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This case study aims to report on the psychological assessment and intervention for a 4-year-old preschooler with selective mutism. A comprehensive assessment that involves parents and teacher interview, classroom observation, Seguin Form Board Test (SFBT), Vineland Adaptive Behaviour Scales Third Edition (Vineland-3), Behaviour Assessment System for Children, Third Edition (BASC-3), Childhood Autism Rating Scale, Second Edition Standard Version Rating Booklet (CARS 2-ST), and School Speech Questionnaire were conducted. The psychological assessment revealed that the child fulfils the criteria for selective mutism. Play-based intervention sessions were then conducted, which involved gradual exposure to the child's teacher and peers and facilitation of verbalization related to child's interests and classroom routines. The child demonstrated improvement in her frequency of verbalizing in the classroom following the intervention, as supported by the improved score in the School Speech Questionnaire (SSQ). This case study illustrates the advantages of a collaborative approach that engages parents, teachers, and peers in the management of selective mutism during early childhood.

The neurodiversity movement challenges the medical model of disability by framing neurodevelopmental disabilities as natural neurological variations rather than deficits. Consequently, as discourse on neurodiversity-affirming practices expands, there is a growing imperative for tailored implementation in school counselling. By emphasising client agency, strengths, and understanding, person-centred therapy arguably holds the potential to support neurodivergent student wellbeing within school counselling and across a multi-tiered system of support. The person-centred therapy modalities, including traditional person-centred therapy, pre-therapy, child-centred play therapy, school-based filial therapy, and collaborative and proactive solutions, offer the flexibility to accommodate diverse age groups, developmental stages, and communication styles. Overall, adopting a neurodiversity-affirming school counselling approach underscores a paradigm shift that supports the wellbeing and autonomy of neurodivergent students.

Therapeutic playgroups have potential to benefit families and children enrolled in early intervention. A pretest-posttest, mixed methods, sequential explanatory design was utilized to explore the effectiveness and feasibility of an 8-week SEE Me (Social Emotional Education) therapeutic playgroup delivered by a collaborative team of providers using a convenience sample of 28 parent and child dyad participants and 19 early intervention providers. Results indicated statistically significant improvements in parent efficacy and parent-child interaction (affection and responsiveness) following participation. Parents and providers highlighted the role of the parent and reported improvements in child engagement, social interaction, and skill development in successful playgroups. Play activities and objects, facilitator support, and parent capacity were rated as supports for feasible delivery; challenges included child engagement and program implementation. These results provide preliminary evidence for both the effectiveness and feasibility of providing therapeutic playgroups as part of comprehensive early intervention services.

Schools are increasingly encouraged to adopt evidence-based or evidence informed interventions and implement them using insights from implementation science. The literature relating to implementation of interventions in schools has focused largely on universal interventions, particularly for social and emotional learning (SEL), which are designed for all children and young people. In contrast, targeted interventions provide additional support for those pupils who may require small group or individual support over and above that provided at the universal level. To date there has been limited consideration of factors which are important for the implementation of targeted SEL interventions. Data from an exploratory case study with two schools implementing Lego therapy are used to illustrate the implementation factors relevant to this targeted intervention. Findings indicate similarities in universal and targeted intervention core components and factors but also a number of distinct elements that are important to consider when implementing Lego therapy and potentially other targeted SEL interventions. Key considerations include the interaction with the wider school system, the pivotal role of the intervention champion, and the importance of external support for problem solving and sustainability. The resulting model may inform further development of implementation frameworks for Lego therapy and other targeted SEL interventions.

