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Article

Psychophysiological Insights into Child-Centered Play Therapy for Trauma: A Case Study

by
Kristi L. Perryman
1,*,
Samantha Robinson
2,3,
Timothy J. Schoonover
4 and
Julia Conroy
5
1
Department of Counseling, Leadership, and Research Methods, University of Arkansas, Fayetteville, AR 72701, USA
2
School of Human Environmental Sciences, University of Arkansas, Fayetteville, AR 72701, USA
3
Center for Agricultural Data Analytics, University of Arkansas, Fayetteville, AR 72701, USA
4
Department of Counseling and Higher Education, Northern Illinois University, DeKalb, IL 60115, USA
5
Office of Play Therapy Research and Training, University of Arkansas, Fayetteville, AR 72701, USA
*
Author to whom correspondence should be addressed.
Trauma Care 2024, 4(3), 208-218; https://doi.org/10.3390/traumacare4030019
Submission received: 16 July 2024 / Revised: 20 August 2024 / Accepted: 27 August 2024 / Published: 30 August 2024
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Abstract

:
Existing literature thoroughly reviews the detrimental consequences that adverse childhood experiences (ACEs) have physically, emotionally, neurobiologically, and financially. It is imperative to develop effective treatments that offer a sense of hope to children who have been impacted. The established relationship between high ACE scores and physiological hyperarousal due to emotional dysregulation is clear in the literature. This relationship indicates that taking psychophysiological measures may be an effective method of gauging the effectiveness of trauma treatments. This study measured the heart rate of a child who had experienced multiple ACEs, during 16 child-centered play therapy (CCPT) sessions, using the Empatica (E4) wristband. Bayesian change point analysis was conducted and multiple changes in the heart rate mean were detected and identified within each session’s time series. Additionally, changes in heart rate variability during the 16 sessions were observed and points of interest, e.g., highest and lowest observed heart rates, were noted. Results suggested the number of breakpoints in the heart rate means within each session, as well as the location, i.e., the time of each breakpoint, so that each significantly detectable change in heart rate mean as well as sessions of noted differences in heart rate variability were discussed alongside what was occurring within the video recorded sessions.

1. Introduction

Research regarding the neurobiology of trauma emphasizes the potential of using psychophysiological measurements, such as heart rate variability and skin conductance, to gauge the impact of trauma treatments. Child-centered play therapy (CCPT) is one of the most widely researched treatments for children. Its principles emphasize the regulatory capacities that ACEs often erode. By measuring changes in children’s psychophysiological measurements in CCPT, clinicians will be able to gain a clearer understanding of the change process. This study is the first to evaluate CCPT from a psychophysiological perspective with a child who has experienced multiple ACEs.

