Theraplay-Based Group Therapy for Juvenile Delinquents : A …journal.kisep.com/pdf/027/2018/0272018003.pdf · 2019. 1. 2. · The PedsQL is a tool used that is used to measure chil-dren’s

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Introduction

In Korea, the rates of juvenile delinquency for property and violent crimes consistently increased between 2006 and 2015 with the highest rates occurring in 2012. While there have been slight decreases since 2015, the ratios of juvenile

社會精神醫學第23卷第2號 2018J Korean Assoc Soc Psychiatry Vol 23, No 2

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property crime, heinous crime (e.g., murder, robbery, arson, sexual violence, etc.) and violent crime (e.g., assault, injury, threat, etc.) have increased by 42.4%, 71.3% and 27.1%, respec-tively. Moreover, the proportion of juveniles who committed violent crimes was 8.7%, with higher proportions of minors committing these crimes in comparison to other criminals.

1인제대학교 상계백병원 정신건강의학과 Department of Psychiatry, Sanggye Paik Hospital, Inje University, Seoul2인제대학교 상계백병원 사회사업실 Department of Social Work, Sanggye Paik Hospital, Inje University, Seoul3윤 치료놀이 상담센터 Youn’s Theraplay Counseling Center, Seoul4인제대학교 부산백병원 정신건강의학과 Department of Psychiatry and Clinical Pharmacology, Busan Paik Hospital, Inje University, Busan†Corresponding author

Theraplay-Based Group Therapy for Juvenile Delinquents : A Randomized and Controlled Trial in Korea

Ji-hye Han, M.D.,1 Yooli Lim, M.D.,1 Jihye Yun, M.D.,2

Miwon Youn, M.D.,3 Je-Wook Kang, M.D.,4 Bongseog Kim, M.D.1†

소년범에 대한 치료놀이 기반 그룹치료 : 국내 무작위대조군 연구

한지혜 1· 임유리1 · 윤지혜2 · 윤미원3 · 강제욱4 · 김봉석1†

■ ABSTRACT

Objectives : The aim of this study is to evaluate the effectiveness of Theraplay-based group therapy with juvenile delinquents.Methods : From January–April 2016, 30 participants of Seoul Reformatory who had Attention-Deficit Hyperactivity Disorder

(ADHD) with three other comorbidities were randomly assigned to either a Theraplay treatment group or a control group. Every participant completed pre- and post-test self-reporting questionnaires to include the Korean Youth Self-Report (K-YSR), the Pediatric Quality of Life Inventory (PedsQL), the Barratt Impulsiveness Scale, a self-control rating, a self-es-teem scale, and the Children’s Depression Inventory. We offered 21 Theraplay sessions for the treatment group and of-fered recreational play for the control group during the test period.

Results : Only the Theraplay treatment group showed statistically significant enhancements in school functioning (p=0.043). The

Theraplay treatment group improved in their self-esteem scores (p<0.001) while the control group showed a decrease in these scores (p=0.036). A comparison between the groups regarding changes from baseline to endpoint scores for certain variables showed significant differences for self-esteem, delinquent behavior, and externalizing behavior (p<0.001, p=0.023, p=0.023, respectively).

Conclusion : The adolescents who received Theraplay displayed significant changes in their school functioning and self-esteem

scores. In order to generalize the results of this study, it is important that future studies include female adolescents and a more diverse range of psychopathology.

KEY WORDS : Juvenile · Delinquency · Theraplay · Questionnaires · Randomized controlled trial · Adolescents.

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As such, it appears that the rate of juvenile delinquency to overall crime is significant, and this is becoming an impor-tant social issue in Korea.1)

Protected juveniles are young individuals who require pro-tection as a result of judge’s trial. The 2016 Ministry of Jus-tice statistics indicate that 7,504 juveniles were placed in the care of juvenile detention centers in 2016. The rates of accep-tance into juvenile detention centers consistently increased from 2005 to 2012, but these rates slightly decreased thereaf-ter.2) However, this downward trend is owed to an actual de-crease in the youth population, while such trends as increasing school violence, lower ages of juvenile criminals, and decreased familial functions due to the economic recession are expected to actually increase the juvenile delinquency problem.