School counselors play key roles in recognizing and addressing students' social-emotional and academic needs and providing short-term counseling and crisis interventions focusing on mental health concerns. Research shows that play therapy is a developmentally responsive intervention for school-aged children (Ray et al., 2014). Many school counseling programs in Taiwan offer play therapy as an elective course in school counselor preparation programs. In the current study, we conducted a phenomenological research to examine 21 pre-service elementary school counselors' perceptions of play therapy training in Taiwan. Analysis of qualitative data yielded four major themes: (a) enhanced understanding of children's world, (b) the power of toys and play, (c) value of play sessions and observers' feedback, and (d) enhanced self-awareness and professional growth. Findings of this study have the potential to inform school counselor education and teacher education training regarding therapeutic skills and attending to children's social-emotional and behavioral growth. Limitations of the study, implications for counselor educators, and recommendations for future research are discussed.

This study aims to examine Child-Centered Play Therapy's effect on reducing behavioral problems in five- and six-year-old children living in Istanbul. The study was conducted with 20 children from socioeconomically disadvantaged families. Families applied for support to a play therapy room established in a primary school. A pre-test and post-test control group design is used. Child-Centered Play Therapy sessions were implemented in the experimental group for eight weeks as individual sessions. Data due to the children's behavior problems were collected from parents via the "Social Competence and Behavior Evaluation-30 Scale" and the family pre-interview form. Mann Whitney-U Test and Wilcoxon Test analyzed data. Results of the experimental group (ingroup analyses) show a significant difference between pre-test and post-test scores of social competence, anger aggression, and anxiety withdrawal subscales, as hypothesized. However, analyses of between groups' post-test comparisons show significant differences only in the social competence subscale. Between groups, post-test scores, comparisons of anger-aggression, and anxiety withdrawal subscales showed no significant differences. The results are discussed; additionally, observations of the researcher as a play therapist are presented.

Background: The target group of this study concerns young people with a mild intellectual disability. The central research question is: What evidence can be found in the literature for common and specific factors for a play therapy intervention for young people with a mild intellectual disability struggling with aggression regulation. Method: The criteria used for selecting articles are presented according to the PRISMA, and the PRISMA guidelines for writing a review have been applied. Results: Common factors have been found in the literature that relate to the relationship between therapist and client and the therapeutic skills of the play therapist. Clues have also been found for specific factors of play therapy, such as the use of play as a language and a connection with the child's inner world. In addition, certain factors have been found that are specific to the target group of this article. The non-verbal element of play therapy is an active part of this.

This study investigated the impact of a 'Jewellery Club' on girls with social, communication and interaction difficulties. The project focussed on three girls aged seven who participated in an intervention using similar principles to the 'Lego Therapy' intervention. An action research approach was followed, where two phases of the intervention were undertaken with participants engaging with a weekly 20 min session for 3 weeks per phase. The impact of the intervention was assessed through the use of a social difficulties log, field notes and unstructured interviews with parents. Findings identified an overall reduction in social difficulties and social anxiety related to school as well as improved play experiences for the participants during unstructured school times and highlighted the importance of the intervention being aligned with the interests of the participants. The findings suggest that reflection on the gendered nature of interventions may be useful when considering how research might be implemented in practice.

Gaming is a natural process for the child, and with the play therapy technique used in this process, opportunities are offered to the child to express their problems and emotions by playing. Play therapy is used in many studies with children. The number of studies conducted on the effectiveness of play therapy in Turkey is increasing with each passing day. In this study, experimental graduate studies related to the play therapy education program from the past to the present (1987-2020) were examined and the results were brought together. A total number of 38 master's and 8 doctoral studies were reached in the YÖK (Council of Higher Education) thesis center related to the subject, but only 7 studies in accordance with the inclusion criteria were analyzed with meta-analysis method. While examining the postgraduate studies, care was taken toward the existence of an experimental and control group in which play therapy was applied. The studies in which play therapy was applied to the experimental group but not the control group were included in this study. In order to calculate the effect sizes, average (X), standard deviation (SS) and sample size (N) values from master's theses were processed in the Excel program. Later, CMA (Comprehensive Meta Analysis) statistical program was used for the analysis required for the study, "Hedges's g" was used to calculate the effect size and the Excel program was used for the collection-processing of the data. As a result of the research, it was found that the effect size of play therapy on children's behaviors has an excellent effect size. It was concluded that 5 of the studies included in the study were excellently effective, 1 was moderately effective, and 1 was broadly effective. These limited studies provide information that play therapy has a positive effect on children.

