Optimizing a School-Based Therapeutic Play Intervention for Preschool Students: A Factorial Experiment Protocol

Background and rationale:

There are a growing number of children in the United States with mental, emotional, or behavioral health concerns (Perou et al., 2013; SAMHSA, 2022). Left untreated, these difficulties may persist through development and contribute to a wide range of negative outcomes in adolescence and adulthood. Consequently, there is a critical need to identify effective strategies that promote protective factors, enhance resiliency, and disrupt the causal processes that facilitate the emergence of subsequent mental health problems. Prevention programs that enhance young children's social and emotional competencies can both alleviate present difficulties and protect youth against future mental health problems (Greenberg et al., 2003; Greenberg et al., 2017).

Early childhood is a critical developmental period for social and emotional growth, with key developmental milestones including the growth of peer social skills and self-regulation abilities. Educational settings are important contexts for fostering young children's social and emotional development. Children who adjust well to the school setting are more apt to thrive in terms of their social and emotional skill development, whereas children who struggle with the transition to the early school years may face challenges across multiple domains (Alzahrani et al., 2019). It is these elevated symptoms detected within the general student population, not diagnoses of specific childhood disorders, that best predict adult mental health outcomes (Mulraney et al., 2021). Consequently, preventive interventions that include universal screening and encourage social and emotional skill development, while also facilitating a positive transition to the educational environment, are ideal.

School-based interventions are well positioned to strengthen children's social and emotional competencies and reduce future risk (National Research Council & Institute of Medicine, 2009). Schools serve as a context for growth in multiple domains of socioemotional development, including interpersonal skill development with peers and adult figures, intrapersonal awareness of academic and non-academic skills, coping with difficulties, and managing the simultaneous demands of curricular and extracurricular activities (Aviles et al., 2006). Further, recent evidence indicates that school-based interventions grounded in child-centered play therapy (CCPT) are related to reductions in children's behavioral, emotional, and academic problems (Ray et al., 2015). There is also some growing evidence that non-clinical preventive interventions grounded in the tenets of CCPT (i.e., Child-Centered Play Interventions; CCPIs) are effective for children's social and emotional development (Perryman & Bowers, 2018). CCPIs are often more feasible and sustainable for schools - for instance, they are facilitated by a specially trained school-based paraprofessional (i.e., child associate) who is supervised by a licensed school-based mental health professional (Peabody et al., 2018). However, research based on CCPIs is limited.

Primary Project is a long-standing CCPI that targets children in kindergarten through third grade (approximately ages 5 - 9) who are having school adjustment difficulties (Johnson et al., 2005; Peabody et al., 2018). The program provides structured play sessions with trained paraprofessional child associates under the supervision of mental health professionals to support children with early school adjustment difficulties. The goals of Primary Project are to enhance school-related social and emotional competencies (e.g., task orientation and peer social skills) while reducing behavioral and interpersonal adjustment difficulties in children.