There are various studies that have identified the psycho-logical, biological, social, and environmental risk factors as-sociated with juvenile delinquents.3-6) In particular, research conducted in Canada by Murray5) highlighted the high-risk factors for becoming a juvenile delinquent as impulsivity, low self-worth, temperament, decreased empathic ability, low IQ, low level of academic achievement, parental conflict, anamne-sis of child abuse, and low socioeconomic status. However, there are no studies that have been conducted in Korea that have focused on identifying the risk factors associated with juvenile crime. In addition, there are no Korean studies that have analyzed the scientific validation of the intervention pro-grams available for addressing these risk factors. According to Murray,5) the presence of attention deficit disorder predicts juvenile delinquency. Also, according to a study by research-ers Fazel, Doll, and Långström,6) attention-deficit hyperactiv-ity disorder (ADHD) was the most common mental disorder among male adolescents who were in juvenile detention and correctional facilities. Based on these results, this study will fo-cus on the juvenile inmates who have ADHD.

The typical reformation programs for juvenile delinquents include the “classroom of love,”7) which is administered at ei-ther the police station or the prosecutor’s office. Other than that, there are self-directed programs that police departments are working with outside agencies.8) However these programs are limited to general education and do not address the mental health of these juveniles. Also the majority of such programs address only light crimes, and there are even fewer interven-tion programs for imprisoned youth.8) Therefore, they are unable to fundamentally reform the youth or to reduce re-cidivism rates.

To fundamentally prevent juvenile crime long-term and to

reduce juvenile recidivism rates, it is critical to develop inter-vention programs that have a core objective of targeting psy-chopathology. Thus, this study aims to evaluate the effec-tiveness of Theraplay with juvenile delinquents at the Seoul Reformatory to determine whether Theraplay can be an effec-tive intervention program.

Method

1. ParticipantsFrom November 2015 to January 2016, three psychologists

evaluated the mental disorders of 200 juvenile detainees at the Seoul Reformatory based on the Diagnostic and Statisti-cal Manual of Mental Disorders 5 (DSM-5) and The Interna-tional Statistical Classification of Diseases and Related Health Problems 10 (ICD-10). Among the 200 subjects, we chose 30 participants who had ADHD as well as three other psychiat-ric comorbidities. These 30 individuals were enrolled in the study and were randomly assigned to either the treatment or control group. However, two participants were excluded from the analysis because their pre- and post-test questionnaires were not accurate.

These subjects volunteered to participate in the study in response to a notice that we sent to the Seoul Reformatory. All the subjects and either one of their parents provided an in-formed consent form prior to participants. We also sent an ex-planation of the study to the participants’ parents. This study was approved by the Clinical Research Ethics Board at Sang-gye Paik Hospital, Inje University College of Medicine.

2. Theraplay-based group and control groupTo assess the effectiveness of Theraplay for juvenile delin-

quents, 21 sessions of Theraplay-based group therapy were administered at the Seoul Reformatory from January 2016 to April 2016. Two Theraplay specialists conducted this treat-ment method twice a week in 60-minute sessions.

Theraplay focuses on the “here and now,” and the founda-tion of this method emphasizes active intervention and close-ness by encouraging direct physical contact and eye contact between the children and the treatment providers. Theraplay was first established by Dr. Ann Jernberg in 1967, and it was later coined “Theraplay” in 1970 by Charles Lyman.9) This treatment method consists of structure, engaging, challenge, nurturing to promote attachment, and now used in 29 coun-tries around the world.10) In the United States, Theraplay is used across many domains, including in daycares and kin-