The purpose of this article is to investigate the efficacy of Sandplay Therapy (SPT) in reducing children's kindergarten entrance anxiety in an effort to provide front-line preschool teachers with insights and strategies for addressing the emotional distress of children in their first days of nursery school. As a case study, the application of SPT to a 3-year-old boy who struggled with his transition into kindergarten was cited. The differences in his emotions and behaviors before and after six sessions of SPT were evaluated, revealing that the intervention through SPT significantly decreased his anxiety level while increasing his willingness to attend nursery school and that he finally developed a sound adaptation to the school, according to the comments of the observers. Findings showed that SPT could help kids feel less nervous about starting kindergarten and adjust better to new situations.

School counselors need creative interventions to engage students in small groups. With students' interests changing quickly, one thing that has remained constant has been a fascination with comic books. They offer an enjoyable and creative way to engage children with stories that resonate with them. Additionally, bibliotherapy is an accessible and easy to implement strategy for children of all ages. This article will discuss the utilization of a comic book in a superhero bibliotherapy group with a diverse group of fourth and fifth grade students from a Gestalt perspective.

School counselors are uniquely qualified to meet the increasing mental health needs of students within the school setting. Play therapy is an evidence-based intervention used by school counselors to address the mental health needs of youth. Job demands require school counselors to provide goal-focused and time-sensitive interventions. Accordingly, this article describes how to utilize play therapy within the ASCA National Model and provides examples for elementary school counselors implementing play therapy interventions with students. A case example illustrates individual play therapy goal setting.

The aim of this study is to examine the effect of psycho-education programme based on structured play therapy on the depression and adjustment levels of divorced family children. A structured play therapy psycho-education programme was applied to the experimental group in the research that was carried out with the participation of 16 child between the ages of 9-12 whose parents were divorced. In the study, a semi-experimental design was used in 2X3 (experimental-control group X pre-test/post-test/follow-up test). As a result of the research, it was found that the psycho-education programme developed based on structured play therapy was effective in increasing divorce adjustment levels of 9-12-year olds children whose parents divorced and reduced their depression levels.

Social learning through friendships is important in child development. Autistic children often initiate and engage in social interactions differently than neurotypical peers. LEGO® based therapy is a group intervention which facilitates social interactions with peers using collaborative LEGO® play. A 1:1 cluster randomised controlled trial with autistic children aged 7-15 comparing 12 weeks' LEGO® based therapy and usual support to usual support alone in 98 mainstream schools (2017-2019) was carried out. The primary outcome was social skills (Social Skills Improvement System) completed by unblinded teachers (not intervention deliverers) at 20 weeks. Analysis used intention-to-treat. Fifty intervention schools (127 participants) and 48 control schools (123 participants) were allocated. Primary analysis included 45 intervention schools (116 participants) and 42 control schools (101 participants). The between-arms difference was 3.74 (p = 0.06, 95% confidence interval: -0.16, 7.63) and 1.68 (p = 0.43, 95% confidence interval: -2.51, 5.87) at 20 and 52 weeks (0.18 and 0.08 standardised effect sizes). Twenty-week outcomes for those receiving per protocol intervention were 4.23 (95% confidence interval 0.27, 8.19) with a standardised effect size of 0.21. Sensitivity estimates were between 3.10 and 4.37 (0.15-0.21 standardised effect sizes). Three unrelated serious adverse events were reported. LEGO® based therapy has a small positive non-significant benefit for social skills at 20 weeks but not 52 weeks.

The COVID-19 pandemic has undoubtedly impacted families worldwide. The long-term impacts of the pandemic's disruptions on childhood and child development may not be known for many years. Early educators can respond to challenges stemming from the disruption in the consistency of schooling and beneficial programming for early learners by generating supportive programming and parenting support that are aimed at addressing the needs of children impacted by the pandemic. Practices such as play-based therapeutic supports can address a child's need to process difficulties they experienced in a child-friendly environment. This article aims to provide context for the detrimental impacts of the pandemic on childhood and the therapeutic role of play as intervention to build resilience.