1.1. Trauma

Childhood trauma and its impact on both children and adults has been explored for over 35 years. It started in the 1990s with a study conducted by Felliti and colleagues [1] regarding the impact that adverse childhood experiences (ACEs) had on adults. They created a 10-question questionnaire that focused on three areas: abuse, household changes, and neglect. They found that adults who experienced ACEs were more likely to experience negative health outcomes. Furthermore, findings indicated that the more ACEs someone experiences, the possibility of having a negative health outcome with more severity also increased [1]. Multiple studies have found that children who experience ACEs are at an increased risk of externalized behaviors (similar to attention-deficit hyperactivity disorder (ADHD)), aggressive behaviors, lack of social–emotional skills, delayed cognitive development, impaired attachment, poor academic performance, emotional dysregulation, and decreased engagement in school [2,3,4,5,6,7,8]. Children who have been exposed to ACEs can have the previously listed symptoms, which could come from the neurobiological impact of those experiences.
A child’s brain develops quickly as they age, and if they are exposed to ACEs during this time, it can negatively impact their progress [9,10,11,12]. Although the understanding of the neurobiological impacts of ACEs has grown, there is much that is still not known. Research has shown that children who have been exposed to ACEs have negative impacts in the following regions: anterior cingulate cortex, dorsolateral prefrontal and orbitofrontal cortex, corpus callosum, Broca’s region, limbic system, and hippocampus [13,14,15,16,17,18,19,20]. In addition to these negative impacts, exposure to trauma triggers the release of large amounts of cortisol into the body which could negatively impact the prefrontal cortex, memory, and executive functioning [21]. The body then is in upregulation mode, which can lead to anxiety and even panic attacks [22,23]. It can also make the connection between the amygdala and prefrontal cortex weak, which can impact normal development [24,25,26].
Due to the changes in brain development, children who have been exposed to ACEs are more likely to have difficulty regulating emotions, heightened sensitivity, aggressive behaviors, and anxiety [27,28,29]. This can cause them to move from hypoarousal to hyperarousal and narrow their window of tolerance [30]. This can stem from the potential damage that the amygdala experiences from exposures to ACEs and can inhibit the ability to respond to stressful situations in a regulated manner. There has been a connection between a sensitive amygdala from exposure to trauma and being thrust into hyperarousal, which leads to a release of adrenaline that can increase blood pressure, heart rate, and oxygen intake [12], which is likely a fight or flight response in which one attempts to get away or fight to survive.
A freeze response, however, results in heart rate deceleration or reduced acceleration, and possibly rigid body posture and reduced verbalizations, induced by the parasympathetic nervous system, resulting in a downregulation [30,31]. In this state, the body is less responsive to external stimuli, which could lead to depressive symptoms [23]. While these reactions may be helpful in dangerous situations to self-protect, they inhibit normal functioning when hyperarousal occurs during non-dangerous situations. An example would be a child who had a traumatic experience with gunfire, and might overreact to loud noises, such as doors slamming, the sound of a dish breaking on the floor, etc. Additionally, it takes people who have experienced trauma longer to move back to homeostasis and calm [12]. Children who have been exposed to ACEs, specifically four or more, experience fight or flight (sympathetic nervous system activation) at higher rates and due to having a damaged parasympathetic nervous system have a difficult time returning to homeostasis [12,32]

1.2. Child-Centered Play Therapy

CCPT evolved from Carl Rogers’ person-centered approach [33], with a focus on the core conditions as the foundation of the therapeutic relationship. These include the ability of the therapist to demonstrate empathy, genuineness, and unconditional positive regard toward their client. CCPT is the most researched type of play therapy and is widely utilized by therapists [34]. According to Landreth [35], play is a child’s language and toys are their words. Using carefully selected, therapeutic toys, the therapist creates a safe environment for the child to play out their innermost feelings and experiences. The CCPT therapist embraces basic principles with a focus on the child, rather than the problem(s), utilizing both verbal and non-verbal skills in a playroom intentionally created and organized with therapeutic toys. CCPT is a non-directive form of play therapy that allows the child to tell their story through their play rather than relying on verbal language alone.
CCPT is an evidenced-based approach with a scientific rating of 3 out of 5 for promising research evidence by the California Evidenced-Based Clearinghouse [36] for working with children between 3–10 years of age with disruptive behaviors associated with trauma and for those exposed to domestic/intimate partner violence. CCPT has been well researched with children demonstrating internalized and externalized trauma as well as those disruptive behaviors associated with trauma such as impulsivity and anxiety [37,38,39,40,41,42,43,44,45,46] and has shown positive results.
There is ample research with CCPT demonstrating its effectiveness in both school and clinical settings and with various populations. Due to the relational focus and developmental appropriateness of CCPT for working with children with trauma-related behaviors and the evidence base, it was chosen as the intervention for this study.

1.3. Physiological Measurements

For over fifty years, psychophysiological measurements, such as heart rate variability and skin conductance, have been taken to provide insight into the regulatory experience that is taking place beneath the surface [47] as they offer an objective and reliable measurement of the biopsychosocial distress taking place within the body. Heart rate variability measures the consistency of the heart’s beating and distribution of blood throughout the body. Individuals who are more prone to have higher heart rate variabilities also tend to have more reactive threat response systems and emotional regulation difficulties [48]. Additionally, those with a freeze response to trauma experience a drop or reduced heart rate [31,49].
Recent studies have begun to evaluate the impact of CCPT from a psychophysiological perspective [50,51], using the Empatica 4 (E4). This device measures heart rate variability, electrodermal activity, blood volume pulse, acceleration, and temperature. Other counseling-related studies have used E4 to measure emotion in leisure experiences [52], collaborative learning experiences [53], synchrony in couples counseling [54], and mindfulness-based cognitive therapy on counseling self-efficacy [55].
There was a single case design conducted to examine the effects of CCPT on the autonomic nervous system among children with generalized anxiety disorder [51]. The study found a causal relationship between the lessoning of harmful physiological effects of generalized anxiety and CCPT. More recently, a study investigated the co-regulatory process and relational mechanisms of CCPT with children with complex trauma using child–counselor physiological synchrony values within and across play therapy sessions [50]. They consistently found large child–counselor heart rate synchrony levels across play therapy sessions.
The current study is the first to use E4 to evaluate change in heart rate during CCPT sessions as it pertains to a trauma response.

