The effectiveness of theraplay and behavior management training to parents to reduce the symptoms of attention deficit hyperactive disorder in children).
The hyperactivity is the most common terms being applied for children with psychological disorder that specifically it is considered as the attention deficit/hyperactivity disorder . According to the results of the US patients controlling center about 4.4 million people of children have been diagnosed with ADHD (center for disease control and prevention, 2005). The plan of the hyperactivity disorder and the attention deficit can be divided into the single intervention to multiple complex intervention therapies. Today, the medication therapy with stimulating medications, parents behavior-based programs, class-based and summer therapeutically interventions are the strongest interventions that they have obtained the most suitable experimental support in this regard. Neurofeedback, dietary, allergy therapy and play-therapy have been also suggested in order to heal the related disorder . According to some experts only two interventions have been vastly applied for the hyperactivity and attention deficit; first the medication therapy can affect on the central neural system  and second the behavior change. The American Academy of Pediatrics considers the combination of these two therapies as the most suitable case for reducing the symptoms of people. About 70% of children under this kind of therapy show the recovery signs of the disease . The benefits of this therapy do not take more than two years . The stimulant medications of the hyperactivity and attention deficit can reduce the educational and social problems as well as the children cognitive affairs such as attention, memory and urgent memory recovering the life quality of these children and increasing the process of learning obtained from the social-mental interventions . Swanson et al  found that most studies represent the positive impact from the medication interventions on the main symptoms of hyperactivity and attention deficit; it is obvious that this kind of intervention can be considered as a part of treatment . According to the Barkley report (1998) about 3545% of the patients are with ADHD and 3-10% have got a combination of ADHD that they never respond to these therapies or treatments and about 70% of children under this treatment show recoveries of the main symptoms of the hyperactivity and attention deficit. The obtained results and experts' viewpoints are completely different together. Along with the impact of the medication therapies on the cognition, educational progression and social skills  in supporting the vastest problems of people with ADHD can overcome the medication therapy issues. Anyway in Iran some researches such as Khoshabi et al., showed that taking Ritalin by ADHD children can rapidly overcome the obstacles of these children reducing the tensions of these children parents indirectly. In the other hand,in educating parents to recognize the symptoms of the related disorder better, the management way of treating children, the way of increasing the positive interactions with children and reduction of the objective behaviors, ignoring the unsuitable behaviors, eliminating the praises and scores in versus unsuitable behaviors, applying target-based planning in public environments, postponing the positive optimizations, applying the school-home notes to praise the school behaviors and the continuation of these tasks at home, reducing tensions between the relations and increasing the parents-dependency issues among children potentiall. Hence, among the carried out studies and the recent approaches in treating the hyperactivity and attention-deficit, the requirement to the multiple interventions is one of the most essential affairs. Parenting management training along with the medication-therapy has been increasingly paid attention in recent decades having the most suitable background in this relation . Patterson  trains the whole parents how to increase their positive interactions reducing the unsuitable behaviors in this regard . Rock and Patterson found out that the role patterns such as teacher and consultant can make positive impact on children ability; in the other hand, Greenberg has emphasized on the dynamic of the relationship between the parents-children vigorously titling it as the Theraplay in this case. The theraplay is made by Greenberg firstly in 1970 in Chicago. The related approach is roughly focused on the recovery of the relationship between parent-child and it is most attractive and physical in this case. Theraplayis coming along with the dependency theories ; it can be adaptive with the growth interpersonal theories particularly in self psychology [24,25,26] and object relation theory [36,37,38,39]. The establishment of the theraplay is based on the importance of the relationship between parent-child as guidance for treatment. According to theraplay children feeling anxiety and unsafely have one of the evaluation indices of the hyperactivity and attention deficit (diagnosis and statistical manual-fourth edition-text revised, DSM-IV-TR). In theraplay treatment, it is tried to make children get into the healthy relationship potentially. These children have enough opportunity to feel safety and security entering into the cohesive relationship with their parents. The caregiver uses his or her fully capacity to adapt and adjust or understand of the children and parents . Theraplay is considered as a model for making healthy relationship between child and parent. A part of the main hypotheses of the approach are as following: interactive relations, experiences are achieved directly, here and present, it is being conducted by adults, cooperation, intimacy, responsiveness and reflection are the main concepts of the process, it is established based on multiple sensation coming with multiplays. The effectiveness of some studies such as Hong  concentrating on the investigation of the theraplay impact on the children self esteem can be felt in this regard; Colman  carried out the same case on autism children; Makela  carried out a study on a domain of problems happening on children behavior; Herbert  achieved a similar study on the attention deficit and hyperactivity that it does not have a background in the Iranian research affairs; considering the multi interventions as behavior management training for the whole parents led to the representation