This study examined the effectiveness of child-centered group play therapy (CCGPT) and narrative therapy in reducing separation anxiety disorder (SAD) and boosting social-emotional behaviours in early childhood (2.5-4-year-olds). An 8-week-randomized controlled trial design with three intervention groups, i.e. CCGPT, narrative therapy, and a combination of both interventions (i.e. combined group), and one control group that provided data at a pre-test and post-test, was adopted. A total of 48 children who showed signs of SAD participated in the study. Results showed that compared to the control group, CCGPT and combined group interventions showed a lower separation anxiety level. Children in all three intervention groups showed lower behavioural problems and higher prosocial behaviours than the control group. The findings suggest that the three interventions could be effective selective psychotherapy methods to promote social-emotional competencies. The CCGPT and combined group, particularly, were effective psychotherapy methods for reducing SAD in early childhood.

Theraplay® is an attachment-based intervention involving adults and children which is practised in a variety of settings across the world. The aim of this scoping review is to explore how Theraplay® has been used as an intervention with children and families in order to inform future practice and to identify any gaps in the current literature. By utilizing a systematic search of key databases and grey literature, eleven papers met the inclusion criteria. Findings showed that Theraplay® has been delivered as an intervention to children and families with a variety of presenting difficulties and in some cases has been used alongside other therapeutic interventions to make a positive change. The review highlights a diversity of methods and measures for the evaluation of outcomes of Theraplay®. Recommendations for further research are suggested.

We are witnessing tremendous changes day by day in the educational field, and new avenues of knowledge are opened up almost daily. Innovations in behavioral psychology and educational technology would certainly balance the disparity in learning that arises due to physical, economic, and social factors. There is an ability within every child, and the potential for the education of the disabled children should be realized and recognized. The ability to play is one of the principal criteria for mental health. The teaching and learning processes have been dramatically altered by the convergence of varieties of technological, instructional, and pedagogical developments in recent times.

Purpose: Anxiety disorders are a common mental health problem on college campuses. Underused creative programs offer intrinsic value to the successful integration of college students. The purpose of this study was to determine the efficacy of the use of building block therapy (LEGO® ) in stress management/reduction in comparison to traditional art therapy through the use of coloring books. Methods: Researchers conducted an intervention over for one-month with eight 1-hour sessions of coloring (n=5) or building (n=5) and compared to a control group (n=6). Students completed pre- and post-study surveys as well as pre- and post-session surveys. Descriptive statistics and the Wilcoxon Signed-ranks test were used for the pre- and post-study data of the control, coloring and building block groups to assess and compare changes in the individuals or between the groups. Results: Building block therapy was found to be non-inferior to the proven stress reduction method of coloring. The coloring group was found to be significant in the perceived reduction of stress (p [less than or equal to] 0.001) with an initial mean of 3.43 and final mean of 1.62, and the building block group was found to be significant (p [less than or equal to] 0.001) with an initial mean of 2.75 and final mean of 1.48. Conclusions: This pilot study sheds light on the importance of creativity in stress reduction. Looking beyond the conventional and enjoying the art of play, adults are able to use "toys" as a method of escape and relaxation. This research will help to elaborate on the anecdotes of pop-culture icons such as David Beckham, Trey Parker and Ed Sheeran to the efficacy of building block activities in stress reduction and help university students better understand alternative methods to mental health therapy and stress reduction. Recommendations: Through building blocks and art therapy students have an opportunity to socialize with other students. This adds significance to the beneficence of building blocks as a stress management tool and may increase possibilities for building social support networks. This study may help faculty and staff of similar universities to explore similar methods to help improve student success and retention.

