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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 3  |  Issue : 3  |  Page : 186-191

Investigation of cognitive-behavioral play therapy effectiveness on cognitive functions in aggressive children


1 Department of Psychology, Faculty of Psychology and Educational Sciences, Tehran University, Tehran, Iran
2 Department of Psychology, Shahid Beheshti University of Medical Sciences and Health Services, Tehran, Iran
3 Department of Psychology, Faculty of Educational Science and Psychology, Shahid Beheshti University, Tehran, Iran
4 Department of Psychology and Education Science, Islamic Azad University, Tehran, Iran

Date of Web Publication29-Nov-2017

Correspondence Address:
Zahra Heidari
Department of Psychology, Shahid Beheshti University of Medical Sciences and Health Services, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jepr.jepr_18_16

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  Abstract 


AIMS: Several brain regions are known to be involved in aggressive behavioral including dysfunction in brain regions contributing to executive functions that lead to loss of some cognitive performance (CP). Play therapy (PT) as an effective treatment is used for a long time and it has a therapeutic effect on cognitive functions. Creativity, learning coping technique, social problem-solving ability, and self-controlling are some of main outcomes of this treatment. This study investigated the effect of cognitive-behavioral PT (CBPT) on working memory (WM), response inhibition (RI), and CP of aggressive children.
METHODS: In a pre–post-design, 18 children with aggressive behavioral were randomized into two groups: experimental and control. Interventions were provided 12 sessions and progressed up to 1 h per session. Executive Function and Stop Signal Task of Cambridge Neuropsychological Test Automated Battery tests were used in pre- and post-assessment.
RESULTS: Findings demonstrated that the treatment improved in RI and CP of aggressive children in experimental group significantly (P < 0.05), but this change is not apparent in WM (P > 0.05).
CONCLUSION: CBPT could be an effective intervention for children with aggression to improve their CP. However, despite this effectiveness, choosing the appropriate exercises to engage more cognitive functions is an important factor for optimizing of this treatment.

Keywords: Aggressive children, cognitive-behavioral play therapy, cognitive performance, executive function


How to cite this article:
Rostami R, Mojtahedy SH, Heidari Z, Ranjbari G, Sadeghi-Firoozabadi V, Ahmadi M. Investigation of cognitive-behavioral play therapy effectiveness on cognitive functions in aggressive children. Int J Educ Psychol Res 2017;3:186-91

How to cite this URL:
Rostami R, Mojtahedy SH, Heidari Z, Ranjbari G, Sadeghi-Firoozabadi V, Ahmadi M. Investigation of cognitive-behavioral play therapy effectiveness on cognitive functions in aggressive children. Int J Educ Psychol Res [serial online] 2017 [cited 2024 Mar 29];3:186-91. Available from: https://www.ijeprjournal.org/text.asp?2017/3/3/186/219423




  Introduction Top


Emotions have particular neural models and involve special cortical and subcortical orbits.[1] There are evidences that the body functions can be effective in the development of emotional experience.[2] Indeed, aggressive behavior as a result of human emotions is related to some of the brain structures including, but not limited to, amygdala, hypothalamus, periaqueductal gray, ventral tegmental area, septal area, inferior temporal cortex, orbitofrontal cortex (OFC), and cerebellum.[3] Investigation of human's aggression is flowed by focusing on the role of OFC [4] and prefrontal cortex,[5] which studies demonstrated the link between dysfunction of the both areas and other brain regions, which is involving in executive functions, and aggressive behavior.[6],[7],[8] Prefrontal cortex is highly developed and responsible for many of the most advanced and “human-like” of abilities and plays a primary role in the planning, initiation, integration, and implementation of complex behavioral acts which are labeled as “executive” by neuropsychologists.[9] Researchers found evidences of the deficit executive function role in expression of aggressive behavioral.[10],[11] As there are evidences that there is relation between some aspects of working memory (WM) and physical aggression,[12] and deficit in this function can be leads to impulsive decision-making.[13] Finn et al., by investigating WM and associative learning in some who have positive or negative family history in alcoholism, revealed the moderating role of WM in behavioral inhibition system settings.[14] Moreover, the relevance of response inhibition (RI) deficit and aggression especially rage was discovered by researchers as using the stop signal task shows low rates of response control in aggressive children.[15]

Prevailing treatment against aggression and violence is neuroleptic.[16] Cognitive-behavioral therapy,[17] emotional self-regulation,[18] and some other kind of therapies were used to deal with aggression. Play therapy (PT) is one of the therapeutic interventions, which was applied to control of aggression using play as the main way of children to show their feelings, motivations, fantasies, and engages [19] and scientists believe that play can be a suitable replacement of language abilities which are weak in children.[20] Individual PT for children, who exposed to stress factors, is effective in reducing maladaptive behaviors [21] and increasing behavioral control.[22] Group PT can be effective in improving social skills and adaptive behavior.[23] Overall, play involves different parts of the brain including motor, visual, auditory, and other sensory areas [2] and in nature needs moment-to-moment process in different body and emotional aspects. Due to this kind of nature, coordination among sensory inputs, motor response, and reflective thoughts and also intervene of emotion and awareness is necessary. The importance of play and feelings in developing the neurobiological function is well supported by scientific researches.[1]