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Han JH·Lim YL·Yun JH·Youn MW·Kang JW·Kim BS

dergartens, in home-based treatments, in institutions for fos-ter care and adoption, in support of single mothers, for edu-cation purposes, in long-term care facilities, for long-term foster care, for parents of disabled children, in public schools that have experienced natural disasters, in juvenile delinquent programs, in camps for children with autism, for families with parental right disputes, and in early intervention programs for homeschooling.11) In Korea, this program is widely utilized for the advancement of self-worth and the improvement of socio-cognitive functions. Theraplay in Korea is currently provided for kindergarten children, children at shelters who have been abused by their parents, runaway adolescents, children with delayed development, children with autism spectrum disor-ders, and children with unstable attachment insecurities.9)

For the control group used in this study, the recreational program was led by two social workers who were trained in mental health. Each session was 60-minutes long and consist-ed of a 10-minute introduction, a 40-minute main exercise, and a 10-minute wrap-up. In order to help the participants focus, each session began with the participants greeting each other and explaining the activities they had engaged in prior to the session. The program utilized recreational activities that the participants found interesting (e.g., flying paper balls, guessing proverbs, matching pictures, and constructing pa-per towers). The activities were generally physical in nature but also utilized various media types (e.g., drawing tools, board games, etc.). The wrap-up portion of the session included eat-ing light snacks while the participants shared their feedback.

Prior to beginning the programs, the participants were asked to complete the Korean Youth Self-Report (K-YSR), the Pediatric Quality of Life Inventory (PedsQL), the Barratt Impulsiveness Scale, a self-control rating, a self-esteem scale, and the Children’s Depression Inventory. The participants later completed all of these measurements a second time af-ter the programs were finished.

3. Measurement tools

1) Korean Youth Self-Report (K-YSR)In this study we used the K-YSR, which was at first devel-

oped by Achenbach12) and adapted to Korean situation by Oh.13) This tool is used for measuring participant’s social com-petence, emotions, and behavior. This tool is divided into a social competence scale and a behavior problem scale.14) So-cial competence scale consists of social scale, school scale and total social competence scale and Behavior problem

scale consists of eight clinical syndrome scales, internalizing problem scale and externalizing problem scales.

2) Pediatric Quality of Life Inventory (PedsQL)The PedsQL is a tool used that is used to measure chil-

dren’s quality of life and has been developed to fit the cogni-tive abilities of children. The PedsQL can also measure chil-dren’s quality of life as perceived by their parents, and it allows the researcher to assess the communication relationship be-tween the children and the parents.15) This tool consists of 23 questions measured on five-point scales (eight physical, five emotional five social, and five school functioning questions). The responses range from “no problem present” (0) to “al-most always problematic” (4). Higher scores indicate a higher quality of life.

3) Barratt Impulsiveness ScaleThe Barratt Impulsiveness Scale was first developed by Bar-

ratt in 1959 and its current version, the BIS-11, was revised in 1995. The BIS-11 contains a total of 30 self-reported questions (including 11 reverse-scoring questions) with each question measured on a four-point Likert scale (1 not at all, 4 al-ways). The response scores are summed, which reflects the re-verse scoring nature of some questions, and a higher total score indicates higher impulsivity.16)

4) Self-control ratingThe self-control rating tools used in this study were the

self-control scale developed by Gottfredson and Hirschi17) and the self-control rating scale developed by Kim.18) These scales were reconstructed and modified by Nam19) and Lee.20) There were 20 questions and each response was measured with 5-point Likert scales with the choices “not at all” (1 point), “generally untrue” (2 points), “average” (3 points), “generally true” (4 points), and “very true” (5 points). The idea is that higher self-control generally leads to the tendency of seeking long-term gratification and lowers the tendency of seeking immediate gratification.21)

5) Self-esteem scaleThis tool was originally developed by Rosenberg in 1965

(and translated by Jeon in 1974) to measure self-esteem (or level of self-respect) and trends in self-approval. There are a total of 10 questions with five questions on positive self-re-spect and five questions on negative self-respect.22)

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6) Children’s Depression InventoryThis scale was developed to measure the level of depres-

sion in children, and it was created by modifying Beck’s De-pression Inventory (BDI, 1967) to fit children aged 8-13 years. This scale consists of 27 questions, and it is designed to reflect one’s emotional state over the previous two weeks in a self-evaluation. The responses to each question are scored from 0-2, with total possible score of 0-54. With this scale, a higher score indicates a higher level of depression.23)

4. Data analysisThis study utilized SPSS 24 for Windows (SPSS Incorpo-

rate, Chicago, IL, USA) for the statistical analysis. A χ2-test and an independent t-test were conducted to analyze the pre-test difference between the treatment group receiving Theraplay and the control group receiving recreational pro-grams. Pre-test and post-test paired t-tests were utilized to assess the effects of Theraplay.