of the question whether theraplay and parent behavior management can reduce the symptoms of the attention deficit and hyperactivity or no? Roshanbin et al in a study carried out the group planning of positive-child nurturing on parenting stress of children 4-10 years old and concluded that this plan can lead to the reduction of parenting stress in the field of child-nurturing affairs. Zarghari et al  specified that parents are not able to make their effectiveness on the reduction of children behavioral problems considerably. The results of Zaree et al  indicated that the behavioral-cognitive theraplay sessions can reduce children behavioral problems potentially. Farzadfar et al  in a study in the field of children-nurturing skills training role on the reduction of mothers tension and children behavioral problems concluded that the mothers of the experimental group had lower tension in compare to the control group and did not show any behavioral problems in this regard. Jadidi et al  concluded that there is observed significant difference between the effectiveness of only two scales of attention and concentration and index of Coners hyperactivity test so that the Ritalin treatment had better effectiveness than the parent management and this significant difference is not observed between three methods of the Ritalin treatment, parent training and nerufeedback in the index of the vibration. But in relation to the effectiveness of these three methods on the recovery of the optimization and parenting dependency, the process of parent management training andRitalin had better effectiveness in compare to the neurofeedback and there is no observed significant difference between the effectiveness of these three groups in the index of the parenting dependency. Sadeghi et al  in a study showed that the function of the family with children of ADHD has been increased due to the influence of the parent management training. Khoshabi et al showed that there is a significant difference between the combination treatments of Ritalin, parents management training and nerufeedback in treating the spiritual problems and attention deficit and concentration so that the combination treatment had the highest effectiveness among these affairs. Mostafavi et al  showed that training the theraplay skills to the mother can reduce considerably the behavioral problems in experimental group in compare to the control ones. Hassani et al  indicated that theraplay based on the behavioral cognitive method can increase the self esteem of the whole children effectively particularly children with the hyperactivity and attention deficit. Bakhshipour et al  concluded that the group-based theraplay can make a better interactive issue among these children with hyperactivity and attention deficit. Other carried out studies showed different results; for example, Janattian et al  concluded that theraplaycan reduce the symptoms of the hyperactivity with attention deficit and responding errors in the post test step increasing the time of response significantly but it does not influence on the responding time. The activities based on theraplay are subjected to structures based on the therapy theory being planned along with the parent management training, learning process and natural relationship and abnormality of children . Moharreri et al reported the effectiveness of the positive parenting training in reducing the symptoms of the related disorder. Goldenberg et al.,  not only consider the training of tension reduction to the parents as an important factor in parents' health but also they showed the same process can be effective for increasing the suitable efficacy of the related children. Theraplayhas been frequently applied in children adaptation problems; for the reason, children showing the vibrating behavioral problems can be prevented by this safe dependency growth . The study of Hoath and Sanders (2002) also specified thatthe application of the positive parenting plan on the relationship between the child-parent reducing their behavioral problems in this case. Makela  studied on 20 children and they used these children as their own behavioral list extraction in the related study. The results of their study showed the significant positive results using the theraplay sessions. Siu (2007) showed that the children in therapy group showed higher self confidence and lower internalization symptoms in compare to the control group. Cross and Howard  figured out that the theraplay is very effective for children with attention deficit and hyperactivity and autism children. Lara et al showed that about 50% of children with attention deficit and hyperactivity show the same adults symptoms; for the reason, it seems that along with the medication therapy, the completion of the psychological treatments and theraplay is very necessary for reducing the symptoms of the attention deficit and hyperactivity of children.
MATERIALS AND METHODS
Sample and sampling method:
The dose of taking daily medication and Ritalin for six months was fixed among children with hyperactivity established in district 4 of Tehran ranging from 7-12 years old and they were divided into three groups of 45 people accidentally in two groups of experimental and a one control group.
Research completion method:
First 45 people of the research population were taken up from the children with hyperactivity and the questionnaire of CSI-4 was given to the parents of these children. Theraplay was given to the experimental group of children to achieve it in ten sessions individually and the behavior management was also given to the parents in ten sessions. After the completion of the sessions the same questionnaire was given to the whole groups as a post test; it should be mentioned that there was no given any consultation for the control group. Also the CSI-4 test was achieved again in order to investigate the effectiveness of the test after passing one month.
Measurement instrument: children disease symptoms inventory (CSI-4):
This questionnaire is designed by Sprafkin and Gadow in 1984 based on DSM-III in order to analyze eighteen behavioral and excitement disorder of children ranging from 5-12 years old; and it was revised again in 1994 along with its fourth printing of DSM-IV being called CSI-4. CSI-4 has two forms of parents and teachers. The reliability of the questionnaire is established based on Cronbach alpha coefficient for parents 0.79 and 0.75 for teachers.