Play contains elements of conformity, disorder, and reconstruction; executive and reflective functions develop during it.[24] Play seems to be effective in the cerebral cortex and frontal lobe maturation and enhancement of higher cognitive abilities such as mental performance.[25] Further, play was introduced as a mechanism to promote problem-solving skills [26] and emotion expression.[27]

Direct information about mechanisms of the game is not available. However, researches about the mechanism of play and physical activity on the brain being done which investigates these mechanisms in both of molecular and supramolecular levels.[28] Brain neurotrophic factors transcription, particularly in the amygdala and the prefrontal cortex, are one of that mechanism that scientists suggest its effectiveness on improving mood and cognitive function.[29] In nonbiological approaches, language ability in children [30] which is known to be effective in both of aggressive behavioral and executive functions [31] and theory of mind, due to the relationship between executive functions, particularly RI, and misconceptions of beliefs and modes,[32] is being investigated by researchers as two important areas.

Considering common neurological bases of aggressive behaviors and cognitive process, the accurate effects of the interventions which aimed these behaviors like PT, on this high brain process, are not clear. The investigation of cognitive-behavioral PT (CBPT) effect on WM, RI, and cognitive performance (CP) is the main aim of this study. For this, cognitive process changes were assessed by Cambridge Neuropsychological Test Automated Battery (CANTAB) tests which are provided by Cambridge Cognition Board. This computerized individual tests show strong link between brain structure and cognitive deficits in different dysfunctions and also is sensitive to interventions and changes.[33]


  Methods Top


This study utilized a pretest/posttest comparison group design to examine the effects of PT on the WM, RI, and CP of children with aggressive behavioral. For the first step, all participants provided written informed consent.

Participants

The population studied was comprised of volunteer children identified as aggressive by parents and their teachers. Eighteen children aged 6–9 years qualified for the study and were randomly assigned to the experimental (PT) and control groups. Nine of the children were assigned to PT and nine were assigned to control. Over the course of the study, two children were removed because of incomplete treatment period and assessment sessions, so the final sample was made of 16 children. The description information for the 16 children in the study is given in [Table 1].
Table 1: Description information of participants

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Procedures

Participants were interviewed using the DSM-IV Structured Clinical Interview for attention deficit/hyperactivity, conduct disorder, and other psychological dysfunctions. Persons who receive psychotic disorder and mental retardation diagnosis were role out from the sample. Participants were evaluated by computerized version of conduct behavioral checklist (Child Behavior Checklist [CBCL]) and were recruited randomly into two groups, experimental and control. The first group was treated by individual CBPT for 4 weeks (three sessions per week). The second group did not receive any intervention between pre- and post-assessment. All subjects complete Spatial WM (SWM), Stop Signal Test (SST), and Stockings of Cambridge (SOC) tests of CANTAB as pre- and post-assessment.

Tools

The Child Behavior Checklist

The CBCL is a well-established and recognized instrument for the identification of behavioral and emotional difficulties in children aged 6–18 years. It consists of 113 items and takes approximately 20 min to complete. These items are rated from 0 to 2 (not true, sometimes true, and often true).[34] Test-retest reliability for all six DSM-Oriented Scales for Iranian society reported 0.89 (α = 0.94).[35]

Cambridge Neuropsychological Test Automated Battery

CANTAB technology contains a suite of touchscreen-based automated neuropsychological tests of cognition, specifically designed to assess central nervous system disorders and cognitive function across a range of domains, including memory, executive function, attention, decision-making and social cognition. Using CANTAB technology ensures studies sensitively detect even the most subtle cognitive effects are easy to set up, administer, and report saving costs, reducing data errors, and increasing the accuracy and validity of study results.[33] All CANTAB tests show good test-retest reliability, and in some studies, correlation coefficient of 9 is obtained for it.[33]

In this study, SWM, SOC, and SST tests (subtest of decision-making) were used to assess cognitive function of participants. [Table 2] shows detail of these tests.
Table 2: Administration time and outcome measures of spatial working memory, Stop Signal Test, and Stockings of Cambridge

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Executive function battery

Executive functions contain six computerized tests: One Touch Stockings of Cambridge (OTS), Attention Switching Task, SOC, Intra-Extra Dimensional Set Shift, Spatial Span, and SWM of which two of six were used. SOC is a spatial planning test which gives a measure of frontal lobe function, and SWM requires retention and manipulation of visuospatial information. This self-ordered test has notable executive function demands and measures strategy use as well as errors.

