Theraplay for Attachment-Related Challenging Behaviour: A Case Series Approach

Childhood challenging behaviours is a common reason for referrals to child and adolescent mental health services. Challenging behaviours have been linked to various implications, including later mental health difficulties, risk-taking behaviours, and increased costs to society. Several risk factors are associated with challenging behaviours, including attachment insecurities. First line intervention for childhood challenging behaviours is Parent Training Programmes (PTP). PTP’s have a well-established and rigorous evidence-base demonstrating good effectiveness. Nonetheless, there are several limitations to PTPs including difficulties with engagement and attrition, alongside PTP’s locating the ‘problem’ within the parent. PTP’s are largely underpinned by behavioural and social learning theory and reportedly lack consideration into the parent-child relationship and attachment. Theraplay is an attachment and play-based therapeutic approach implemented in many services across the world despite there only being a limited evidence base. However, it has been found to be a promising approach for various presenting difficulties including challenging behaviours. Theraplay is hypothesised to create change in children’s internal working models by strengthening the overarching parent-child interactions based on four core concepts: Structure, Engagement, Challenge, and Nurture. Change is facilitated through sessions with the child, parent, and therapist using games based on the four concepts. Despite Theraplay’s world-wide use, the evidence-base is scarce and is lacking in design rigour. An increase in both the quantity and quality of research into Theraplay’s effectiveness, alongside if (and how) Theraplay works seems appropriate. The current study could be deemed a valuable contribution to the evidence base of an under-studied approach. The current study implemented a multiple case series design to investigate the effectiveness of Theraplay on challenging behaviour and parent-child attachment. The case series design allowed investigation into Theraplay’s key processes of change; a) Theraplay’s four core constructs, and b) child attachment. Three families participated in baseline, intervention, and follow-up phases. A mixed method approach of data collection and multiple forms of analyses was implemented. In light of COVID-19, the Theraplay interventions for two families were adapted and ended abruptly in line with service and governmental restrictions. Results found no evidence of Theraplay being effective at reducing childhood challenging behaviour and enhancing parent-child attachment. Gradual, yet positive, increases in Theraplay-based interactions and mechanisms of change were observed. However, the change in mechanisms had no effect on challenging behaviour or attachment. Findings may have been influenced by the measures used and the limited number of sessions implemented. Further research is warranted into Theraplay’s effectiveness. In particular, the use of a ‘gold standard’ attachment measure alongside intervention is recommended, with more understanding into the parental role as the potential mechanism of change within sessions required