Internalized Emotional Disturbances (IED)

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Method

For the present study a systematic literature review was conducted. Several databases were used as a research tool, including key words. Namely, this method appertains to identifying, critically appraising and reporting with clarity the research having already been conducted within a specific topic. The appropriate research studies were selected after a number of inclusion and exclusion criteria has been applied. The method additionally incorporates the scrupulous analysis and the quality assessment of the collected data (Moher et al. 2009).

Search procedure

The search for this study was conducted in total three databases, more specifically in PsycINFO, ERIC and ScienceDirect. All the above databases carry researches from the field of education, psychology, occupational therapy, health care and clinical psychology, thus carrying relevant for the present topic information. A hand search procedure was also conducted in order to reach the maximum possible amount of relevant articles. The search was performed in March 2017.
The search words were selected according to relevance with the aim and research questions and also in accordance with the inclusion and exclusion criteria (see Table 3.1). A flowchart is exhibited in Appendix A, describing the overall search procedure. A combination of thesauri and free text key words was used in the two out of three databases, namely in PsycINFO and ERIC, while only free text was used in ScienceDirect. In all databases search words were used for the clusters ’play behaviors’, ’play’ and ’internalized emotional disturbances’. Applied filters (e.g. for Age group) and some truncations (*) of words were additionally implemented in the databases. In PsycINFO and ERIC, the search procedure was conducted in ”Advanced Search mode” whereas in ScienceDirect the search was done in ”Expert mode”. The total list with all the search words used in the three databases is appeared in Appendix G.
Some filters were also applied. In PsycINFO those filters appertained to the Age group (« Childhood (birth-12 yrs) » OR « Preschool Age (2-5 yrs) » OR « Infancy (2-23 mo) »), the Type of publication (« Scholarly Journals ») and the Date Range (2000 to 2017). Accordingly, in ERIC the filters concerned again the Publication type (”Scholarly Journals”), the Education level (« Early Childhood Education » OR « Preschool Education » OR « Kindergarten » OR « Grade 1 ») and the Date range (2000 to 2017). Finally, in ScienceDirect only the date range was limited to 2000 until 2017 along with the publication type which was restrained to scholarly journals.

Selection criteria

The inclusion and exclusion criteria, as they appear in Table 3.1, were applied in order to facilitate the research and limit the number of the -appropriate for the topic- articles. Thus, the present study included only 13 articles that were peer reviewed, empirical studies and published from year 2000 until 2017. The purpose of the date restriction was to identify more current researches in order for the topic to be up to date. Regarding the sample, both clinical and nonclinical cases of Internalized Emotional Disturbances (IED) were taken into consideration in the search procedure. The reason of the selection lies in the fact that preschooler’s nosology of IED is a field yet being examined, due to the fact that early childhood is an age that children still go under rapid social and emotional alterations (Egger & Angold, 2006).
Therefore, both children who were diagnosed and children with symptoms of IED were incorporated in the study, whereas children with typical development were excluded. The original plan was to limit the age span of the children to 3 to 6 years old, however due to the fact that only four studies were identified, the age span was expanded from 2 until 7 years old, hence including the first year of compulsory school.
Systematic reviews were also excluded since they encompass their own inclusion criteria. In this point it must be highlighted that two experimental studies were also incorporated. Thus, an experimenter and/or researches weres initiating the play and provided the appropriate material. Consequently they just observed the targeted children playing. The reason above this is that the adults did not lead the play and remained on observations. As it is mentioned in the one experimental study “these postgame waiting periods, each of which lasted 4 minutes, constituted the SolFP situation. It was the children’s behavior during these situations in which the authors were actually interested” (Mol Lous et al. 2000, pp.251). Additionaly, as it is stated in the other included experimental study ”the adult player conducted the session in a nondirective manner, showing interest, reflecting feelings or the content of the play, and gently facilitating play when necessary” (Cohen et al. 2010, p.166). Moreover, since the main focus of this study is observational studies in child initiated play, any kind of articles containing adult-led activities and interventions were excluded.

Selection process

The results from the three databases used in the present study were transferred in and checked via Covidence, a web-based data extraction protocol used for the process of screening, extraction and analysis of the articles (Babineau, 2014). The total number of articles being identified was 854. A manual search was also applied, thus 7 more articles were identified. Therefore, the articles reached the number of 861 in total, of which 2 were duplicates hence automatically being excluded from Covidence. . The procedure on Covidence
included the reduction of articles using the choices “Yes”, “No” and “Maybe” on title and abstract level and “Include”, “Exclude” on full text level. The manual search articles were not included on Covidence and they were examined separately. After title and abstract along with full text screening, the final selection included 6 articles that were totally adapted to the inclusion and exclusion criteria, as they appear on Table 3.1. A flowchart displaying the total process of selection can be found in Appendix A.

