations were only
done in the classroom setting during
academic teaching time (e.g., math,
reading, social studies). Observations
were not done during recess, lunch,
or center time. The DOF provides
scores on the Total Problems scale, the
On-task scale, the DSM-oriented At-
tention Deficit/Hyperactivity Problems
scale, and six syndrome subscales.
The Total Problems scale measures
students’ overall demonstration of
behavioral concerns that could include
withdrawn, immature, or oppositional
behaviors; attention problems; or hy-
peractivity. The On-task scale provides
information about a child’s time spent
on-task and following classroom ex-
pectations. The Attention Deficit/Hy-
peractivity Problems scale is made up
of two subscales: Inattention subscale
and Hyperactivity-Impulsivity sub-
scale. McConaughy and Achenbach
reported a mean inter-rater reliability
for classroom observations of .88
for the Total Problems scale, .97 for
On-task, and .79 for Attention Deficit/
Hyperactivity Problems. They also
evaluated and established validity of
the DOF by comparing the assessment
results of referred and nonreferred
children, and by the strong correlation
with other assessment instruments that
measure behavior such as the Child
Behavior Checklist and the Caregiver-
Teacher Report Form (Achenbach &
Rescorla, 2001).
Following the directions of the DOF
manual (McConaughy & Achenbach,
2009), a trained examiner observes
the identified children in 1-minute
intervals over a 10-minute period. Fol-
lowing the observation period, the ex-
aminer completes an 88-item checklist
designed to measure classroom behav-
iors such as fighting, speaking out of
turn, daydreaming, fidgeting, attention
seeking, task avoidance, demanding
attention, and bullying. A minimum
of two observations and a maximum
of six observations within an obser-
vation set are required to obtain a
single score on an individual child. In
this study, each child was assigned an
observer. The observers conducted two
observations within a 5-day period to
get a single data point. One observa-
tion was completed before lunch and
one after lunch in order to get a better
assessment of the children’s typical
behavior. The DOF was completed by
advanced counseling program gradu-
ate students.
Procedure
The principal investigator obtained
IRB approval before recruiting partici-
pants. Once approval was received,
the school counselor informed teachers
of the study and asked them to refer
students who demonstrated externaliz-
ing classroom behaviors. Examples of
externalizing behaviors could include
poor ability to concentrate, disorgani-
zation, distractibility, avoidance of do-
ing work or putting forth much effort,
inability to sit still, demandingness,
VOLUME 20, NUMBER 1 (2016-2017) | ASCA 93
 impulsiveness, or general disruptive-
ness. Consent and assent forms were
sent home with identified children and
were returned to the school counselor
upon receiving guardian consent and
child assent. To protect students’
privacy, the principal investigator was
not made aware of potential partici-
pants until consent and assent were
obtained. At that time, DOF observa-
tions began at staggered intervals. The
staggered start time created a multiple
baseline data pattern to minimize
external validity threats so behavioral
change could be more likely attributed
to the intervention (Lundervold &
Belwood, 2000, Morgan & Morgan,
2003; Ray, 2015; Rubin, 2008). Each
participant received a minimum of
three baseline data points.
AS PLAY THERAPISTS DEVELOP A
CONCEPTUALIZATION OF EACH CHILD, THEY ARE ABLE
TO CREATE A TREATMENT PLAN THAT RESPONDS TO
THE INDIVIDUAL NEEDS OF EACH CHILD.
Intervention
The two participants received biweek-
ly Adlerian play therapy sessions each
week for 6 weeks. They received an in-
dividual session at the beginning of the
week and a group session (both par-
ticipants together) near the end of the
week. Per Sweeney et al. (2014), two
participants is sufficient for group play
therapy. Participants received more
individual sessions than group sessions
because of the staggered start times.
Individual sessions were 30-minute
sessions following the Adlerian Play