This study evaluated whether a play-based, teacher-facilitated peer network intervention could improve basic social communication skills of children with autism spectrum disorder (ASD). The study was conducted in a regular classroom, using the principles of peer mediation and an integrated playgroup model. A single-subject multiple baseline design across three participants with ASD and Tau-U were used to determine the size of the effect. The results indicated that basic social communication skills of all three target participants significantly improved from the baseline condition in all three aspects measured: the duration of social interaction, social initiations, and responses to their peers. In the maintenance condition, three target participants retained increased social communication skills yet at lower levels than during the intervention condition. Overall, the results suggested that the intervention package was effective at improving the social abilities of children with ASD and applicable in classrooms. Practices, implications, and recommendations for future research are discussed.

Adaptations for specific cultural populations are needed to respond to children affected by natural disasters. After Hurricane María, we provided disaster response training to mental health professionals and Disaster Response Play Therapy services to children in Puerto Rico. In this article, we describe culturally specific, field-tested preparation and procedures to promote Puerto Rican children's mental health after disasters. We recommend cultural adaptations for training mental health professionals and providing children's disaster response in Puerto Rico.

This article presents the results of a 2-year exploratory case study on the impact of the "flipped" classroom design on generalist and advanced-practice social work skills in a large urban graduate university setting and looks at the role physical space plays in student perceptions of learning outcomes. Quantitative data were obtained with the Practice Skills Inventory (PSI) and the Play Therapy Attitudes, Knowledge and Skills Survey (PTAKSS). Participants provided qualitative data in the form of weekly reflection journals and evaluations of class activities. A mixed-methods analysis revealed statistically significant improvement in overall general practice skills and in specific play therapy clinical skills. Student-generated feedback on the physical learning environment as well as instructor workload and preparatory requirements are discussed.

This study aimed to test the effectiveness of a counseling program based on play in reducing sleep disorders in children of sexual abuse. The participants were 3 male and 3 female children who were sexually abused and registered at Al Hussein Social Foundation of the Ministry of Social Development in Amman, Jordan. They participated in a play-based group counseling program for 15 sessions. The results indicated the effectiveness of the counseling programs in decreasing sleep disorder symptoms in these children. Based on the results, the study recommends using similar methods for other counseling patients who suffer from sleep disorders, such as traumatized children, juvenile delinquents, and children with chronic and intractable diseases, and constructing counseling programs to reduce sleep disorders based on other therapeutic approaches such as drama, narrative therapy and emotion-centered theory.

The aim of this study was to investigate the effect of a play-based program on reducing the effects of student's abuse and to improving their self-esteem. To achieve this goal, a sample was selected and composed of 60 male and female abused students. They were divided into two groups: control group and experimental group which both consisted of 30 students. The experimental group was divided into two groups: the first consisted of 15 male students, while the second consisted of 15 female students. The measure of exposure to abuse and the self-assessment scale were applied as an anterior and posterior test of both experimental and control groups. The experimental group was only exposed to training through the training program. After completing the data collection, the means and standard deviations of the performance of the experimental and control groups were calculated on the study scales. The multivariate variance analysis was also conducted to identify the impact of the training program on gender. The results of this study showed statistically significant differences at the mean level (a = 0.05) between the performance mean of experimental and control groups. These differences were in favor of the experimental group that improved their level of self-esteem and decreased the level of exposure to abuse. The results also showed that there were no statistically significant differences at the level of significance (a = 0.05) between the female and male performance means.

The author demonstrates that war places children's play under acute stress but does not eliminate it. He argues that the persistence of children's play and games during periods of armed conflict reflects the significance of play as a key mode for children to cope with conditions of war. Episodes of children's play drawn from the recent Syrian Civil War illustrate the precariousness and importance of children's play and games during contemporary armed conflict and focus attention on children's play as a disregarded casualty of war. The article compares the state of underground children's play in contemporary Syria with the record of clandestine games played by children in the Holocaust to substantiate its claim that children adapt their play to concretize and comprehend traumatic wartime experience. The article posits that play is both a target of war and a means of therapeutically contending with mass violence.