Title and abstract screening

From the remaining 859 articles, 792 were reviewed on title and abstract level. The biggest number of excluded articles referred to measurements which focused on externalized behaviors and children above the age of seven years old (n=582). Another reason of exclusion was the adult-led play activities and the fact that the study focus was on children’s social competence and emotional regulation (n=147). From the remaining 147 articles of title and abstract screening, 56 articles were not available for free and 11 articles referred to wrong outcomes such as play therapies and interventional processes and 49 articles assigned children with Autism Spectrum Disorder (ASD). Finally, 18 articles referred to the effect of a specific kind of play on children with emotional problems and teachers attitudes. Information about the number of articles and the reasons of exclusion can be obtained from the flowchart in Appendix A as well.

Full text screening

After the title and abstract appraisal of 792 articles, 67 articles were addressed for full text review. From the above total number (n=67), 23 articles were immediately excluded, due to the fact that they were not available for free. The remaining 44 articles were carefully examined first for meeting the inclusion and exclusion criteria and then proceeding on methods and results part. Subsequently, 28 more articles were excluded from the research, since they concentrated on wrong study focus, which was mainly the academic performance, emotional dysregulation and social competence of the targeted group.
Another reason for exclusion was that many studies measured different behavioral outcomes and included children with externalized behaviors and specifically with focus on Attention Deficit Hyperactivity Disorder (ADHD) syndrome (n=19). This fact left the full text screening with nine articles. Three more articles were then excluded due to the fact that the results appeared disordered and confusing to interpret. Thus the outcome of the study was unclear. The above procedure left the present study with 6 articles in total for analysis, which were adjusted on an extraction protocol (see Appendix E).

Quality assessment

Reagarding the quality assessment, two quality assessment tools were used in the present study; one for the quantitative studies being included and one for the case study. As for the former, the Quantitative Research Assessment Tool (CCEERC, 2013) was utlized. Regarding CCEERC, the quality assessment tool is a means to evaluate the selected studies and facilitate the procedure of reviewing and analyzing the desirable results, depending on the quality of each included study. Thus, normally, articles with low quality are either excluded from the research, or are viewed cautiously (especially when the number of included articles is below five, thus critically limited).
In the present study, the above tool was adjusted2 in order to justify the aim and research questions, hence containing additional sections about peer review, aim and research questions, study design, control group as well as information about play behaviors and types of play. The rating of the tool was also altered to 2 for the highest, 1 for the medium and 0 for the lowest, since the official tool contained a scale of 1, 0 and -1. The official tool also included a ’Not Applicable’ (NA) option which was erased for the present study. Thus, the articles were assessed whether they presented a High, Medium High, Medium Low or Low quality (see Appendix C for final results). The final edition of the quality assessment tool included 17 items in total, being incorporated into 4 broad sections. Namely, the Article publication & Background section (i) included questions about peer review, aim and research questions, while the Method section (ii) incorporated questions about play behaviors types of play, study design, control group, population, randomized selection fo participants, sample size, response and attrition rate. The Measurement section (iii) contained questions about main variables or concepts and operationalization of concepts, whereas in the Analysis section (iv) information about numeric tables, missing data, appropriateness of statistical techniques, omitted variable bias and analysis of main effect variables can be found (see Appendix B for adapted version of the tool).
As for the case study being included, the Quality Assessment tool for Case Series Studies (NIH, 2014) was adapted. The above mentioned is an assessment tool provided by the National Institutes of Health, tailor-made for Systematic Evidence Reviews and Clinical Practice Guidelines in order to gauge and examine the quality of a case study. Therefore, the article was assessed on a rating scale of High, Medium and Low quality. The official tool contained three possible answers of ”Yes”, ”No” and ”Other (CD, NA, NR)3 without rating points. However, in the present study, the ”Yes”, ”No” and NR answers were used and were rated with 2, 1 and 0 points respectively, due to measurement convenience. The tool initially consisted of nine questions, where one more was added (regarding types of play) and one of the existed nine was adjusted for the purpose of the study (regarding play behaviors). Therefore ten questions in total were answered for the quality of the case study (see Appendix D).
After the assessment, regarding the quantitative studies, three were found of Medium High quality and two of Medium Low quality. Regarding th case study, it was rated as High quality (see Appendixes C and D for scores). Therefore all six studies remained for review and analysis.

Table of Contents
1 Introduction
2 Background 
2.1 Child Initiated Play (CIP)
2.2 Internalized Emotional Disturbances (IED)
2.3 Play behaviors in preschool context
2.4 Engagement
2.5 Aim
2.6 Research questions
3 Method 
3.1 Search procedure
3.2 Selection criteria
3.3 Selection process
3.4 Quality assessment
3.5 Data extraction
4 Results 
4.1 Information about the selected articles
4.2 IED being mentioned in the selected articles
4.3 Play behaviors being identified
4.4 Types of CIP children manifesting IED tend to engage in
5 Discussion 
5.1 Reflections of findings related to other research
5.2 Limitations and implications of research
5.3 Methodological issues
6 Conclusion 
References
Appendix
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Examining play behaviors of children with internalized emotional disturbances in preschool context