Therapy Treatment Manual (Kott-
man, 2009). The individual treatment
provider was a biracial woman and an
advanced counseling program gradu-
ate student with specialized training
in Adlerian play therapy. She received
weekly supervision by the first author
who is well versed in Adlerian play
therapy. Her sessions were recorded
and compared against the Adlerian
Play Therapy Session Skills Checklist
to assess for treatment fidelity.
94 ASCA | PROFESSIONAL SCHOOL COUNSELING
The group sessions lasted 45 min-
utes and incorporated principles of
Adlerian play therapy with group play
therapy. To date, a treatment protocol
for group Adlerian play therapy does
not exist. The treatment provider
was a European American woman, a
licensed mental health counselor, and
Registered Play Therapist-Supervisor.
She had extensive training and experi-
ence in school-based interventions and
Adlerian play therapy. Weekly consul-
tation was conducted to ensure client
care.
All sessions were conducted at
an elementary school. Because the
school did not have a designated
playroom, the counselors used a
spare room for a playroom and used
a mobile play kit. Throughout the
sessions, toys were supplied from
each of Kottman and Meany-Walen’s
(2016) categories: aggressive, expres-
sive, family/nurturing, pretend/fan-
tasy, and scary toys.
Two treatment providers were
used to mimic a treatment design
that aligns with the ASCA National
Model (ASCA, 2016) in which re-
sponsive services were delivered by a
school counselor and indirect student
services by a school-based mental
health provider. The two treatment
providers consulted weekly to discuss
themes and treatment plans. Likewise,
the treatment providers consulted
with teachers multiple times over the
course of the study to explore family
and classroom functioning, improve-
ments or regressions in behaviors,
and other concerns as they arose. The
treatment providers also shared with
teachers their observations, beliefs
about the child’s lifestyle, and strate-
gies that were successful in therapy
sessions.
Data Analysis
Consistent with SCRD, visual and
statistical analysis was conducted to
assess for change and treatment effect.
Observational data using the DOF
were gathered several times through-
out the three phases of the study:
baseline, intervention, and postinter-
vention. Two observers were blinded
to the intervention start date and
treatment details. Each participant was
assigned to an observer, who observed
that participant over the duration of
the study. The baseline phase lasted for
a minimum of three weeks, identified
by Lundervold and Belwood (2000) as
adequate for a baseline. In some cases,
the baseline did not reach a stable level
due to teachers desiring the interven-
tion to start.
To determine that change could be
attributed to Adlerian play therapy
treatment intervention, visual analysis
was used (Lundervold & Belwood,
2000; Rubin, 2008). Visual analysis
and the calculation of the percentage
of data exceeding the median (PEM)
are some of the most utilized and ac-
cepted methods of analyzing SCRD
data (Lenz, 2013; Morgan & Morgan,
2003; Rubin, 2008). Using Kennedy’s
(2005) recommendations, we graphed
all of the data points to compare the
treatment results over time. We calcu-
lated and analyzed level (mean) and
variability (degree of difference be-
tween the trend and each data point)
within each of the specific phases.
The PEM statistic is a pragmatic
approach for practitioners, school
counselors, and researchers, and is
analyzed by determining the median of
the baseline phase and then calculating
the percentage of data in the treatment
phase that overlaps with the median
(Lenz, 2013; Morgan & Morgan,
2003). For example, to calculate the
PEM for on-task scores, a line was
drawn from the median baseline data
point through the treatment phase and
follow-up phase data points. The num-
ber of intervention data points that
exceed the median baseline data point
was divided by the total number of
data points in the intervention phase.
The result was the effect size statistic.
 FIGURE 1 ANDREW’S ON-TASK SCORES
An increase in scores indicates improvement.