2. Materials and Methods

2.1. Purpose of the Study

The purpose of the current study was to explore trends in average heart rate over time of a child who had experienced multiple ACEs utilizing heart rate data collected with E4 during 16 CCPT sessions. An additional purpose of the study was to identify sudden changes in average heart rate during CCPT sessions and, utilizing video recordings, determine if any detectable shifts in heart rate were associated with specific behaviors, events, or experiences that were occurring at the moment.
Specifically, the following research questions were posed:
  • How do heart rate measures change over time across 16 CCPT sessions?
  • Are there detectable shifts in average heart rate during a CCPT session?
  • Are detectable shifts in average heart rate associated with certain in-session behaviors, events, or experiences?

2.2. Participant

The participant for this study was a five-year-old, White male kindergartener who was attending a charter school in the southern U.S. for children who have experienced trauma. Due to the school being designed for children who have experienced trauma, many of them had externalized behaviors. There would often be children in the hall who were dysregulated and screaming, which could be heard during play therapy sessions. Although this does not make for an ideal clinical setting, it was decided that this would be the most appropriate place to complete the sessions due to the accessibility for the client. The study took place in a rural setting, and the participant had limited ability to attend sessions in an outpatient setting. The participant was given the pseudonym Kobe.
Kobe resided with his biological mother with his father having had parental rights terminated. The father was no longer allowed to see Kobe. Background information was provided by Kobe’s mother. He had previously been diagnosed with ADHD and generalized anxiety disorder. Due to the diagnosis, he was prescribed and took Guanfacine throughout the entire study. Kobe’s symptoms were mainly internalized, and he would often present in school as quiet and shy. He did not have many externalized behaviors.
Kobe had a total of eight ACEs on the expanded questionnaire and seven on the original ten-question survey. Kobe was exposed to the following: parental divorce, living with someone who was depressed or mentally ill, living with someone who was previously incarcerated, living with someone with a drinking problem, living with someone who had a problem with street or prescription drugs, having been insulted or humiliated by an adult in the household, had a parent or adult in the household make him feel afraid that he might be physically hurt, and often hearing or witnessing domestic violence.

2.3. Instrumentation and Procedure

The E4 is an instrument that measures the blood volume pulse, which also informs heart rate variability and changes in electrical skin properties, as well as peripheral skin temperature. The E4 is a wristband that is similar in appearance to a watch, making it an ideal noninvasive device to collect heart rate data during play therapy sessions. The E4 has been used in research with children [56,57,58], and specifically with children in play therapy research [50,51].
The E4 was worn by Kobe during sixteen child-centered play therapy (CCPT) bi-weekly sessions that each lasted for approximately 30 min. Due to the non-directive nature of CCPT, there was no specific focus in each session, allowing Kobe to take the lead. Since he came from various activities including physical education, recess, and class, Kobe spent the first five minutes in the nurse’s office prior to beginning play sessions to establish a baseline. During that time, Kobe sat still and would often read a book, or the school nurse would read with him. Although this study involved one participant and lacked a control group, Kobe established a baseline with the E4 wristband before each session. This allowed us to analyze the data with some level of control. This baseline ensured that Kobe began each session in a state of homeostasis, factoring in the effects of his Guanfacine medication.
In order to ensure research fidelity, each session was video recorded, and a child-centered play therapy research integrity checklist (CCPT-RIC) for a random five minutes from each session was completed to ensure CCPT skills were being utilized appropriately. The play therapist scored an average of approximately 94% on the CCPT-RIC across all sessions, which is within the recommended range of 90%–100%, if CCPT skills are being utilized correctly [59].

