short-term group pt 2002

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International Journal of Play Therapy, 11(1),pp . 43-63 Copyright2002,APT, Inc.

SHORT-TERM GROUP PLAY THERAPYWITH CHINESE EARTHQUAKEVICTIMS: EFFECTS ON ANXIETY,DEPRESSION, A N D ADJUSTMENTYih-Jiun Shen

Texas Tech University bstract This study investigated the effectiveness of short-term child-centeredgroup play therapy in elementary school settings with Chinese children inTaiwan who experienced an earthquake in 1999. Children in the experimentalgroup scored significantly lower on anxiety level and suicide risk after playtherapy than did children in the control group. The effects of the treatmentsupport previous studies of play therapy with American children. Thesefindings reveal the possibility of disaster intervention services adopting W esternhelping techniques with schoolchildren of non-Western cultures.

EFFECTS O N ANXIETY, DEPR ESSION , A N D ADJUSTM ENTNumerous tragedies occurred when a devastating earthquakehit Taiwan at 1:50 a.m. on September 21,1999 (Chen, 2000). The so-called921 Earthquake, registering 7.3 on the Richter scale, terminated morethan 2,300 lives and disrupted those of countless child survivors

(McGeveran, 2001). On the other side of the globe, Seattle childrenexperienced a life-threatening earthquak e on February 28, 2001, andmany of them reported significant feelings of insecurity. A major quake,defined as Magnitude 6 or greater, occurs more often than most peopleare aware of and nearly always victimizes youngsters (United StatesGeological Survey, 2000). In the past 30 years, earthquakes tookthousands of youths' lives in China (1976), Iran (1990), India (1993),Japan (1995), and Turkey (1999) (McGeveran, 2001). DespiteYih-Jiun Shen, Ed.D., Assistant Professor in the Division of Educational Psychology andLeadership, College of Education, Texas Tech University, Lubbock, TX 79409. E-mail:[email protected].


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seismologists' efforts to predict earthquakes, they rem ain one of n ature'smost destructive events (Durkin & Thiel, 1993). During the recoveryprocess, the youngest members of a population cannot be exempt fromthe aftereffects of disasters and shou ld not be overlooked.The negative impact of severe quakes on children'sphysiological and psychological well being varies from mild to severeand months to years (Gordon & Wraith, 1993; Pynoos et al., 1993).Children's reactions documented across cultures include somaticcomplaints (e.g., palpitations, headaches, stomachaches, tiredness, andenuresis) (see, e.g., Galante Foa, 1986). The psychological disturbancesinclude mild feelings of insecurity, trouble focusing, pessimism,regression, low self-efficacy, aggressiveness, depression, anxiety, fears,and suicidal ideation (Azarian, Skriptchenko-Gregorian, Miller, Kraus,1994; Bradburn, 1991). The event can even lead to posttraumatic stressdisorder (De Silva, 1993; Pynoos et al., 1993). Traumatic events such ascatastrophic earthquakes in early life often imprint the minds of affectedindividuals and impact personality development (Bland, O'Leary,Farinaro, Jossa, & Trevisan, 1996; Shen & Sink, in press). Lacking thematurity to deal with these intricate repercussions, children often needmental health assistance.Among the numerous mental health interventions, playinterventions, also termed play therapy, and art expression techniquesprovide natural means for connecting with child victims of earthquakes.Hofmann and Rogers (1991) reported on an art-play, short-term,intensive crisis intervention that combined the format of large and smallopen groups to help the child survivors of a 7.1 magnitude Californiaearthquake regain a sense of control in a shelter. Because art materialsare often considered standard playroom supplies, practitioners ofteninclude art techniques in the practice of group play therapy.Incorporating play media, the intervention honors young children'sinnate behaviorplay and provide them outlets for expression. Hence,after a life-threatening experience, school-age children's emotions andthoughts are not limited by their verbal ability.