A PEM equal or greater than 90% 9

indicates a “very effective” treatment, 8
70-90% indicates an “effective” treat- 7

On-task Behaviors
ment, 50-70% indicates “question- 6
able” effectiveness, and less than 50%
5
is considered “ineffective” (Scruggs &
4
Mastropieri, 1998).
3

RESULTS
2
1
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14
This section describes qualitative and
quantitative results of the participants. Weeks
Pseudonyms are used to protect par- baseline intervention follow-up
ticipants’ privacy.

Participant 1: Andrew
Over the 6-week intervention period,
Andrew participated in a total of 11
FIGURE 2 ANDREW’S TOTAL PROBLEM SCORES
Adlerian play therapy sessions (4 A decrease in scores indicates improvement.
group sessions and 7 individual ses-
70
sions); the teacher engaged in three
consultations with the group therapist 60
Total Problem Behaviors

and the school counselor met once

50
with the individual therapist.
Andrew demonstrated personality 40
priorities of control and pleasing. In
30
individual sessions he was reserved
and obediently followed directions. 20
He believed it was important to please 10
the play therapist to avoid being in
trouble or disliked. In group sessions, 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14
he attempted to control himself and Weeks
others. He preferred to be in charge baseline intervention follow-up
and insisted that others knew he was
in charge. His goal of misbehavior
was most often attention. He sought
attention in unproductive ways such
as being loud, boisterous, and bossy, FIGURE 3 ANDREW’S ATTENTION-DEFICIT HYPERACTIVITY SCORES
or by being well behaved and overtly
A decrease in scores indicates improvement.
seeking attention for his good behav-
ior. In group sessions, he frequently 40
interrupted others in order to get the 35
attention of the play therapist. His
30
ADHD Symptoms

most significant Crucial C deficits were

count and courage. He did not believe 25
he counted or was worthy of relation- 20
ship on his own merit. He believed he
15
needed to act or behave a particular
way in order to get approval and feel 10
as though he counted. He also worked 5
hard to be perfect and did not show 0
courage to make mistakes. His attempt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
to rigidly control himself often back- Weeks
fired as he was not able to keep the baseline intervention follow-up
standards he held for himself; he would