2.4. Data Analysis

To detect changes (specifically sudden or abrupt changes) in the mean heart rate of each therapy session, a Bayesian change point analysis was conducted using the bcp package in R Version 4.3.1 (R Core Team, Vienna, Austria) [60]. This approach to change point detection implements the procedure proposed by Barry and Hartigan [61] and utilizes Markov Chain Monte Carlo (MCMC) to sample from the posterior distribution of the partition and the parameters. Unlike many frequentist procedures for change point detection, this Bayesian procedure provides the probability of a change point at each detected change point location. Following change point detection, the video was reviewed again to understand if detectable shifts in average heart rate were associated with certain in-session events.
Note: Wristband data from each session was trimmed to reflect the last 30 min (1800 s) that the wristband was worn, accounting for the slight differences in the time spent waiting for each session to start.

3. Results

3.1. Descriptive

Figure 1 represents the heart rate over time during each 30-min session across all 16 sessions. Density plots for recorded heart rate during each of the 16 sessions are displayed in Figure 2, allowing the distribution of the heart rate within each session to be observed. Descriptive statistics for participant heart rate during each of the 16 sessions are displayed in Table 1.
Despite the lowest recorded heart rate being observed in Session #4, Session #10 had the lowest average heart rate of all sessions. The session with the highest average heart rate was Session #13. The most variability in heart rate based on the standard deviation of the heart rate was observed during Session #1 whereas the least variability was observed during Session #6.

3.2. Change Point Detection

The time points for detected change in the average heart rate during each session are displayed in Table 1. There were discernible shifts in the average heart rate during all sessions, except for Session #3. Session #10 had the most change points with five different time points detected. The average number of detected change points per session for all sessions was approximately 2.31 (SD = 1.35).

3.3. In-Session Behaviors, Events, or Experiences

Videos were reviewed to note the in-session events that were occurring in sessions of interest, e.g., those sessions exhibiting the highest or lowest average heart rate, and those with the most and least variability. Additionally, the video was inspected at the specific times corresponding to each detected change point to determine how in-session behaviors, events, or experiences were associated with the participant’s heart rate.
Notable observations occurred in sessions with discernible shifts in average heart rate during all sessions except for the third session. Interestingly, the child expressed more aggression in this session than in others, yet his heart rate remained the most stable. Similarly, session two was also a more stable session with posterior probabilities of change points in session two being only as high as 72–83%. Despite the stability in the heart rate, these sessions involved aggressive play. This is an indicator that the child likely has a freeze response to trauma [62], in which one is immobilized, causing his psychophysiological functioning to slow down.
The most variable session was session one. Just before the most likely detected change point in average heart rate, the child had asked to use the restroom, and this was likely the reason for the variable heart rate. Not only was he excited to be exploring the playroom for the first time, but he also had to use the restroom.
The lowest heart rate throughout the 16 sessions was observed during session four. However, during this low heart rate period, loud yelling could be heard outside the room while another child threatened to kill someone. This is, again, likely a freeze response as the child’s body was immobilized when faced with a fearful situation.
The session with the lowest average heart rate was session ten. At the most likely detected change points in the average heart rate, there was one period when the child was playing with a dinosaur and said, “Get out of there”, while loud yelling was again taking place outside of the door by another child. The other most likely change point was detected at a time when he told the therapist to say, “Brave Wyatt”, and “I want you to say it”, which was unusual and seemed important. He appeared quieter and calm this session and somewhat inhibited. This behavior had also been observed in the classroom during this week. It is not known what the child was referencing in his statement, but this, combined with the notable loud yelling outside the door, seemed significant in terms of his physiological response.
The session with the highest average heart rate was session thirteen. Detectable changes in average heart rate occurred at unexpected times when video observation suggested that he was intently working on Legos and not engaging, as opposed to a moment when the child was aggressively striking a drum, though there was no change in average heart rate detected at that time. The physical energy appeared very elevated as he repeatedly hit the drum loudly and hard. Again, his observed physiological response did not match the E4 data during this time and was likely a freeze response with his heart accelerating more slowly. It would also not have been expected for his heart rate to rise during the time he appeared to calmly work on Legos and appeared disengaged with the therapist. It is possible that his heart rate is changing over time as his body regulates differently as he recreates his life experiences through the language of play.