Results

1. Comparison of the groups’ demographic characteristics and baseline scores

Table 1 illustrates the demographic characteristics of the treatment and control groups. A comparison of the demo-graphics between the two groups indicates that the average age of the treatment group was 16.07±0.83 years and the control group’s average age was 16.50±1.16 years, which suggests that there was not a significant difference for age. In addition, the number of crimes punished was 3.50 for the treatment group and 3.14 for the control group, indicating no significant difference for crimes between the groups. As shown in Table 2, we compared both groups’ baseline scores from every measurement tool, and the results indicated that the treatment group received a significantly lower score (t=9.073, p<0.001) than control group on the self-esteem scale. For the K-YSR, the treatment group had significantly lower scores than control group for both delinquent behavior (t=2.632, p= 0.019) and externalizing behavior (t=2.490, p=0.019). There were no other significant differences between the groups for any remaining demographic items or baseline scores.

2. Post-treatment changesTable 3 illustrates a comparison of the two groups regarding

their scores in the pre- and post-treatment stages. The re-sults from the K-YSR, the PedsQL, the BIS, and the self-con-

trol scale were categorically compared, and we also com-pared the groups’ total scores. The results indicate that there was a significant increase in the scores for school function-ing (t=-2.244, p=0.043) and self-esteem (t=-7.247, p<0.001) for the treatment group that received Theraplay. In addition, for the control group that participated in only recreational play, there was a significant decrease in the group’s self-esteem score (t=2.344, p=0.036).

3. Comparison of baseline and endpoint scoresWe performed independent t-tests in order to observe any

differences between the groups regarding any changes from their baseline scores to their endpoint scores. As shown in Ta-ble 4, the results indicated that there were significant changes in both groups for the self-esteem, delinquent behavior, and externalizing behavior scores.

Discussion

To summarize the results, there were no significant differ-ences between the treatment and control groups regarding their demographic characteristics. The results also demon-strated that, based on the pre- and post-test scores the treat-

Table 1. Comparison of demographic characteristics

Theraplay group(N=14)

Control group(N=14)

Mean SD Mean SD

Age 16.07 0.83 16.50 1.16No. of crimes punished 3.50 2.62 3.14 1.29

N % N %

FamilyBoth parents 4 28.57 5 35.71Single parent 8 57.14 8 57.14No parent 2 14.29 1 7.15

Economic statusHigh 2 14.29 2 14.29Middle 8 57.14 6 42.855Low 4 28.57 6 42.855

School recordHigh 1 7.15 1 7.14Middle 5 35.71 0 0Low 8 57.14 13 92.86

SuicidalityHigh 9 64.29 13 92.86Middle 2 14.29 0 0Low 3 21.43 1 7.14

SD : standard deviation

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ment group had significant increases in self-esteem, while the control group experienced decreases in self-esteem. This re-sult supports Kim’s24) finding that it is possible to improve the self-esteem of low-income children by practicing group Theraplay program, and also supports the findings of Joo’s25) research, which found that a group Theraplay program im-proved elementary school students’ general self-esteem.

The increase of school functioning of PedsQL in treatment group means that they showed an improvement in general school curriculum and vocational training which Seoul Re-

formatory offers, such as paying more attention, keeping up well with school work, doing less school absences. It can be inferred that the rise in self-esteem score in the treatment group led to high school functioning score and this is in line with Lee’s study26) that shows positive correlation between self-esteem and school achievement.