VOLUME 20, NUMBER 1 (2016-2017) | ASCA 95

 become discouraged and compensate
by acting out or finding negative ways
to gain attention and find belonging.
As such, he struggled with the life tasks
of friendships, family, and school. An-
drew had several assets. He was kind
and generous. He was thoughtful and
wanted to be in relationships with oth-
ers. He was able to show respect for his
play therapists and his group members
by sharing, being interested in others,
and giving compliments.
THE TREATMENT PROVIDERS CONSULTED WITH
TEACHERS MULTIPLE TIMES OVER THE COURSE OF
THE STUDY TO EXPLORE FAMILY AND CLASSROOM
FUNCTIONING, IMPROVEMENTS OR REGRESSIONS IN
BEHAVIORS, AND OTHER CONCERNS.
Three treatment goals were devel-
oped for Andrew: (a) reduce his desire
and need for perfection, (b) increase
his Crucial C of connect, and (c)
increase constructive ways of getting
attention. Whereas not each of these
goals directly addressed externalizing
behaviors, the goals were chosen be-
cause of his behaviors associated with
those areas. For example, we believed
his disruptive classroom behavior was
related in part to his desire to perform
perfectly. Increasing his ability to be
flexible with himself and his feeling
of connection with classmates and
the teacher could reduce his problem
behaviors. Some playroom strategies
included allowing the child to take
the lead and make decisions in which
there was no right or wrong way of
doing something, having the play ther-
apist demonstrate making mistakes,
and permitting the group to play silly
games that honored imperfections.
Other strategies included playing
games and activities that required
the child to take turns; he received
encouraging feedback for his attempts
regardless of the outcome, and the
play therapist showed genuine interest
in ideas or things that were important
to Andrew. Sharing power in the play-
96 ASCA | PROFESSIONAL SCHOOL COUNSELING
room by taking turns was used to help
him experience not being in control
and still being safe. Teacher consulta-
tion suggested that he improved his
social skills and reduced his external-
izing behaviors in the classroom. She
suggested that while he made progress,
she was still concerned with his ability
to maintain the improvement and be-
lieved he was capable of making more
progress on his classroom and social
behaviors. The teacher and school
counselor were also aware of persis-
tent family dynamics that influenced
his behaviors and self-concept to a
great extent. They agreed that family
intervention or longer treatment might
be advantageous for Andrew.
Figures 1, 2, and 3 represent the
results of the behavioral observations
for Andrew. Visual analysis of the
On-task scores on the DOF (Figure 1)
revealed maintenance or a slight increase
of scores over the study period, which
indicates improvement. During the inter-
vention and follow-up phase, there was
relatively little variance and no change.
The level, or mean, for each phase is as
follows: baseline phase, 6.5; intervention
phase, 7.1; follow-up phase, 6.5. The
levels for On-task scores demonstrated
an improvement in the desired behaviors
from baseline to intervention phase and
a return to baseline functioning during
follow up. The PEM statistic was calcu-
lated across each phase to estimate the
effectiveness of each treatment phase.
Andrew’s median baseline On-task score
was 6.5. The Adlerian play therapy
intervention phase PEM statistic was
100%, indicating a very effective treat-
ment, and the follow-up phase revealed
66.6%, which indicated a questionably
effective treatment effect.
The visual analysis of the DOF Total
Problems scores (Figure 2) showed
significant variability over the course
of the study duration. However, the
clear downward trend in Total Prob-
lems indicated improvement. Follow-
ing the start of the intervention, there
was an 18 point reduction in scores.
The level for each phase is as follows:
53.3 during the baseline, 46.6 dur-
ing the intervention phase, and 51.2
during the follow-up phase. The levels
for the Total Problem scores suggested
improvement in the behaviors from
baseline to intervention period and less
of an improvement from baseline to
follow-up. Andrew’s median baseline
data point was used to determine the
PEM statistic for the intervention and
follow up phases. The median base-
line point was 45. The intervention
phase PEM statistic of 42% revealed
no treatment effect and the follow up
phase PEM statistic was 33%, which
also demonstrated no treatment effect.
The visual analysis of the DOF
ADHD scores (Figure 3) showed
variability over the three phases. No
clear visual trend emerged. The first
observation following the intervention
phase showed a 14 point reduction in
ADHD behaviors, indicating improve-
ment. The level for each phase is as
follows: 26.4 during the baseline, 22
during the intervention phase, and
25.5 during the follow-up phase. The
levels for the ADHD scores suggested
improvement in the behaviors from
baseline to intervention period and less
of an improvement from baseline to
follow-up. Andrew’s median baseline
data point was used to determine the
PEM statistic for the intervention and
follow up phases. The median baseline
point was 33. The intervention phase
PEM statistic was 100%, indicating
very effective treatment effect. The
follow-up phase PEM statistic was
66.7% or a questionably effective
treatment effect for Adlerian play
therapy at reducing ADHD symptoms.
Participant 2: Grayson
Over the 6-week intervention period,
Grayson participated in a total of
12 Adlerian play therapy sessions
 FIGURE 4 GRAYSON’S ON-TASK SCORES
An increase in scores indicates improvement.

(4 group sessions and 8 individual 10

sessions); and the group therapist 9
engaged in four teacher consultations 8

On-task Behaviors
and one parent consultation. 7
Grayson demonstrated a personal- 6
ity priority of superiority. He believed 5
he needed to be the best and when he 4
determined that he could not be the 3
best, he became discouraged and gave 2
up. It was at this point that he engaged 1
in disruptive behaviors, which appeared 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14
to meet his goal of misbehavior, atten-
Weeks
tion. He desired attention and needed
baseline intervention follow-up
attention from adults. His initial way
of functioning was to gain negative at-
tention. Consistent with his desire to be
better than others, his Crucial C in need
of adjusting was courage. He resisted
taking risks and engaging in activities
FIGURE 5 GRAYSON’S TOTAL PROBLEM SCORES
in which he could not predict success. A decrease in scores indicates improvement.
The life tasks of school, friendship,
30
and family were in need of strengthen-
ing. Although he showed promising
Total Problem Behaviors