School personnel, especially school counselors, may be the onlyprofessionals who can provide mental health assistance such as playinterventions to children because families are disrupted and parents arestriving to fulfill family members' basic needs. In the aftermath of


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PlayTherapy with Chinese Earthquake Victims 45

disasters, the reestablishment of order and security requires effectivelarge-scale social services, typically delivered through schools serving asresponse loci (Gordon, Farberow, & Maida, 1999). Roje (1995) describedhow the use of art therapy with children in an elementary school settingafter a Los Angeles earthquake facilitated the resumption of their normalfunction. Galante and Foa (1986) reported an empirical study with 300Italian elementary students. The students participating in play-and-artsmall groups once a month for one academic year significantly reducedtheir earthquake fears. The number of high-risk students was alsoreduced. These reports exemplified the successful use of playinterventions in the school setting after the disasters.Although the study of Galante and Foa might be mostsystematic investigation of the effectiveness of art or play interventionswith school children who had survived severe earthquakes, the specifictheoretical orientation of the intervention was not identified. Moreover,there was no control group to contrast the program effects with thereduction of psychological reactions as the children developed and timepassed. An examination of the contemporary literature addressingtheoretical underpinnings of play therapy indicated that the child-centered approach seemed to be favored due to its broad range ofapplicability (Landreth, Homeyer, Bratton, Kale, & Hilpl, 2000; Shen,1998). However, few studie s have repo rted its effectiveness with d isastersurvivors in schools and w ith children of non-W estern cultures.Because the recuperative process after an earthquake requiresthe victims' cooperation and compliance, intensive short-term groupplay therapy not only provides children with these aspects during thehealing process (Sweeney Hom eyer, 1999), bu t can also be efficient forschool counselors, who are often stressed by limited time and a lack ofhuman resources after disasters. The need to study the effects of suchshort-term interventions delivered via a group emerged-specifically, theeffects of intensive child-centered group play therapy on earthquakesurvivors in their daily learning environment. The purpose of this studywas to investigate the effectiveness of the use of short-term child-centered group play therapy in elementary school settings with Chinesechildren in Taiwan who had experienced the 921 Earthquake in 1999.Specifically, this study examined the following questions: How effectiveis child-centered group play therapy in reducing the levels of anxiety


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and depression in affected Chinese children in Taiwan through theirself-report? How effective is this approach to improving the lifeadjustment of children as perceived by their pa rents?

METHODA pretest-posttest control group design, with one experimentalgrou p of subjects receiving treatm ent and one control group receiving notreatment, was used (Heppner, Kivlighan, & Wampold, 1999). Pretests

and posttests with the parents were conducted within 2 weeks of thetreatment. The tests with the children were conducted the day beforeand the day after the treatment to evaluate the effect of the independentvariable, the child-centered group play therapy, on the dependentvariables, the children's anxiety, depression, and life adjustment.ParticipantsParticipants were recruited in a rural elementary school locatedin midwestern Taiwan, an area that experienced the 921 Earthquakewith more than 1,000 aftershocks during the following months. Three ofthe five buildings of the elementary school were condemned, and manystudents w ere transferred to other schools. The paren ts of 244 Grades 3through 6 students were contacted for their children and themselves toparticipate in this study. Sixty-five (25%) parents of the targeted studentpopu lation agreed to participate; the relatively low num ber might reflecttraditional Chinese culture's unfamiliarity with Western psychologicalinterventions or Chinese parents' unawareness of or hesitance inrecognizing their children's needs (Shen, 1998). These 65 children werescreened using the Children's Mental Health Checklist (CMHC) (seeGordon et al, 1999), and 30 of these were identified as being at a highrisk for maladjustment. The 30 students included 10 third graders (4boys and 6 girls), 8 fourth graders (4 boys and 4 girls), 8 fifth graders (3boys and 5 girls), and 4 sixth graders (3 boys and 1 girls). Their agesranged from 8 to 12 years. These children w ere ran dom ly assigned to anexperimental group comprising 15 children and a control groupcomprising 15 children, who received no play therapy treatment. The 15students in the experimental group included 5 third graders (3 boys and2 girls), 4 fourth graders (2 boys and 2 girls), 3 fifth graders (1 boy and 2