In the present study, prior to the intervention of the Ther-aplay program, the baseline for the YSR’s delinquent behavior and externalizing behavior score was higher in the control group (M=97.93±1.94, M=90.71±13.30) than in the treat-

Table 2. Baseline scores for all measurement tools

Theraplay group (N=14) Control group (N=14)T

Mean±SD Mean±SD

PedsQLPhysical 79.91±18.50 81.70±16.39 0.270Emotional 57.14±17.29 69.29±23.44 1.560Social 78.57±25.38 86.07±26.54 0.764School functioning 51.07±27.12 72.86±29.00 2.053Total 68.40±16.96 78.03±19.00 1.415

BISMotor scale 25.29±3.22 25.21±4.78 -0.046Non-planning scale 29.50±3.94 28.00±4.46 -0.944Attention scale 19.07±3.10 18.79±4.14 -0.207Total 73.86±5.53 72.00±10.21 -0.599

Self-control scaleImmediate gratification 59.79±4.63 62.71±5.51 1.523Delayed gratification 28.50±7.85 30.93±5.26 0.962Total 88.29±11.45 93.64±9.54 1.345Self-Esteem Scale 15.21±4.48 29.86±4.06 9.073**CDI 44.86±8.99 50.93±6.97 1.998

K-YSRSocial competence scale

Social 60.00±36.82 42.07±32.13 -1.373School 10.64±13.68 22.57±17.58 2.004Total social competence 44.21±31.45 35.42±31.88 -0.734

Behavior problem scaleWithdrawn 59.00±37.03 59.43±29.33 0.034Somatic complaints 49.93±34.87 61.64±36.30 0.871Anxious/depressed 55.93±36.52 56.14±33.90 0.016Social problems 52.21±38.15 67.79±30.11 1.199Thought problems 61.79±29.06 62.57±28.50 0.072Attention problems 39.64±28.31 56.71±22.94 1.753Delinquent behavior 72.14±36.61 97.93±1.94 2.632*Aggressive behavior 51.79±37.96 72.93±27.90 1.679Internalizing problems 56.86±35.89 59.93±35.14 0.229Externalizing behavior 63.43±38.78 90.71±13.30 2.490*Total behavior problems 58.86±35.02 74.71±24.78 1.383

* : p<0.05, ** : p<0.001. BIS : Barratt Impulsiveness Scale, CDI : Children’s Depression Inventory, K-YSR : Korean Youth Self-Report, PedsQL : Pediatric Quality of Life Inventory, SD : Standard deviation

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ment group (M=72.14±36.61, M=63.43±38.78). However, after the intervention, the delinquent and externalizing be-havior scores for the two groups were 88.00±15.51, 80.71±24.29 (treatment group) and 86.93±24.47, 78.57±30.22 (con-trol group), showing very little difference between the two groups. Moreover, a comparison of the endpoint changes be-tween the groups indicated that the self-esteem scores were significantly elevated in the treatment group (M=12.07±6.23) but the scores of delinquent behavior (M=15.86±34.41) and

externalizing behavior (M=17.29±39.55) were higher, sug-gesting that the problematic behavior increased. On the other hand, the control group experienced a reduction in problem-atic behaviors as evidenced by a decrease in their delinquent and externalizing behavior scores. Considering the effect of recreation program itself, any therapeutic intervention might appear to have temporarily decreased problematic behaviors. Rather, we want to find out the significance of the study from the self-esteem score that rose after Theraplay. As shown in

Table 3. Change in scores from pre- to post-treatment

Theraplay group (N = 14)

tControl group (N = 14)

tPre Post Pre PostMean±SD Mean±SD Mean±SD Mean±SD

PedsQLPhysical 79.91±18.50 77.01±25.70 0.517 81.70±16.39 85.27±16.23 -0.857Emotional 57.14±17.29 68.87±28.52 -1.493 69.29±23.44 77.50±22.25 -1.555Social 78.57±25.8 77.50±23.10 0.146 86.07±26.54 79.29±23.44 1.416School functioning 51.07±27.12 65.00±22.95 -2.244* 72.86±29.00 79.64±16.69 -0.799Total 68.40±16.96 72.67±21.27 -0.85 78.03±19.00 81.06±17.20 -0.678