25
academic skills, his classroom behaviors
that interfered with his ability to func- 20
tion well in school would soon limit his
15
academic achievement. Grayson had
several assets. He was kind and wanted 10
relationships with others. He was able
to use appropriate social skills in one- 5
on-one interactions. He was smart and
desired to do well in school. He felt 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14
loved, supported, and cared for by his Weeks
sister, mother, and teacher. baseline intervention follow-up
Three treatment goals were devel-
oped for Grayson: (a) become more
aware of his behaviors and their
impact on other people, (b) increase
his social skills and his ability to use FIGURE 6 GRAYSON’S ADHD SCORES
them, and (c) demonstrate construc-
A decrease in scores indicates improvement.
tive strategies to gain attention from
adults. Play therapy techniques and 16
skills used to help foster these goals 14
were providing encouragement and
12
ADHD Symptoms

reinforcement when he behaved in

socially proactive ways. For example, 10
when he shared or took turns, the play 8
therapist metacommunicated about his
6
behaviors and the potential thoughts
or feelings from the group members. 4
The play therapist also disclosed 2
how she felt when he shared or took 0
turns. Creative projects were used 1 2 3 4 5 6 7 8 9 10 11 12 13 14
that allowed him to practice focusing, Weeks
following through, and taking risks baseline intervention follow-up
at completing a task he may not have