The author argues for a functionalist understanding of autism. Instead of explaining autism as an inborn or otherwise neurological deficit, autism may be understood as a functional disturbance: the impairment of the abstract attitude. The abstract attitude is a concept developed by German neuropsychiatrist Kurt Goldstein (1987-1965) to describe severe behavioural disturbances in brain-injury, frontal lobotomy, and psychosis (Goldstein, K., & Scheerer, M. (1941). Abstract and concrete behaviour: An experimental study with special tests. "Psychological Monographs," 53(2), 1-151). The abstract attitude involves volition, will, and perspective, and is necessary for humans to understand and communicate through language or make judgements and evaluations. One finds in the abstract attitude an important aspect of being human (Goldstein, K. (1959). Abnormal mental conditions in infancy. "Journal of Nervous and Mental Diseases," 128(6), 538-557). Contemporary research that supports Goldstein's thesis is presented, as well as the promise of child-centered play therapy for autism treatment.

The growing interest in addressing the mental health needs of Chinese children through play therapy calls for an understanding of the cultural roots and norms of Chinese families. To help professionals succeed in this traditionally Western treatment when providing cross-cultural play therapy, the authors make recommendations concerning the location and appearance of the play therapy facility, including its waiting room and playroom. They discuss the need for carefully introducing play therapy to Chinese parents and suggest Western and Chinese toys and play items that are therapeutically appropriate for Chinese children. The authors also propose an outdoor play area based on the therapeutic rationales of contemporary neuropsychology. With this culturally sensitive discussion, the authors seek more effective play therapy not only for the children living in Chinese societies--mainland China, Hong Kong, and Taiwan--but also in countries with major Chinese child populations.

School counselors are charged with meeting the academic and personal/social needs of all students. Aggression can have a significantly negative effect on both areas in the school environment. It is imperative that these aspects are addressed in culturally and developmentally appropriate ways. Creative approaches based in play and art can be effective and appropriate in addressing these concerns for a multitude of students. This article will present insights and theory-based creative interventions for working with aggression in elementary school counseling sessions.

Outcome research examining the effectiveness of teaching methods in counselor education is sparse. The researchers conducted a qualitative investigation utilizing an instrumental case study to examine the influence of a constructivist-developmental format on a play therapy counseling course in a large CACREP accredited university in the Southeastern United States. Results indicated that the constructivist-developmental lens was effective in promoting the professional development of counselors-in-training. The researchers offer course-specific recommendations as well as areas of future research.

The current study utilized a single-group pretest-posttest design to evaluate students' self-perceived competence and comfort of using a variety of play therapy techniques and interventions with a range of client populations as a result of taking a one-week intensive course in Play Therapy. In an effort to conduct course evaluation and explore student's self-perceived comfort and competence related to play therapy the researchers created the "Play Therapy Comfort and Competency Survey" based on the content of the course. The results indicated statistically significant scores between the pre- and posttest measures, as measured by participants' self-perceived higher competence and comfort levels after taking the course. Results from this preliminary study are promising as students' self-perceived competence and comfort using play therapy was greater as a result of taking the one-week intensive MHS 6421 Foundations of Play Therapy and Play Process course. Limitations of the study and implications for future research are discussed.

The communication process between care providers and children can, at times, be complex. Young children typically lack the verbal language necessary for complex emotional expression. In this article, the authors contend that using some basic "child centered play therapy" (CCPT) techniques would be beneficial in enhancing communicative patterns in a childcare setting. The use of CCPT responses by caregivers can be effective in encouraging emotional and social development in children. Because child care providers spend a great deal of time with children, this approach may lead to a more nurturing and stable relationship than parents are able to provide.