BISMotor scale 25.29±3.22 25.14±5.63 0.879 25.21±4.78 24.29±5.58 0.639Non-planning scale 29.50±3.94 28.64±4.14 0.679 28.00±4.46 27.29±3.95 0.426Attention scale 19.07±3.10 17.93±2.46 1.628 18.79±4.14 17.36±2.70 1.157Total 73.86±5.53 70.17±9.10 1.867 72.00±10.21 68.93±7.42 1.162

Self-control scaleImmediate gratification 59.79±4.63 62.29±4.29 -1.82 62.71±5.51 62.50±5.50 0.188Delayed gratification 28.50±7.85 29.50±5.32 -0.386 30.93±5.26 30.07±7.74 0.558Total 88.29±11.45 91.79±7.83 -0.944 93.64±9.54 92.57±10.79 0.55Self-esteem scale 15.21±4.48 27.29±5.24 -7.247** 29.86±4.06 26.64±5.68 2.344*CDI 44.86±8.99 46.93±14.72 -0.428 50.93±6.97 46.79±9.87 1.9


Social 60.00±36.82 52.36±43.10 0.474 42.07±32.13 44.83±32.84 -0.179School 10.64±13.68 29.29±27.21 -1.973 22.57±17.58 22.50±27.39 0.009Total social competence 34.14±25.73 43.36±36.90 -0.673 27.14±21.58 31.21±24.84 -0.396

Behavior problem scaleWithdrawn 59.00±37.03 63.79±27.73 -0.414 59.43±29.33 71.00±31.74 -1.21Somatic complaints 49.93±34.87 59.29±3345 -0.721 61.64±36.30 69.71±39.00 -0.601Anxious/depressed 55.93±36.52 58.57±30.25 -0.19 56.14±33.90 58371±39.81 -0.186Social problems 52.21±38.15 68.50±27.00 -1.113 67.79±30.11 69.50±29.86 -0.174Thought problems 61.79±29.06 72.07±29.80 -0.88 62.57±28.50 67.07±34.99 -0.434Attention problems 39.64±28.31 61.50±17.09 -2.089 56.71±22.94 58.21±30.76 -0.147Delinquent behavior 72.14±36.61 88.00±15.51 -1.724 97.93±1.94 86.93±24.47 1.747Aggressive behavior 51.79±37.96 70.36±25.36 -1.792 72.93±27.90 69.36±35.86 0.389Internalizing problems 56.86±35.89 61.29±32.46 -0.328 59.93±35.14 65.86±38.56 -0.455Externalizing behavior 63.43±38.78 80.71±24.29 -1.635 90.71±13.30 78.57±30.22 2.029Total behavior problems 58.86±35.02 75.21±24.07 -1.714 74.71±24.78 71.14±34.53 0.379


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the Rosenberg, Schooler, and Schoenbach27) study, teenagers with low self-esteem are committing more delinquent crimes than teenagers who do not have low self-esteem. In addition, Hur28) and Seo’s research29) showed that adolescents who have low self-esteem could make more problem behavior, and also it has been studied that self-esteem is a major variable that affects juvenile’s problem behavior.30) When we synthe-sized the results of these studies, an increase in self-esteem could have positive effect on problem behavior.

In comparison to Korea, other countries have conducted

more research on juvenile delinquency and intervention and rehabilitation programs. Researchers Woolfenden, Williams, and Peat31) produced a meta-analysis to analyze the effective-ness of these programs on preventing juvenile delinquency. The results of this meta-analysis confirm that familial care and parental education can reduce juvenile crime recidivism rates. In addition, authors Landenberger and Lipsey32) veri-fied the effectiveness of cognitive behavioral therapy while scholars Reitzel and Carbonell33) used a meta-analysis to val-idate the effectiveness of cognitive behavioral programs for

Table 4. Comparison of endpoint change in outcome variables from the baseline scores

Theraplay group (N=14) Control group (N=14)T

Mean±SD Mean±SD

PedsQLPhysical -2.90±21.00 3.57±15.59 0.926Emotional 11.42±28.65 8.21±19.77 -0.346Social -1.07±27.40 -6.79±17.93 -0.653School functioning 13.93±21.22 6.79±31.78 -0.679Total 4.27±18.80 3.03±16.70 -0.185