Table 1: results of Levin F test to investigate the equality of variances Proportion Sig of Levin F 1st DF 2nd DF level Symptoms of attention 2.9 2 42 0.06 deficit and hyperactivity
As it mentioned in table 1, the significance level is measures the Levin F test higher than 0.05 in the score of the attention deficit and hyperactivity; hence the zero hypothesis of Levin F test is confirmed; that is, the variance of three groups is equal together in the score of the attention deficit; thus, the mentioned scores have the ability of parametric statistics completion; schefe following-up test and single variance analysis parametric statistics were also applied in order to test the hypotheses in this case.
The single variance analysis statistics is used to investigate the mean difference of the attention deficit and hyperactivity scores between experimental and control groups. The significance level F is lower than 0.05 (p=0.001) representing the significant level statistically. Thus it can be concluded that there is a significance difference between the means of experimental and control groups.
There is a significance difference between the means attention deficit and hyperactivity disorder of theraplay intervention and behavior management training group (Sig = 0.001); hence it can be stated that the difference between the means of two groups is not accidental and the variable of the group consultation can influence on the hyperactivity and attention deficit of children. Due to the means of the above mentioned table, the degree of the mean scores of pre and post tests in experimental group 1 is higher (intervention-therapy of theraplay); it can be stated that the effectiveness of the intervention-therapy is enough to reduce the symptoms of the hyperactivity and attention deficit among the related children.
There is a significance difference between the means attention deficit and hyperactivity disorder of theraplay intervention and behavior management training group (Sig = 0.001); hence it can be stated that the difference between the means of two groups is not accidental and the variable of the theraplay intervention can influence on the hyperactivity and attention deficit of children. Due to the means of the above mentioned table, the degree of the mean scores of pre and post tests in experimental group 1 is higher than the control group (intervention-therapy of theraplay); There is a significance difference between the means attention deficit and hyperactivity disorder of theraplay intervention and behavior management training group (Sig = 0.398); hence it can be stated that the difference between the means of two groups is accidental and the variable of the behavior management training can influence on the hyperactivity and attention deficit of children.
Tdependent statistics is used in order to investigate the means symptoms of attention deficit and hyperactivity in the group of theraplay intervention; the measured t is about T=0.695, DF= 14 that it is higher than 0.05 as the significance level; hence it is observed that it is not significant statistically (Sig= 0.499); it can be stated that the difference between the means of two test steps is accidental and the variable of time cannot be effective on the degree of attention deficit and hyperactivity disorder; hence, the degree of the theraplay is sustainable on reducing the symptoms of the attention deficit and hyperactivity.
Tdependent statistics is used in order to investigate the means symptoms of attention deficit and hyperactivity in the group of theraplay intervention; the measured t is about T=1.78, DF= 14 that it is higher than 0.05 as the significance level; hence it is observed that it is not significant statistically (Sig= 0.096).
The significance level of Levin F test is higher than 0.05 to investigate the variances of two groups (sig=1); thus it can be stated that the variances of two groups are equal together; T dependent statistics is used in order to investigate the means symptoms of attention deficit and hyperactivity in the group of theraplay intervention; the measured t is about T=1.74, DF= 28 that it is higher than 0.05 as the significance level; hence it is observed that it is not significant statistically (Sig= 0.096).
Discussion and conclusion:
There is a difference between the effectiveness of theraplay and behavior management training in reducing the symptoms of the attention deficit and hyperactivity of children. In this field, there is no found any research background for two approaches; however, there have been carried out some researches like Jadidi et al , Hajebi and Khoshabi et al showing that the approach of the behavior management training is not only factor to reduce the symptoms of the related disorder. Theraplay is very effective in reducing the symptoms of the attention deficit and hyperactivity of children. This finding is coincident with the research of Wetti and Franke carrying out various studies in the same field and they concluded that the theraplay can be effective on children with attention deficit and hyperactivity. Also it is coincident with the studies of Greenberg representing the recovery of children with hyperactivity and attention deficit. Morgan showed the influence of the theraplay on the optimization of self-confidence, self esteem and self control. About 16 children in a five months course in New York without the observation group were investigated and they were completed based on the Likert Scale (positive, little positive, without change, negative) by teachers and parents. In the end the results showed 90.9 recoveries of parents and teachers in this pavement while the ranking by the caregiver showed 62.5 recoveries in this regard. The behavior management training to parents is very effective in reducing the symptoms of the attention deficit and hyperactivity. In the present study the behavior management training could not make influence on reducing the symptoms of the attention deficit and hyperactivity; this finding is coincident with the research of Zargharinezhad et al showing that the behavior management training did not have considerable influence on the reduction of the same disorder potentially; but the research of Balali et al showed that the plan of the parent training is very effective in reducing the children behavioral problems. This is not coincident with the above mentioned study. Also the research of Jadidi et al  concluded that there is a significant difference between the effectiveness of three methods of Ritalin, training parents and nerufeedback in two scales of attention and concentration and index of Coners hyperactivity test ADHD so that the Ritalin treatment is very effective in compare to the parent training; the research of Hajebi et al indicated that the scores of the evaluation scale of Coners test is significant in terms of the parents management training and child-parent interactions. Hence, the process of parents' management training can be effective in the recovery of the children with ADHD symptoms. The effectiveness of theraplay is sustainable in reducing the symptoms of the attention deficit and hyperactivity. The difference between the means of two tests is accidental and the variable of time could not be effective in children with hyperactivity and attention deficit. Thus the degree of the theraplay effectiveness on the reduction of the disorder is going towards the sustainable time. There is no found any confirming factor for the above mentioned study here.