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Play Therapy with Chinese Earthquake Victims 47

girls), and 3 sixth graders (2 boys and 1 girl). Classified according togrades and genders (White & Flynt, 1999), the children were assigned tofive play groups; each group com prised 3 children.InstrumentsBecause existing instruments were not available to measureChinese children's anxiety, depression, and life adjustment, theresearcher used Mandarin Chinese, the official language of Taiwan, toadminister the following instruments, designed primarily for Americanchildren of diverse ethnic groups. Using the same person to administerall of the instruments could consistently enhance the quality control andreliability. The paren ts com pleted the first two instrum ents. The childrencompleted the last two ins truments.Children s Mental Health Checklist (see Gordon et al, 1999).The CMHC, designed in response to the 1989 Loma Prieta earthquake innorthern California, consists of 25 yes-or-no, adult-reported items.Parents are instructed to check each of the 25 situations described in thechecklist. Example items follow: Has the child had more than one majorstress within a year before this disaster, such as a death in the family, amolestation, a major physical illness, or divorce? New behaviorsexhibited for more than three weeks after the disaster (e.g., W akingfrom dream s confused or in a sweat? Severe clinging to adults? )Individual item scores reflect the psychological harmfulness of thesituation to a child with points ranging from -10 to +15. The higher achild's final score, the higher the potential need for mental healthintervention. Normative data regarding validity and reliability are notavailable, but this checklist initially served as a critical tool in screeningchild earthquake survivors whose psychological trauma required crisisintervention.Filial Problem Checklist(FPC) (Horner, 1974). The FPC, a 108-item parent-rated instrument, allows parents to indicate the adjustmentof their children in problematic situations, including behavior,psychological circumstances, interpersonal relationships, somaticproblems, eating, sleeping, and school performance. Parents considereach of the problem atic situations (e.g., gets into trouble, poo rmem ory, dan gero us habits ) of their children and rate those that bestmatch the situation on a scale of1{it istrue, but notreally aproblem), 2{the


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problem is mild), and 3 (it is a severe problem). Normat ive s ta t i s t ics aboutvalidity and reliability are not available, but the FPC was used in manystudies of parents' perceptions about their children who were providedchild-centered group play therapy (Landreth Lobaugh, 1998).Revised Children s Manifest Anxiety Scale (RCMAS)(Reynolds & Richmond, 1985). The RCMAS, a 37-item self-reportinventory, measures children's anxiety, including physiological anxiety,worry/oversensitivity, social concerns/concentration, and a lie factor.The children are instructed to answer the true or false questions, such as I worry about what is going to hap pen . and It is hard for me to keepmy mind on my schoolwork. Used in stud ies of children suffering fromvarious disasters and catastrophes (Gordon et al., 1999; Lonigan,Shannon, Finch, Daugherty, Taylor,1991;Yule Udwin,1991;Yule &Williams, 1990), the measure is a widely used self-report instrument ofchildren's anxiety. The reliability and validity of the scale are reflectedby a coefficient alpha reliability exceeding .80, a test-retest reliabilitycoefficient of .68, and correlations of .67 for females and of .65 for malescompared with the Trait scale of the State-Trait Anxiety Inventory forChildren (Spielbereger, Edwards, Lushene, Montuori, & Platzek, 1973)on validity (Rabian, 1994; Reynolds & Richmond, 1985). The RCMASprovided the children an opp ortunity to repo rt their mental status beforeand after the treatment.Multiscore Depression Inventory for Children (MDI-C)(Berndt & Kaiser, 1996). The MDI-C, a 79-item self-report inventory,measures a child's depression, involving anxiety, self-esteem, sad mood,instrumental helplessness, social introversion, low energy, pessimism,defiance, and suicide risk. The child is instructed to answer the true orfalse questions, such as I feel very sick, and It's hard to feel hap py.Because this is the first psychological inventory of child depression, w ithitems created and written in their own words, this measurement hasexcellent face validity. This inventory also has convincing statisticalreliability and validity, with an alpha coefficient reliability of .94, a test-retest reliability of .92, and a correlation of .84 on validity (Berndt &Kaiser, 1996). The MDI-C was another standardized measurement thatallowed the children to report their mental status before and after thetreatment.