4. Discussion and Conclusions

The preliminary results of this study found multiple dynamic changes in heart rate means and changes in heart rate variability were detected and identified during the sixteen CCPT sessions. Low heart rate variability was present during sessions with the most aggression and loud, angry outbursts happening outside the door. This is an indication that the child likely has a freeze or immobilization response to trauma. There was also a rise in heart rate during a later session in which the child appeared detached and calm, which had not happened in other sessions. It is therefore possible that his body reactivity was beginning to change.
Detecting changes in physiological measurements such as heart rate can assist therapists make sense of the internal responses of children which may or may not be fully visualized. Changes in heart rate were detected at time points for this child that may not be consistent for children without a freeze response to trauma. Further work needs to be done to determine how shifts in physiological measurements are associated with CCPT session experiences and child behavior. Research comparing CCPT to other types of play therapy with children who have experienced various types of trauma could also be helpful in choosing therapies. Additionally, future work will explore sudden changes in heart rate variability (as opposed to just changes in average heart rate) as well as exploring changes in other physiological measurements. While this work is preliminary and exploratory, data-driven insights about the physiological impact of CCPT on a child who has experienced complex trauma are promising and can help therapists better understand the physical and internal experiences of their patients during sessions.
A limitation of this study is that data were collected for one child. While steps were taken to ensure a baseline was established, more research is needed that includes more participants. Another possible limitation is that the medication the child was on has a possible side effect of irregular or fast heartbeat. The child in this study had been on the medication for several months and there were no concerns regarding changes in heart rate.

Author Contributions

Conceptualization, K.L.P., T.J.S. and J.C.; methodology, K.L.P. and S.R.; formal analysis, S.R.; investigation, K.L.P., T.J.S. and J.C.; data curation, S.R.; writing—original draft preparation, all authors; writing—review and editing, all authors; visualization, S.R.; supervision, K.L.P.; project administration, K.L.P.; funding acquisition, K.L.P. All authors have read and agreed to the published version of the manuscript.

Funding

E4 wristbands used to conduct this research were funded by a grant from the University of Arkansas College of Education and Health Professions.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of the University of Arkansas (Protocol 171509; Approved on 16 July 2020).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors upon request.

Conflicts of Interest

The authors declare no conflicts of interest.

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Traumacare 04 00019 g001
Figure 1. Trend lines for observed heart rate across sessions, with each session reflected by different colors.
Figure 1. Trend lines for observed heart rate across sessions, with each session reflected by different colors.
Traumacare 04 00019 g001
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Figure 2. Density plots for observed heart rate across sessions, with each session reflected by different colors.
Figure 2. Density plots for observed heart rate across sessions, with each session reflected by different colors.
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Table 1. Means, standard deviations, and points of detected change for heart rate across sessions.
Table 1. Means, standard deviations, and points of detected change for heart rate across sessions.
SessionMeanSDChange Points
(Seconds from ‘Start’)
0190.6915.05722, 1284, 1404, 1770
0291.569.99791, 799, 1481
0390.679.91NA 1
0496.869.361397, 1711, 1723
0596.9012.49201, 495, 1576
0688.916.951215
0798.9712.7912, 866
0893.1114.50357, 1749
0989.4310.26467
1084.217.5447, 490, 1149, 1327, 1513
1189.3712.201417
1289.698.74938
13107.729.9284, 467, 1684
1487.499.68880, 940
1594.8511.25609, 671, 899, 1671
1690.9912.36372, 511
1 No change point was detected during Session #3.
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MDPI and ACS Style

Perryman, K.L.; Robinson, S.; Schoonover, T.J.; Conroy, J. Psychophysiological Insights into Child-Centered Play Therapy for Trauma: A Case Study. Trauma Care 2024, 4, 208-218. https://doi.org/10.3390/traumacare4030019

AMA Style

Perryman KL, Robinson S, Schoonover TJ, Conroy J. Psychophysiological Insights into Child-Centered Play Therapy for Trauma: A Case Study. Trauma Care. 2024; 4(3):208-218. https://doi.org/10.3390/traumacare4030019

Chicago/Turabian Style

Perryman, Kristi L., Samantha Robinson, Timothy J. Schoonover, and Julia Conroy. 2024. "Psychophysiological Insights into Child-Centered Play Therapy for Trauma: A Case Study" Trauma Care 4, no. 3: 208-218. https://doi.org/10.3390/traumacare4030019

APA Style

Perryman, K. L., Robinson, S., Schoonover, T. J., & Conroy, J. (2024). Psychophysiological Insights into Child-Centered Play Therapy for Trauma: A Case Study. Trauma Care, 4(3), 208-218. https://doi.org/10.3390/traumacare4030019

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