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Evidence Based NeuroCogni2ve Play
Lynne Kenney, PsyD www.lynnekenney.com
EBT’s CBT & Play
! One challenge clinicians who use play as a modality encounter is how to write treatment goals and progress notes that incorporate evidence-‐based methods into their work.
! What follows are evidence-‐based methods and modali2es one may reference in treatment plans and progress notes. The key is to focus on the rela2onships between the skill deficits and what cogni2ve-‐behavioral or evidence-‐based tools you use to meet treatment goals.
CBT Assump2ons
! Thoughts determine feelings and behaviors ! Psychological disorders involve maladap2ve thinking
! CBT helps a pa2ent overcome difficul2es by ! iden2fying and changing dysfunc2onal thinking ! Changes in thinking are presumed to lead to ! Changes in Feelings ! Power to choose new behaviors
Communica2on Skills (Mahaffy & Kenney, 2012)
! Language – Recep2ve – Expressive/Labeling – Intraverbal (asking and answering “Wh” ques2ons, commen2ng, etc.) – Interverbal (knowing what you are saying outloud) – Vocabulary (generaliza2on and discrimina2on of new words) – Social Language (pragma2cs)
• Gree2ng • Informing • Reques2ng • Talking turns in conversa2on • Staying on topic • Informing the uninformed listener • Asking for help when not understanding • Rephrasing when misunderstood • Introducing topics • Telling a story or experience in a clear sequence
Communica2on Skills II
– Vocal Imita2on – Tone (high, medium, low, angry, sad, defiant) – Volume of voice/voice inflec2on – Syntax and Grammar – Requests (making and responding to) – Interpersonal (sta2ng needs and requests) – Managing verbal impulsivity – Responding calmly and appropriately – Managing talking space between speaker and listener – Using appropriate facial expressions – Refraining from sarcasm or belialing
Social Competency Skills
– Eye contact – Gree2ngs/Goodbyes (addressing friends by name)
– Ask “on topic” ques2ons/comments (age appropriate) – Manners (please/thank you/ “May I___?”)
– Reading social cues – Reading non-‐verbals – Understanding social norms – Repea2ng social rules of engagement
Group Engagement Skills
Sidng s2ll in circle 2me Staying on task in circle 2me Responding with raised hand
Transi2ons between tasks Following rules/direc2ons Ini2a2ng tasks Remaining on task un2l comple2on
Group responses/songs
Par2cipa2on in group ac2vi2es
Following mul2-‐step direc2ons
Copying from model Cleaning up
Family Interac2on Skills
Listening with eye contact, nodding, repea2ng back
Responding with ac2on
Responding with words
Monitoring verbal tone, rate of speech and volume
Responding to single task demands
Responding to series of task demands
Responding immediately when asked to do so
Using task lists
Self-‐ini2a2on in tasks
Nego2a2ng politely Using manners
Responding to 2me limits
Caring for another’s needs with words or ac2ons
Respec2ng space/privacy
Accep2ng “no”
Choosing an alterna2ve when the answer is no
Managing verbal intrusions
Wai2ng one’s turn
Managing 2me
Types of Play
! Child-‐centered ! Communica2on related ! Cogni2ve-‐behavioral ! Direc2ve ! Expressive arts ! Imaginary play ! Non-‐direc2ve ! Medita2on ! Mindfulness ! Movement
! Parallel Play ! Perpendicular Play ! Reciprocal Play ! Re-‐construc2ve Play ! Sand Tray ! Social skill related ! Story-‐telling ! Trauma-‐based ! Visualizing and verbalizing
Tools of Play
! Dolls & Dollhouses ! Drawing and Art ! Kimochis ! Medita2on and Mindfulness ! Music and Dance ! Playgrounds ! Puppets ! Sand Tray ! Sport Courts ! Therapy animals ! Water/bean tables
Modali2es
! Child-‐centered Play ! Solu2on-‐focused Play ! Behavior Modifica2on ! Cogni2ve Behavioral Therapy/EBT
! Developmental Play ! Psycho-‐educa2on ! Skill Development
! Auditory, learning, social, communica2on, academic
Techniques
! Alliance Building ! Animals ! Art ! Child as teacher ! Games ! Make-‐believe ! Modeling ! Music (inTime, drums, body as orchestra) ! Pretend ! Sand Tray ! Scaffolding ! Social Stories ! Worksheets
Cogni2ve Restructuring
! Iden2fy nega2ve thoughts that predict bad things will happen-‐ thinking traps
! Evaluate nega2ve thoughts to determine if they add-‐up
! Use realis2c posi2ve self-‐talk to argue with nega2ve thoughts and reshape thoughts
! Replace thinking traps with coping thoughts ! Challenge Nega2ve Thoughts ! Challenge Nega2ve Expecta2ons ! Posi2ve Self-‐Talk
Ac2ve Listening Skills
! Aaending (alert, orient, interact) ! Acknowledging ! Non-‐verbal communica2on ! Resta2ng ! Reflec2ng ! Summarizing ! Ques2oning ! Providing feedback ! Suppor2ng speaker ! Checking percep2ons ! Silence
Anxiety Interven2ons
! Cognitive awareness and restructuring identify and challenge negative thoughts and expectations; positive self-talk
! Exposure methods (imagination, in vivo) ! Psycho-education ! Somatic management skills training
self-monitoring, skill identification and execution
Distress Management
! Learn to iden2fy precursor thoughts ! Learn to iden2fy, name and label feelings ! Establish level of distress (ra2ng scale 1-‐5) ! Develop Ladder of s2muli or triggers situa2ons, objects, cues, sensa2ons
! Develop list of pre-‐planned calming skills
Social Asser2veness
! Child learns to iden2fy needs, thoughts, feelings, impulses and behavior
! Child role-‐plays language in session, prac2ce generaliza2on at home and in school
! Use toys, puppets sand tray to prac2ce ! Use relaxa2on, coping strategies and fear/worry/feeling ra2ngs during interven2ons
Execu2ve Func2on Skills
Aaen2on, focus, distrac2bility Alert, orient, engage, respond Cogni2ve control, shih and flexibility Tracking (visual, auditory) Memory, input, manipula2on, output Emo2onal regula2on and modula2on Problem solving, decision making Impulse control and management Organiza2on, planning, and 2me management Motor management planning, pacing, ini2a2on, maintaining, stopping
Thinking Skills
Organiza2on Planning Decision-‐making Ini2a2on, execu2on, review Aaen2on to detail Finding the data Problem solving Explaining one’s answer Crea2vity/Imagina2on
Self-‐Regula2on Skills
Percep2on ~ sensory Recognizing internal energy state Recognizing escala2on or de-‐escala2on Ini2a2ng, maintaining and changing energy Labeling, naming or expressing a feeling U2lizing calming skills
EBT Skill Analysis
Problem Skill Domain Modality Tools Ac7on Child bites classmates
Impulse ID Thinking Role Play Hula hoops Child was encouraged to describe the antecedents to bi2ng behavior.