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ProcedureA school counselor with child-centered play therapy trainingprovided the intervention through a small-group format in theM andarin Chinese language in the playroom of an elementary school. Inorder to provide crisis intervention, a fully furnished playroom wasestablished in the storage room of the school's gym. The installation ofthe playroom wa s strongly influenced by a growing trend among schoolcounseling professionals to implement play interventions in theelementary schools of Taiwan (Shen, 1998). Each play therapy group,

consisting of 3 children, received ten 40-minute group play therapysessions during a 4-week span of time. Each group met two to threetimes per week.Results The collected data were analyzed using analysis of covariance(ANCOVA) and an independent t test to examine the significance of thedifference between the experimental g roup and the control group on theadjusted means for each hypothesis. To statistically equate theexperimental and control groups, ANCOVA was applied to adjust thegroup means on the posttest. The posttest score was treated as adependent variable and the pretest as the covariate. Because in eachgroup there was one student failing to complete the posttests on RCMASand MDI-C, missing values were substituted with the group means.Although Tabachnick and Fidell (1996) suggest using a more stringentcutoff of p>.01,significance of differences was tested at the .05 level.Table 1 shows pretest and posttest means and standard deviations foreach of the measures.The assumptions of linearity and homogeneity of regression forthe ANCOVAs were met, for there were no significant interaction effects(Hinkle, Wiersma, & Jurs, 1994): RCMAS total score, F(l, 26) = .64, p =.432; Physiological Anxiety subscale, F(l, 26) = 1.42, p = .244;Worry/Oversensitivity subscale, F(l, 26) = .16, p = .688; SocialConcerns/Concentration subscale, F(l, 26) = .31, p = .583; and Liesubscale, F(l, 26) = .32,p= .574; MDI-C total score, F(l, 26) = .003,p =.960; Anxiety subscale, F(l, 26) = .15,p= .699; Self-Esteem subscale, F (l,26) = .20, p = .662; Sad Mood subscale, F(l, 26) = .29, p = .596;Instrumental Helplessness subscale, F(l, 26) =.001,p= .976; Low Energy


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subscale, F(l, 26) = .29;p= .594; Pessimism subscale, F(l, 26) = .09,p =.771; Defiance subscale, F(l, 26) = .00,p= .994; Suicide Risk, F(l, 26) =2.13,p = .156; Infrequency score, F (l , 26) = 1.29,p= .267; FPC total score,F(l , 26) = 1.48,p= .234. For the score that did not m eet the homogeneity-of-regression assumption, Social Introversion subscale on MDI-C,independent ttest wa s applied.According to the student self-reports on the RCMAS, the overallanxiety level in the experimental group was significantly decreased incomparison to that in the control group: RCMAS total score, F(l, 27) =10.17,p= .004. Based on the Cohen (1977) ranges, the following RCMASresults of the treatment effect were large. The partial 2of .274 indicatedthat the overall treatment effect was large. The physiological anxietylevel in the experimental group was significantly decreased incomparison to that in the control group: Physiological Anxiety subscaleof the RCMAS, F(l, 27) = 11.66,p=.002. The partia l 2of .189 indicatedthat the treatment effect was large. The worry/oversensitivity level inthe experimental group was significantly decreased in comparison tothat in the control group: Worry/Oversensitivity subscale of theRCMAS, F (l, 27) = 4.22,p=.050. The partial 2of .135 indicated that thetreatment effect was large. The social concerns/concentration level in theexperimental group decreased, whereas that in the control groupincreased; the difference between the control group and experimentalgroup, however, was not significant: Social Concerns/Concentrationsubscale of the RCMAS. The difference of the Lie factor scores betweenthe experimental group and the control group was not significant: Liesubscale of the RCMAS, F( l, 27) =.15,p= .700.According to the students' self-reports, the suicide risk level inthe experimental group was significantly decreased in comparison tothat in the control g roup: Suicide Risk score of the MDI-C, F( l, 27) = 6.28,p = .019. The partial 2 of .019 indicated that the treatment effect wasbetween small and medium. The overall depression level in theexperimental g roup decreased; the difference between the control groupand experimental group, however, was not significant: MDI-C totalscore, F(l, 27) = .30,p = .585. In addition, the anxiety, self-esteem, sadmood, instrumental helplessness, low energy, pessimism, and defiancelevels in the experimental group decreased; the differences between theexperimental group and the control group, however, were not