VOLUME 20, NUMBER 1 (2016-2017) | ASCA 97

 believed he could do well. Throughout
individual and group sessions, Gray-
son was given attention when he did
things in a prosocial manner such as
following directions, walking quietly
in the hall, putting forth effort, and
being patient. The intention of this
strategy was to contradict Grayson’s
beliefs and actions that reinforced to
him that he only received attention for
disruptive behaviors.
Grayson showed improvement in
the group and individual sessions. He
was able to stay focused for longer
periods of time and used constructive
behavior more frequently. In group
sessions he was beginning to build
mutual and collaborative relationships
with peers. Teacher consultation sug-
gested slight improvement in his be-
havior. She remained concerned about
his symptoms of ADHD and suggested
to his mother that he be evaluated for
medication. He was not on medication
for ADHD during the study.
CREATIVE PROJECTS WERE USED THAT ALLOWED THE
CHILD TO PRACTICE FOCUSING, FOLLOWING THROUGH,
AND TAKING RISKS AT COMPLETING A TASK HE MAY
NOT HAVE BELIEVED HE COULD DO WELL.
Figures 4, 5, and 6 represent the
results of the behavioral observa-
tions for Grayson. Visual analysis
of the On-task scores on the DOF
(Figure 4) revealed a steady increase
in on-task behaviors and only slight
variability. The levels for each phase
are as follows: baseline phase, 5.1;
intervention phase, 7.5; follow-up
phase, 8.2. The levels for On-task
scores demonstrated an improvement
in the desired behaviors across all
three phases of treatment. The PEM
statistic was calculated across each
phase to estimate the treatment effect
of each treatment phase. Grayson’s
median baseline On-task score was
6. The Adlerian play therapy inter-
vention phase and follow-up phase
PEM statistic was 100%, indicating
a very effective treatment effect for
98 ASCA | PROFESSIONAL SCHOOL COUNSELING
Adlerian play therapy on his on-task
behaviors.
The visual analysis of the DOF Total
Problems scores (Figure 5) showed a
moderate level of variability over the
course of the study duration, with a
clear downward trend in Total Prob-
lems upon the start of the intervention,
which indicates improvement. Follow-
ing the start of the intervention, there
was a 19 point reduction in scores. The
level for each phase is as follows: 19.2
during the baseline, 16.2 during the
intervention phase, and 7.8 during the
follow-up phase. The levels for the Total
Problem scores suggested improvement
in the behaviors from baseline through
intervention and follow-up phases.
Grayson’s median baseline data point
was used to determine the PEM statistic
for the intervention and follow up
phases. The median baseline point was
18. The PEM statistic for the interven-
tion and follow-up phases was 100%,
which indicates a very effective treat-
ment effect for Adlerian play therapy on
Grayson’s problem behaviors.
The visual analysis of the DOF
ADHD scores (Figure 6) showed vari-
ability over the three phases. Midway
through the intervention phase, a clear
downward trend emerged. The first
observation following the intervention
phase, showed a 7 point reduction in
ADHD behaviors, indicating improve-
ment. The level for each phase is as
follows: 10.6 during the baseline, 8.4
during the intervention phase, and
5.3 during the follow-up phase. The
levels for the ADHD scores suggested
improvement across the study period.
Grayson’s median baseline data point
was used to determine the PEM statis-
tic for the intervention and follow up
phases. The median baseline point was
14. The intervention and follow-up
phases PEM statistic was 100%, indi-
cating very effective treatment effect.
DISCUSSION
Review of the two participants sug-
gests that Adlerian play therapy was
clearly effective in reducing Grayson’s
targeted behaviors as evidenced by
very effective treatment results for the
intervention and follow-up phases on
the DOF On-task, Total Problems, and
ADHD scales. This is particularly im-
portant in counseling-related outcomes
because it is advantageous for changes
to be maintained or improved after the
intervention is removed. Andrew also
showed very effective treatment results
for Adlerian play therapy during the
intervention phase on the On-task and
ADHD scales. The intervention and
follow-up phases on Total problems
revealed no effect and the follow-up
phases on the On-task and ADHD
scales revealed questionably effective
treatment effect.
The ASCA National Model (2012)
offers several recommendations
regarding responsive services that we
followed in this intervention. For ex-
ample, ASCA directs school counselors
to use goal-focused and brief interven-
tions. In our intervention, we used a
theoretically framed intervention that
targeted goals specific to each child.
Counseling was brief in nature and the
ultimate goal was to increase positive
classroom behavior, thereby support-
ing the mission of the school. The
ASCA National Model (2012) also
recommends collaboration with stake-
holders; in this intervention, we col-
laborated with parents, teachers, and
mental health providers to support
student achievement. Last, we advo-
cated for the students by empowering
them through creating an intervention
directly related to their educational
barriers. Using Adlerian play therapy
is one way to support various aspects
of the ASCA National Model (2012)
when providing responsive services.
Consistent with Adlerian play
therapy practice, people are viewed
as unique and in need of individual-
ized treatment plans. Grayson showed
significant improvement during the
6-week intervention. A longer treat-
ment intervention might have shown
stronger results for Andrew. Further-
more, the Total Problems and ADHD
scales had variability throughout the
phases of treatment with Andrew. We
cannot claim certainty, but the vari-
ance might be related to his unstable
family atmosphere and family therapy
might be more effective at reducing his
problematic behaviors. More frequent
sessions might help to stabilize his be-
haviors, or a longer baseline and inter-
vention period could help to provide