Impulse labeling
Thinking Child was encouraged to ID and label the feeling impulse.
Behavioral Inhibi2on
Self-‐Reg Child was able to name two inhibi2on strategies.
Problem Impact
Problem Frequency Severity Impact
Child bites classmates
2 x per day 5 Removal from class, isola2on, class disrup2on
EBT Progress Note
! Today’s clinical hour focused on iden2fying thoughts and impulses that lead to child’s bi2ng classmates in school. Used thought and internal energy iden2fica2on strategies to label thoughts and impulses. Once child was able to iden2fy thoughts that lead to impulse to bite we walked through the three steps to behavioral decision making with hula-‐hoops and polyspots, keeping motor inhibi2on strategy front of mind.
! Cogni2ve reinforcement was employed with sample incident review naming each part of what thoughts and impulses lead to which behaviors.
! Child leh session with experience labeling worksheet as well as two alternate strategies, f/u w teacher Friday for review of when and under what condi2ons new strategies were employed.
References and Sources
Bannink, Fredreik 1001 (2010) Solu2on-‐Focused Ques2ons Boyce, Sioban (2014) Not Just Talking: helping your child communicate from day one
Connolly, Sucheta M.D. Director, UIC Pediatric Stress and Anxiety Disorders Clinic -‐ ppt
Curran, Linda (2013) 101 Trauma-‐Informed Interven2ons
Drewes, Athena (Ed) (2009) Blending Play Therapy with Cogni2ve Behavioral Therapy
Joiner, Lindsey (2010) The Big Book of Therapeu2c Ac2vi2es
Jongsma, Arthur et al. (2014) The Child Psychotherapy Progress Note Planner
Kypers, Leah (2011) Zones of Regula2on
Mennu2, Rosemary et al. (2013) Cogni2ve-‐behavioral interven2ons in Educa2onal Sedngs
Van der Kolk, B. (2014) The Body Keeps Score
Young, Wendy (2014) Bouquet of Posi2ve Thoughts
Research Studies Arnberg, A. & Ost, L. (2014) CBT for children with depressive symptoms: a meta-‐analysis Cogn Behav Ther. 2014; 43(4):275-‐88.
Braaon, S. & Ray, D et al. (2005) The Efficacy of Play Therapy Outcome With Children: A meta-‐Analy2c Review of Treatment Outcomes. Professional Psychology: Research and Prac2ce, Vol 36(4), Aug 2005, 376-‐390.
James, AC. et al (2013) Cogni2ve behavioural therapy for anxiety disorders in children and adolescents, Evid Based Mental Health 2013;16:4.
Haskins, Edmund (2012) The Cogni2ve Rehabilita2on Manual; Transla2ng Evidence-‐Based Recommenda2ons into Prac2ce.
Hove, J. & Schwartz, M. (2014) Deconstruc2ng the Ability to Move to a Beat. Journal of Neuroscience, 12 34(7):2403-‐2405.
LeBlanc & Ritchie (2001) Counselling Psychology Quarterly, Volume 14, Number 2, 1 June 2001, pp. 149-‐163(15).
Reddy, L. et al. (2005) Empirically Based Play Interven2ons.
Rubia, K. et al. (1999) Synchroniza2on, an2cipa2on, and consistency in motor 2ming of children with dimensionally defined aaen2on deficit hyperac2vity behaviour. Percept Mot Skills. 1999 Dec; 89(3 Pt 2):1237-‐58.
Tierney, A. & Krause, N. (2013) The Ability to Move to a Beat Is Linked to the Consistency of Neural Responses to Sound. The Journal of Neuroscience, 33(38).
van der Fels, IM. (2014) The rela2onship between motor skills and cogni2ve skills in 4-‐16 year old typically developing children: A systema2c review J Sci Med Sport.
Westendorp, M. (2014) Effect of a ball skill interven2on on children's ball skills and cogni2ve func2ons. Med Sci Sports Exerc. 46(2):414-‐22.
20 NeuroCogni2ve Play Ac2vi2es