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significant: Anxiety subscaleof theMDI-C,F(l,27)=2.06,p=.162;Self-Esteem subscale of the MDI-C, F(l, 27) = 1.32, p =.260; Sad Moodsubscaleof theMDI-C, F( l, 27)=.16,p=.694, Instrumenta l Helplessnesssubscaleofthe MDI-C, F(l , 27)=1.28,p= .269;andLow Energy subscaleof the MDI-C, F(l, 27) = .10,p = .760. The difference between theinfrequency score in the experimental group and that in the controlgroupwas not significant: Infrequency score of the MDI-C,F(l, 27) =1.08,p= .307.According totheparents,theimprovementinthe life adjustmentofthechildrenin theexperimental groupwasincreased.Thedifferencebetween the experimental group and the control group, however,wasnot significant: FPC to tal score, F(l, 27)=.92,p= .345.

DISCUSSIONThe study results point to the effectiveness of group playtherapy intervention with Chinese elementary school students who

experienced a destructive earthquake. Significant score changes werefoundforsomeofthe variables.Response malingering, as described in the manuals, was notevident because the means of the pretests and posttests on the Liesubscaleof theRCMASand the Infrequency Scoreof theMDI-Cfor theexperimental groupandcontrol groupdid notfall intothecategoriesofinaccurate self-report andresponse bias. Therefore,thestudentsinbothgroups were considered to have provided accurate and unbiased self-reports. The internal validityofthis study, thus ,was enhanced (Heppneretal.,1999).After the group play therapy treatment was completed, theexperimental group scored significantly lower than did the controlgroupon self-reported anxietyasmeasuredby theRCMAS. Becauseanelevated anxiety score may reflect fears or phobias, the tendency ofenvironmental pressuretoaffect studentsin theexperimental g roupwasdecreased more than for those in the control group. The significantdecrease in the experimental group on the Physiological Anxietysubscaleand theW orry/Oversen sitivity subscalemay beattributed tothe fact that the behaviors they measure are quite sensitive to specificsymptoms that children often experience after natural disasters.The


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ques tions include the following: It is ha rd for me to get to sleep atnight. I have bad dream s. I wake up scared some of the time. Iworry a lot of the time. I am afraid of a lot of thing s. I worry aboutwh at is going to hap pen . The abrupt environmental change in acommunity that has experienced an earthquake often results in childrenbeing stressed, which is reflected in symptoms such as sleepingproblems, nightmares, irritation, worry about becoming orp hans, fear ofdarkness and vibrations, loss of purpose and concentration, and a lack ofa sense of security. The lower scores on the Worry/Oversensitivitysubscale by the experimental group indicate that these children's anxietywas reduced.The results of the RCMAS suppo rt other studies of play therapyin general (Clatworthy, 1981;Johnson & Stockdale, 1975; Milos & Reiss,1982;Ray Bratton, 2000; Shelby & Tredinnick, 1995). The experimentalgroup scored significantly lower in comparison to the control group onanxiety as measured by the RCMAS. The results reflect the assertion ofSweeney and Homeyer (1999) that intensive short-term group therapycan be effective. In addition, the results support Kot's (1995) findings,which indicated that short-term, intensive, child-centered therapeuticplay groups were successful. This study also supports Axline's (1947)assertion emphasizing the therapeutic power of the child-centeredapproach with children who have limited power to change theirenvironments. It appeared that the use of child-centered group playtherapy helped the children in this study become less apprehensivewhen facing environmental stress, which was often beyond thechildren's control. The assum ption of the child-centered approach is thatindividuals' growth and behavior are driven by their inherent capacityfor self-awareness, self-realization, and self-direction. Whenenvironmental situations overwhelm the process, children may expresstheir discomfort through behavioral or physiological symptom. Oncethese feelings are expressed, identified, recognized, and accepted byothers, children may be relieved from the confusion and can focus oncoping with the disturbing feelings and conditions.