A single-blind randomised control trial investigated the effectiveness of the Learn, Engage and Play (LEaP) playgroup. Seventy-one children with developmental delay were randomly allocated to an 8-week LEaP playgroup or control group and followed up at 12 and 28 weeks. On the primary outcome measure, LEaP demonstrated significant within group changes at 28 weeks (parenting distress p = 0.018) but no between group changes. On secondary outcome measures, at 12 weeks LEaP produced significantly better outcomes than control in goal achievement (performance p = 0.022; function p = 0.008) and family-support (p = 0.024), with LEaP continuing to demonstrate significantly better goal achievement (child performance p = 0.042; function p = 0.012) at 28 weeks. Findings indicate LEaP may assist in improving family-support and goal achievement outcomes for children with developmental delays.

Small-group interventions are often used in schools to support the development of children's social skills. One such intervention, Lego®-Based Therapy (LBT), is increasingly popular internationally in schools. Although LBT has an emerging evidence-base, there is limited research exploring effective LBT implementation. An in-depth, exploratory multiple-case study design was used to explore the process of LBT assimilation in two English mainstream primary schools which were considered to have implemented LBT effectively and reported positive programme outcomes. Data collection was through structured observations and semi-structured interviews based upon Durlak and DuPre's (2008) established implementation framework. Transcripts were subjected to Hybrid inductive-deductive thematic analysis was used to identify themes which were triangulated with observation data. The data largely correlated with the Durlak and DuPre (2008) framework, identifying ley themes of: provider characteristics, characteristics of the intervention, organisational capacity and the need for a support system when implementing the intervention. Themes of facilitator factors and participant responsiveness emerged inductively, suggesting that a revised model of implementation is required for LBT. Recommendations include calling for EPs to use models of implementation when working with schools, as a cyclical, iterative process to promote positive outcomes and, therefore, cost-effectiveness of school investment in interventions. Limitations and future research are discussed.

The purpose of this study was to conduct a content analysis of the syllabi of play therapy courses offered by school counseling programs that hold accreditation from the Council for Accreditation of Counseling and Related Educational Programs. We collected and analyzed 27 course syllabi to (a) identify trends in the content of these courses and (b) examine whether course objectives are consistent with the American School Counselor Association School Counselor Professional Standards & Competencies.

Background: Pediatric cancer treatments interfere with the patient's life on physical, psychological, and social levels. Hospital Clowns (HCs) use nonpharmacological techniques to reduce the distress that hospital treatments can cause and increase children's wellbeing, but few studies have analyzed their effects. Objective: This study examined the HC effects on the physical and emotional responses of pediatric patients during ambulatory chemotherapy. Given the variability in patients' adjustments to cancer treatment, the role of a child's age and temperament, and caregiver anxiety was considered in explaining the responses over and beyond the HC effects on patient outcomes. Method: Following a quasi-experimental design, 82 pediatric patients were assigned to one of two conditions: HC intervention versus control group (CG) in two separate trials. Pediatric patients self-reported of physical symptoms (pain, nausea, and fatigue) and emotional states (distress, happiness, and calm) were measured at baseline and post-chemotherapy in both trials. Caregivers provided information on children's temperament and reported their own anxiety. Marginal Multilevel Modeling was used to examine the effects of the HC interventions on the outcomes by controlling caregiver anxiety, and child age and emotionality. Results: Compared to the CG, patients receiving the HC visit during chemotherapy reported higher levels of calm and happiness, and less fatigue, pain, and distress. HCs did not affect nausea. Conclusions: This study showed the importance of HCs as agents of supportive pediatric care, whose short-term effects during ambulatory chemotherapy seem to contribute to increasing the well-being of pediatric patients.

In 1998, Sturrock and Else introduced the Play Cycle which has been integrated into both playwork theory and practice. An online survey with 157 responses found that playworkers' understanding Play Cycle varied to how they were first introduced to the theory. In addition, understandings of the six elements of the Play Cycle were significantly different from the original author's definitions. To provide a more consistent use of the Play Cycle in both future research and practice, this article offers new definitions for each element of the Play Cycle based on the results from this study. This has implications for any childhood setting where the Play Cycle is used, including playgroups, nurseries and out of school provision catering for primary-aged children.