more clear results of the intervention.
Different from other Adlerian play
therapy research (e.g., Meany-Walen et
al., 2014; Meany-Walen, Bullis, et al.,
2015; Meany-Walen, Kottman, et al.,
2015), this study design intentionally
included teacher consultation through-
out the intervention period. The design
and analysis did not allow for data to
be separated in a way that provided
information about the degree of ef-
fectiveness of the teacher consultation.
However, based on anecdotal evidence
through discussion with teachers, the
collaboration with the play therapists
created a sense of teamwork and sup-
port, which was appreciated by the
teachers. Teachers felt less stress and
isolation in handling the behaviors of
these children when they felt support-
ed by the play therapists. This might
be similar to the collaborative nature
encouraged between school counsel-
ors and teachers (ASCA, 2016). The
reduced stress and deeper understand-
ing of the children’s lifestyles could
influence how teachers interact with
the children in the classroom, which
has the potential to impact children’s
classroom behaviors.
SCHOOL COUNSELING
IMPLICATIONS
School counselors are often over-
loaded with responsibilities and have
limited time to deliver the ASCA Na-
tional Model expectation of respon-
ADLERIAN PLAY THERAPY WAS CLEARLY EFFECTIVE IN
REDUCING TARGETED BEHAVIORS AS EVIDENCED BY
TREATMENT RESULTS FOR THE INTERVENTION AND
FOLLOW-UP PHASES.
sive services (ASCA, 2016). Teaming
up with school-based mental health
providers can alleviate the workload
and aligns with ASCA’s (2012) recom-
mendation of coordinating indirect
student services. In this study, children
received twice-weekly Adlerian play
therapy sessions. One session was an
individual play therapy session and
the second was a group session. Two
treatment providers collaborated in
providing services: one represented a
school-based mental health provider
(individual sessions) and one repre-
sented the school counselor (group
sessions). This might replicate an in-
tervention plan that is more attainable
at schools where there is an elevated
ratio of students to school counselors.
School counselors can partner with
community school-based counselors.
The increase of school-based counsel-
ors and recognition of the advantages
of providing mental health services
in school settings creates support for
collaboration (Brown et al., 2006).
Various benefits exist when school
counselors and school-based mental
health providers work together: (a)
school counselors receive additional
support, (b) school counselors can
tend to other ASCA standards, (c) the
two professionals can consult and col-
laborate on students’ progress, and (d)
more students can receive services. Of
additional benefit, school counselors
have regular contact with teachers and
can create consultation periods that fit
with the teachers’ schedules. Likewise,
because school counselors are attuned
to the school climate and rules, the
school counselor can help to create
classroom interventions that fit with
the school policies and expectations.
In response to the original research
questions, the authors concluded that
Adlerian play therapy showed mixed
results in reducing children’s problem
behaviors and improving students’ on-
task behavior. Results from this study
and teacher report suggest improve-
ment in students’ behaviors or the
start of positive change in the students’
behaviors.
LIMITATIONS AND
RECOMMENDATIONS
FOR FUTURE
RESEARCH
The behavioral symptoms assessed in
this study were measured by objective
observers, which is a strength of this
study. However, no quantitative data
was collected by stakeholders such as
teachers or parents. Future studies that
include parent observation or teacher
report, such as the Child Behavior
Checklist or Teacher Report Form
(Achenbach & Rescorla, 2001), could
provide useful information about the
changes noticed by these adults.
A standard limitation in interven-
tion research is that stakeholders wish
for the intervention, and potential
improvement, to be implemented in a
timely manner. In this case, teachers
were eager to start the intervention
period because of the participants’
behaviors that caused disruptions in
their classes. Ethically, we wanted
to be able to help the teachers and
students as soon as possible. Thus, we
implemented the intervention before a
stable baseline was established. With-
out a stable baseline, the results of
the intervention should be interpreted
with caution. We are unable to attest
that the statistical and visual results
are typical or accurate. It is also likely
VOLUME 20, NUMBER 1 (2016-2017) | ASCA 99
 that the inconsistent baseline data
points contributed to treatment effects
that resulted in “very effective” or “no
treatment effect” results. Future stud-
ies that allow for baseline periods with
stability before starting the interven-
tion are warranted.
Adlerian play therapy is developing
a strong body of literature to sup-
port its effectiveness. However, the
majority of the designs published are
SCRD. These designs offer significant
information such as changes across the
study period; however, they are not
deemed stringent enough to contribute
to an intervention being considered
evidence based. More Adlerian play
therapy studies that use a rigorous
randomized controlled trial design will
help inform Adlerian play therapists
and potentially move Adlerian play
therapy toward an evidence based
treatment.
Students with externalizing behav-
iors, off-task behaviors, and other
behaviors associated with ADHD
often find themselves in the school
counselor’s office for disciplinary
action or responsive services. Early
intervention for these children is war-
ranted in order to prevent more seri-
ous problems over the course of these
children’s development. Based on the
results of this study, we cautiously sug-
gest that Adlerian play therapy may
have promise for children who have
classroom behaviors that are disrup-
tive to themselves, their peers, and
their teachers. n
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