BISMotor scale -1.14±4.87 -0.93±5.44 0.110Non-planning scale -0.86±4.72 -0.71±6.27 0.068Attention scale -1.14±2.63 -1.43±4.62 -0.201

Total -3.14±6.30 -3.07±9.89 0.023Self-control scaleImmediate gratification 2.50±5.14 -0.21±4.26 -1.521

Delayed gratification 1.00±9.70 -0.86±5.75 -0.616Total 3.50±13.87 -1.07±7.29 -1.092Self-esteem scale 12.07±6.23 -3.21±5.13 -7.084**CDI 2.07±18.11 -4.14±8.16 -1.171


Social -7.64±60.36 2.21±46.26 0.485School 18.64±35.35 -0.07±28.38 -1.545Total social competence 9.21±51.27 3.5±33.11 -0.350

Behavior problem scaleWithdrawn 4.79±43.27 11.57±35.79 0.452Somatic complaints 9.36±48.57 8.07±50.26 -0.069Anxious/depressed 2.64±52.00 2.57±51.62 -0.004Social problems 16.29±54.77 1.71±36.92 -0.825Thought problems 10.29±43.75 4.50±38.83 -0.370Attention problems 21.86±39.15 1.50±38.25 -1.392Delinquent behavior 15.86±34.41 -11.00±23.55 -2.410*Aggressive behavior 18.57±38.77 -3.57±34.39 -1.599Internalizing problems 4.43±50.49 5.93±48.73 0.080Externalizing behavior 17.29±39.55 -12.14±22.40 -2.423*Total behavior problems 16.36±35.70 -3.57±35.23 -1.487


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reducing recidivism. Given that inappropriate parental care negatively influences delinquency and problematic behaviors throughout childhood, existing studies have argued that it is important to recover distorted family relationships in order to prevent recidivism.34) Also, previous research has established that effective programs for juvenile delinquents try to con-nect parents and adolescents to reform their relationships.35) The results of this study fit into this context because the foun-dation of Theraplay stimulates positive interactions between parents and their children. While the present study utilized researchers to administer the Theraplay, parents are actually able to lead intervention at home and administer Theraplay on their own. Therefore, it is possible that Theraplay can lower the recidivism rates of juvenile delinquents in reformatories.

In a review of studies that have identified causes of juve-nile delinquency, we learned that internal personal charac-teristics (e.g., self-respect, self-expression, and self-control) and environmental factors (e.g., home, school, and the re-gional community) were all important variables that influ-enced delinquency. Among these factors, self-efficacy is a psychological factor that importantly influences the choices underlying one’s actions, and it can be regarded as influenc-ing decisions on how to organize and execute an action.36) Furthermore, existing studies have shown that a higher in-dividual efficacy is a key variable for adolescent development from childhood to adulthood,37) and that a higher self-efficacy leads to a higher satisfaction in daily life and a higher ability to manage stress.38) Moreover, researcher Lee39) conducted a 24- subject study in Korea to verify the effectiveness of Theraplay for improving interpersonal relationships and self-awareness among university students. Additional studies support these results and have also argued that Theraplay effectively im-proves variables related to interpersonal relationships40) and self-awareness.41) The results of these existing studies are di-rectly related to the findings of the present study, which dem-onstrated that self-esteem significantly increased in the treat-ment group. The present study therefore presents a future opportunity for Theraplay to be applied to adolescents in re-formatories as a reformatory intervention program.

The study is meaningful because it was the first in Korea to target adolescents in reformatories and to randomly as-signed these participants to treatment and control groups. In addition, the majority of studies in Korea have focused on in-fant, toddler, and elementary school students.42) While a few studies in Korea have included adolescents, such as the re-search by Sunwoo40) that analyzed social anxiety in adoles-

cents, the present study is important because it has expanded the scope of adolescent research to include the effects of Ther-aplay on this age group.