Stop Signal Test

SST is a classic stop signal RI test, which uses staircase functions to generate an estimate of stop signal reaction time. This test gives a measure of an individual's ability to inhibit a prepotent response.[33]

Data analysis

Kolmogorov–Smirnov test confirmed the normality of data. Comparing analysis of two groups was done by independent t-tests, and for intergroup comparison, paired t-tests was used. To evaluate the homogeneity of data, Levine test was used.


  Results Top


Data normality

[Table 3] shows the Kolmogorov–Smirnov test outputs for checking data distribution. According to the normal distributions of all variables (P > 0.05), data analysis was followed by parametric tests.
Table 3: Investigation of data distribution by Kolmogorov–Smirnov test

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Data analysis

Statistics details and the result of comparing pre-posttest of Play therapy (PT) and control groups have been shown in [Table 4]. Extreme data were omitted because of some limitations and prerequisite of statistical analysis.
Table 4: Statistic report and means comparison of cognitive functions

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Due to the results of Levin test in the mentioned three functions was upper than the error rate (Response Inhibition (RI) significant = 0.245; WM significant = 0.563; CP significant = 0.155), t- test was applied in equal variances assumed. Outputs showed no significant difference in the baseline (all P > 0.05). In between-group comparison, RI and CP demonstrated significant difference in postassessment (P < 0.05) although there was not the same in WM (t = 1.547, significant = 0.147).

Significant level in paired t-test of RI was lower than the error rate (significant = 0.0429). However, it was in the error rate in WM and CP (P > 0.05). [Table 5] illustrates the result of paired t-test.
Table 5: Posttest intergroup comparison of cognitive functions

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  Discussion Top


This study demonstrates CBPT effect on two of three mentioned cognitive functions in aggressive children. RI is one of them that show changes in both of inter- and between-group comparisons. PT as a fortune to express feelings and emotions in a new way (including fiction, theater, and conversation), can influence RI during the treatment sessions by increasing the language ability. This effect on expressing problems has been approved and associated with increasing communication skills in both expressive and understanding dimensions.[30] Due to the existed assumptions of deficit of expressing ability in aggressive children and the interaction of this deficit with cognitive executive function specially WM and RI,[13] it is possible to assume a kind of relation between increasing the skills and functions. More investigation is necessary to support this assumption.

Stop thoughts and remote control games as the self-controlling and RI tasks, by presenting conditioning principle, providing awards, direct learning effect, playing role and stories, highlights observational learning effects that suggested by social learning theory. According to social learning theory, observational and instrumental learning can play critical role in showing impulsive and aggressive behaviors and on the other hand can be effective in self-controlling.[36]

Theory of mind which refers to interpreting of mental and emotional states abilities can contribute to the improvement of RI. Studies clear the relation between executive functions specially RI and misunderstanding of beliefs and states.[32],[37] In PT, particularly in emotion controlling program, children face up to different educational an experimental situations to identify and replace emotions, beliefs, and states. Possibly the mentioned experiments and trainings can influence their RI through the theory of mind.

In considering association of RI in cognitive level and impulsive and self-controlling in behavioral aspect,[38] the result of this study was supported by others that work in behavior levels. As in the accomplished studies, individual and group PT's increased self-control (SC) rating.[22] Furthermore, cognitive-behavioral therapy effectiveness on SC,[39] inhibitor role of psychological intervention such as PT on impulsive actions,[40] and the effect of PT on adjustments [41] was proved.

WM shows no significant change in both inter- and between-group investigations that is in contrast with the scant studies of MW affectability during behavioral interventions. As adaptive training can influence WM function,[31] mindfulness plays protective role.[42] This contradiction can come up because of variety in duration, aimed group, treatment protocol, etc.

Cognitive functions improvement was distinctive in comparison of CP posttest scores between groups. Due to direction of maturation from aggressive response to social problem-solving and utilization of verbal ability as a mediator to present negative feedback encounter to inadequate actions,[43] it is possible to consider cognitive ability as effective factor in control of aggression. PT provides efficient situation to learn problem-solving skills particularly in social and emotional views. Existed identifying emotions, coping technique, and conclusion tasks in the plays was applied to improving problem-solving ability using conditioning and learning principles. Furthermore, pretend play suggested as effective factor in cognitive improvement by researchers.[44] Many evidences support the relation of cognitive eligibility and pretend play,[45] reduction in aggressive response as a result of increasing problem solving, specially was approved.[46] PT known as a sufficient way to facilitate creativity and cognitive process [47],[48] beside the lasting effect on verbal intelligence and thinking fluid.[49]

PT as effective treatment in controlling the aggressive and impulsive response and improving problem-solving, impulsivity and social communication was considered for a long time. The results of this study are in line with the previous findings.


  Conclusion Top


CBPT could be an effective intervention for children with aggression to improve their CP. However, despite this effectiveness, choosing the appropriate exercises to engage more cognitive functions is an important factor for optimizing of this treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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