Specifically, the results of the RCMAS are consistent withprevious investigations regarding a reduction in fears and anxiety withthe application of child-centered play therapy with children ages 9 to 13(Rae, Worchel, Upchurch, Sanner, & Daniel, 1989; Schmidtchen &


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Hobrucker, 1978; Tyndall-Lind, 1999). One factor contributing to thesignificant differences between the experimental group and the controlgroup seemed to be the climate fostered in the play therapy process: Thecounselor provided a sense of safety, security, permissiveness, andacceptance. Children in the control group also spent time playingoutside the playroom but did not significantly decrease their anxietyscores. The counselor's infusion of helping strategies into children'snatural behavior, play, seemed to provide a calming influence. Theconsistent feelings of trustworthiness and stability rising intrinsically inthe relationship between the children and the counselor further helpedthe child survivors better anchor themselves psychologically.Although previous studies investigating the effects of play andart therapy (Springer, Phillips, Phillips, Cannady, & Kerst-Harris, 1992;Wilde, 1994) and of child-centered play therapy (Tyndall-Lind, 1999)showed positive results in the reduction of children's depression, thedifference in the decrease of the depression level between the controlgroup and the experimental group in this study was not significant. It isnoteworthy, however, that the experimental group scored significantlylower than did the control group on the level of suicidal ideation. Itshould be noted that the Suicide Risk factor listed in Table 1 is based onthe results of one item, the Suicide Risk Indicator on the M DI-C. There isno subscale m easuring suicide risk; nevertheless, the ideation is reportedin the literature on children's reactions to devastating earthquakes andthus is worthy of examination. Stud ents' responses to the item I have asuicide plan are interpreted as a tho ug ht rathe r than a real or specificplan. The treatment appeared to exert a positive influence on thestudents' view of life andself,thus reducing their suicidal thoughts. Thefeatures of esteem building and encouragement in child-centered groupplay therapy may be contributing factors in explaining the significanceof the experimental g roup score on the posttest. During the play therapysessions, the students' competency was consistently reflected throughverbalization, thus validating their confidence and self-esteem.With regard to children's life adjustment, parents in previousstudies reported reductions in the number of problem behaviors afterusing child-centered play therapy with their own children, so-called filialtherapy,in a variety of situations (e.g., Guerney, 1976; Landreth &Lobaugh, 1998; Yuen, 1997). The findings of th is s tudy, how ever, do not


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support those studies. Although parents in both the experimental groupand the control group perceived that their children's life adjustment wasimproved (see Table 1), the difference between the two groups was notstatistically significant on the FPC after the treatment. An importantfactor could be that after the major earthquake, followed by numerousaftershocks, the parents' collaboration with the school was likely todiminish. The parents might have had less energy and time for theirchildren and thus became less observant. A student's mother completingthe pretest might not be available for the posttest, and thus a father oraunt living with the child had to complete the posttest. The standardthey set might have been different; however, the substitution situationwas unavoidable in the post-earthquake chaos. In addition, the recoveryprocess is more complicated for children with ongoing problemsunrelated to the earthquake trauma (Roje, 1995). Work with thesechildren often uncovered parental divorce and alcohol or drug abuse,and emotional neglect was also detected in the play sessions. For thesechildren, longer intervention was necessary.