The effectiveness of the parent management training is subjected to the time sustainability in this regard since the observed difference is not significant statistically (sig=0.096); this finding is not coincident with the research result of Balali et al concluding that the difference of score in experimental group is significant than the observation or control group after 4 months ending the training course; however, the research of Alizadeh showed that parent training did not influence on the reduction of the symptoms (p>0.05) that it is coincident with the research. Also the research of Barlo and Corn and Wels et al indicated that the lack of parent behavior management training could be happened that it is coincident with the same research. Here it can be pointed to the research of Barlo and Corn that they have carried out a meta-analysis regarding to the related interventions and the parents educational or training affairs; they concluded that about one-third of the parent training interventions cannot reach to the significant difference between the experimental and control groups. The degree of the two interventions programs could be subjected to the time suitability in order to reduce the symptoms of the attention deficit and hyperactivity potentially. The analysis of the research hypothesis showed that due to the significance level higher than 0.05 errors; hence it is observed thatit is not significant statistically (sig=0.096). in this field, there is no found any research to confirm the effectiveness of the theraplay and behavior management training in this case.
Received 26 September 2014
Received in revised form 20 November 2014
Accepted 25 December 2014
Available online 2 January 2015
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(1) Faezeh Askari, (2) Ali Delavar, (3) Abdollah ShafiAbady
(1) Department of Counseling, Science and Research Branch, Islamic Azad University, Tehran, Iran.
(2,3) Professor of Tehran AllamehTabatabaie University, Tehran, Iran.
Corresponding Author: Ali Delavar, Professor of Tehran AllamehTabatabaie University, Tehran, Iran E-mail: email@example.com
Table 2: results of single variance analysis statistics for the difference scores of attention deficit and hyperactivity between three groups (theraplay intervention therapy, behavior management and control group) Resources Variable of changes Total squares DF Symptoms of attention Between groups 84.31 2 deficit and hyperactivity Intergroups 47.6 42 Total 131.91 44 Variable Mean squares Proportion of F Sig level Symptoms of attention 42.15 37.19 0.001 deficit and hyperactivity 1.13 Table 3: results of Scheffe test to compare the means of the pre and post tests scores of attention deficit and hyperactivity between experimental and control groups Behavior Groups Groups Theraplay management Control Means -3.07 0.47 -0.07 Theraplay -3.07 -- 0.001 0.001 Behavior management 0.47 0.001 0.398 Control 0.07 0.001 0.398 -- Table 4: attention deficit and hyperactivity of theraplay intervention between the following-up and post test Difference Mean Std deviation of means Following up 5 1 0.133 Post test 4.86 1.12 Degree of t DF Sig level Following up 0.695 14 0.499 Post test Table 6: results of t dependent groups to investigate the mean difference of the attention deficit symptoms and hyperactivity of parents' behavior management training of experimental group between the following-up and post tests Mean Std deviation Difference of means Following up 6.13 1.06 -0.33 Post test 6.46 0.91 Degree of t DF Sig level Following up -1.78 14 0.096 Post test Table 7: results of t dependent groups to investigate the mean difference of the attention deficit symptoms and hyperactivity of parents' behavior management training of experimental group between the following-up and post tests Mean Std deviation Difference of means Theraplay 0.13 0.743 0.467 Parent behavior -0.33 0.724 management Degree of Levin F Sig level Theraplay 0.001 1 Parent behavior management Degree of t DF Sig level Theraplay -1.74 28 0.092 Parent behavior management
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|Author:||Askari, Faezeh; Delavar, Ali; ShafiAbady, Abdollah|
|Publication:||Advances in Environmental Biology|
|Date:||Dec 15, 2014|
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