This study is not without limitations. The first limitation is that this research only included male adolescents as partici-pants because the Seoul Reformatory is for boys only. Second, the sample size was small with only 14 participants in the treatment group and 14 in the control group. In order to ex-pand these findings to all adolescents, it is important that future studies recruit more participants and have a more di-verse sample. In particular, it is important that Theraplay is expanded to the dozen reformatories throughout Korea to evaluate its usefulness as an intervention program for ado-lescents in reformatories. A third limitation is that we did not control for demographic and personal characteristics (i.e., age and career) in selecting the researchers who adminis-tered the Theraplay and recreation programs. It is possible that the effectiveness of the treatment would vary depending on the individual characteristics of the treatment provider. A previous study did find that a more experienced counselor was able to create a greater ability for participants to empa-thize with the provider.43) Accordingly, additional research needs to be conducted that establishes more detailed control factors such as age, gender, and career of the researchers de-livering the program.

Conclusion

In this study, the administering of Theraplay led to signifi-cant changes in the school functioning and self-esteem of ad-olescents in reformatories. Theraplay could potentially have the positive effect of improving the psychopathology of juve-nile delinquents. However, in order to generalize the results of this study, it is important that future research includes female adolescents and a more diverse psychopathological range.

■ AcknowledgementThis study was supported by a research fund from the Seoul

National Hospital, Ministry of Health and Welfare, Republic of Korea (HM15C1040).

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■ 국문초록

소년범에 대한 치료놀이 기반 그룹치료 : 국내 무작위대조군 연구

인제대학교 상계백병원 정신건강의학과,1 인제대학교 상계백병원 사회사업실,2

윤 치료놀이 상담센터,3 인제대학교 부산백병원 정신건강의학과4

한지혜1 · 임유리1 · 윤지혜2 · 윤미원3 · 강제욱4 · 김봉석1

목 적 :

본 연구의 목적은 소년범에 대한 중재프로그램으로써 치료놀이 기반 그룹치료의 효과를 평가하는 것이다.

방 법 :

2016년 1월에서 4월까지 서울 소년원의 재소중인 소년범들 중 ADHD와 세 가지의 공병질환이 있는 30명을 대상으로 각각 치료놀

이군과 대조군으로 무작위 배정하여 치료군에는 치료놀이를, 대조군에는 레크레이션 프로그램을 21세션 제공하였다. 모든 참가자들

은 프로그램 시행 전과 후에 한국 청소년 자기행동 평가척도(K-YSR), 소아용 삶의 질 검사(PedsQL), Barratt 충동성 척도(Barratt

Impulsiveness Scale), 자기통제력 척도(self-control rating), 자기 자존감 척도(self-esteem scale), 소아우울척도(Children’s De-pression Inventory)에 답하였다.

결 과 :

프로그램 전 후 변화에서 학업수행점수(p=0.043)는 치료놀이군에서만 통계적으로 유의한 수준의 호전을 보였으며, 자아존중감

점수의 경우 치료군에서는 상승한 반면(p＜0.001), 대조군에서는 하락하였다(p=0.036). 치료 전후 그룹간의 변화에서는 자아존중감,

문제행동, 외현화 문제 항목에서 유의미한 차이를 보였다(순서대로 p＜0.001, p=0.023, p=0.023).

결 론 :

치료놀이를 시행한 소년범에서 학업수행 점수와 자아존중감 점수가 유의미하게 상승하였다. 하지만 본 연구의 결과를 일반화하

기 위해서는 추후 여자 소년범을 포함하고 보다 다양한 범위의 정신병리를 포함한 연구가 진행되어야 할 것이다.

중심 단어0:0 치료놀이·소년범·소년 범죄·청소년·무작위 대조군 연구·설문지.

J Korean Assoc Soc Psychiatry Vol 23, No 2, November, 2018

Documents

Theraplay-Based Group Therapy for Juvenile Delinquents : A …journal.kisep.com/pdf/027/2018/0272018003.pdf · 2019. 1. 2. · The PedsQL is a tool used that is used to measure chil-dren’s