An examination of the scores on the children's SocialConcerns/Concentration subscale of the RCMAS and the SocialIntroversion subscale of the MDI-C from a cultural perspective isnoteworthy. These results show a decline in the experimental group ascompared to the control group after the completion of the intervention.Some of the items stated on the Social Introversion subscale, such as Ilove playing with friends and I enjoy playing, appear to go againstthe societal and parental expectations in Chinese culture. According tothe manua l of the MDI-C, a yes as an answer to the above itemsimplies the willingness or capability of interacting with others. Positiveanswers to these items, however, might be viewed as immaturity orinappropriateness in school-aged Chinese children (Shen, 1998).Typically, school-aged Chinese children are not encouraged toplay (Shen, 1998). A fourth-grade girl told the counselor, My mom said,'If you spent your time there just for play, you should not participate inthe prog ram any more .' But I will complete the program . Anotherstudent, a fifth-grade boy, explained, I will not get a good grade for myart class. I was punished by my mom because my grades dropped. Herefused to complete the last two play sessions. Acknowledging thepositive influence of play in child development and the importance of


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mental health interventions after the disaster, the teachers andadministers in the school supported the intervention program. However,it was difficult for some students to fully enjoy the interventionprogram. It is not surprising to find that academic emphasis is givenpriority over mental health concerns in Asian societies, especially wherethe C hinese cu lture is strong (Shen, 2001).Because of their parents' expectations, as well as those of theculture, students might give positive answers to test items on the SocialCon cerns/C oncen tration subscale, such as I feel someone will tell me Ido things the wrong w ay and A lot of people are against me . Positiveansw ers to these items, according to the m anual of RCMAS, indicate thechildren's incapability of living up to the expectations of othersignificant individuals in their lives. However, the Chinese children whogave positive answers to those items might, in fact, have the capacity tolive up to their significant others' expectations. The validity of the twosubscales, when applied to Chinese children, is questionable.In addition, the activity of child-centered free play seemed tocreate a dilemma for some older children, especially the boys, in theexperimental group. The two exam ples discussed above exemplified thecontrast. Although the applicable age of children varied, in general, itmay be more effective to apply child-centered group play therapy withchildren younger than 11.According to the researcher's observation, theparticipants aged 10 and younger seemed to be more comfortable andenjoy the free play. However, after realizing what they were expected todo in the playroom, the older children, especially boys, were lesscomfortable and even quite resistant. According to Piaget's cognitive-developmental theory, children aged 11 and 12 are reaching the formal-operational stage. In contrast to you ng children, to whom free play is anintrinsically satisfying activity, older child ren are able to perform mentalactions on ideas as well as propositions and tend to enjoy task-orientedactivities (Shaffer, 1999). Based on that fact, the high percentage of fifthand sixth graders, 40%, in this study might reduce the program'sefficacy. Thus, the age issue m ay explain w hy the changes of the anxietyon the MDI-C and life adjustment on the FPC in the experimental groupwere not statistically significant in comparison to those in the controlgroup.


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LIMITATIONS AND RECOMMENDATIONSAlthough the results of this study indicate that group playtherapy is effective in the reduction of anxiety and suicidal thoughts andhas potential with Chinese elementary school children who survive anearthquake, several limitations must be considered. First, the smallsample number limits the generalizibility of this study. Futureinvestigators may consider recruiting participants from severalelementary schools. Second, because the participants' age and gender

could be influential factors in the program results, contrasting theeffectiveness of child-centered group play therapy with large groups ofchildren of different age ranges (e.g., age under 11 vs. above 11) andgenders (e.g., boys above 11 vs. girls above 11) merits futureinvestigations. Third, the parental substitution of com pleting the posttestlimited the chance of obtaining accurate parental perception of thechanges of children. Future studies may incorporate qualitativemethodology into the evaluation process, so a comprehensive view canbe ensured. Fourth, the results are weakened by the lack of data fromcomparison control groups, with the use of different theoreticalapproaches. Further researchers are encouraged to add matched groups.Fifth, the lack of instruments designed for Chinese children decreasesthe validity of this study in measuring the mental health conditions ofthe population. On one hand, to minimize this effect, future researchersshould carefully examine cultural differences and languagemeaningfulness when adopting or adapting instruments. On the otherhan d, the lack of app ropriate instrum ents may w ell suggest that Chinesechildren are a forgotten grou p, and their mental health concerns may beignored not only by the population per se but also by the mental healthprofession. The development of mental instruments related to thepopulation is needed.

