Implications for Practice

Both our earlier laboratory studies and our more recent research on play behavior in the natural setting provide important information for clini-cal practice, i.e., assessment and treatment of depression in preschoolers.

Decreased quantity and quality of play was not only observed in depressed children during the videotaped standardized play procedures with trained observers in our first studies. Teachers observed similar characteristics of play behavior in children at risk for depression in the natural preschool setting. Although the latter study had some methodological limitations that restrict the strength of the conclusions, the study results suggest that untrained teachers are able to detect children at risk for depression based on their play observations. If teachers are trained to observe emotion regula-tion problems and disrupregula-tions in play behavior they may be able identify children at risk for depression. Their observations can be used for the early detection of depression and add specific information to the observations of parents and other caregivers.

The results of the first to studies strongly suggest that standardized play ob-servation procedures should be part of the diagnostic assessment procedures in clinical settings. More in particular, observations of the play behavior of referred children during play narratives can provide important information for clinical diagnosis of preschoolers. From our research it is clear that play narratives with sad mood induction are most effective in distinguishing

suMMary, ConClusions, anD GEnEral DisCussion 99

among depressed and nondepressed preschoolers, and therefore deserve to be incorporated in such a clinical diagnostic assessment. The use of videotaped play sessions and objective observers during clinical assessments offers op-portunities to observe both content and behavioral aspects of play behavior.

Future research should also focus on the possibilities to use interventions during play for improving emotion regulation in depressed children or children at risk. Our research clearly showed that sad mood has a disrup-tive effect on play behavior in these children. Recent research indicates that typical children make more use of positive coping strategies, such as introducing happy moods and smiling or helping the play figures to solve the problem in a positive way in play narratives than mood disturbed children. For typical children the use of positive coping strategies increased in more challenging stories, whereas mood disturbed children’s positive coping markedly decreased (Beresford et al. 2007).

It is an important question whether the use of positive coping strat-egies can be taught to depressed children as intervention or treatment (Oppenheim, 2006). Luby, Lenze, & Tillman (2012) found indications that it is indeed possible to improve depressed children’s coping behavior dur-ing play interactions and direct communication. In usdur-ing Parent Child Interaction Therapy with Emotion Development (PCIT-ED; Luby et al., 2012) found positive effects of teaching and in vivo coaching of parents to promote positive play techniques and emotion regulation competences in interaction with their children. Significant improvements were found in decreasing the severity of depression in general and specific symptoms like negativity and liability of the children. Improvements were also found for emotion regulation and emotion differentiation, as well as for executive functioning like memory and planning/ organizing. Although this pilot study was preliminary, in need for replications and follow-up of the effects, it offers promising possibilities to use play not only for detection of depression in preschoolers, but also as an intervention to work on the affect regulation problems and to improve depressed children’s functioning in general.

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