In light of the study findings, the advocacy of group playtherapy, the utilization of short-term treatment, and the developmentofmental health measurements for Chinese children should beunderscored. Recognizing the fact that play is in conflict with traditionalChinese thoughts, yet is becoming more valued in the developingChinese society (Shen, 1998, 2000, 2001), mental health professionalswho adopt play therapy with Chinese children are encouraged to


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educate teachers and especially parents on the importance of mentalhealth interventions and the rationale for using the media of play. Schoolcounselors are encouraged to provide short-term treatment interventionfor Chinese children, thus alleviating some of the concerns related toacademic achievement. This study demonstrated that child-centeredgroup play therapy could be effective in anxiety reduction in anintensive 10-session 4-week model, and it could be more effective toapply the approach with children aged younger than 11.Because of theshared psychological effects on children following various disasters andcatastrophes (Farberow, & Gordon , 1981; Gordon, Farberow, & Maida,1999; Shen & Sink, in press), counselors may find the model beingapplicable when assisting children after natu ral disasters.

The results of this study support child-centered group playtherapy as a useful intervention for Chinese children possessing anxietyand suicidal ideation, an important indicator of depression. Chinesechildren who have experienced natural disasters can benefit from a crisisintervention using child-centered play therapy . The findings point to thepotential of extrapolating to children traumatized by various disastersand catastrophes. The results suggest that child-centered group playtherapy can be helpful internationally and interculturally in promotingthe well-being of children of a non-Western culture through a Westernhelping technique.


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Table 1Pretest and Posttest Means and Standard Deviations for the DependentVariables by Each Condition

Pretest PosttestM SD M SDMeasureRCMAS total score E 18.000 7.973 13.412 7.775C 17.067 8.606 16.945 9.056Physiological anxiety : E 7.200 2.336 4.871 2.387C 5.533 3.182 5.271 3.390W orry/Oversens itiv ity : E 7.000 4.276 5.495 4.144C 7.333 3.940 7.362 3.858Social conce rns /

Concentration: E 3.867 2.134 2.836 2.250C 4.000 2.360 4.236 2.411Lie factor: E 3.733 2.282 3.081 2.251C 3.533 2.295 3.347 2.844MDI-C total score: E 35.000 14.293 29.671 13.533C 41.200 21.512 36.471 20.009Anxiety: E 6.600 2.746 4.752 2.818C 6.800 3.649 5.819 3.402Self-esteem: E 3.267 2.154 2.764 2.128C 4.133 2.722 4.164 2.840Sad mood: E 4.067 2.685 3.657 2.742C 5.067 3.348 4.057 3.218Ins trum ental help lessness: E 4.467 2.615 3.717 2.596C 6.000 3.229 5.783 3.534Social introvers ion: E 1.800 1.740 2.017 2.172C 3.133 1.959 2.483 1.638Low energy: E 3.933 1.907 3.441 2.061C 4.133 2.875 3.774 2.883Pessim ism: E 4.533 2.200 3.945 1.711C 5.200 2.859 4.412 1.955


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Table (con d)Pretest and Posttest Means and Standard Deviations for the DependentVariables by Each Condition

Pretest PosttestM SD M SDMeasureDefiance: E 5.933 2.738 5.155 2.949C 6.200 3.212 5.488 3.561Suicide risk: E .400 .507 .012 .046C .533 .516 .456 .481Infrequency score: E 2.733 2.154 4.255 1.283C 3.867 1.922 3.388 1.635FPC: E 93.333 76.598 69.333 67.063

C 104.867 76.989 93.356 66.482Note.RCMAS = Revised Ch ildren 's M anifest Anxiety Scale; MDI-C =Multiscore Depression Inventory for Children; FPC = Filial ProblemChecklist; E = experimen tal grou p; C = control grou p

short-term group pt 2002

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