Childhood Trauma and Play Therapy Intervention for Traumatized Children
Ogawa, Yumiko, Journal of Professional Counseling, Practice, Theory, & Research
Play therapy is examined as an intervention for traumatized children. Difficulties in assessing Post-Traumatic Stress Disorder (PTSD) in children according to the existing criteria are described, and the aspects of play therapy that facilitate the curative potential in children are analyzed. Release Play Therapy and Child-Centered Play Therapy are discussed as possible approaches in the treatment of traumatized children.
War, terrorism, earthquakes, hurricanes, airplane crushes, and school shootings are catastrophes that are all too common in the world today. In addition, on a daily basis, people are exposed Ut the risk of personal trauma, such as car accidents, medical surgery, or abuse. According to Vogel and Verriberg (1993). the earliest study of children's reactions to disaster was the research done by Perry in 1956 on children who were sitting in a theater in Vicksburg, Mississippi, when it was struck by a tornado. Tt wasn't until the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III) (American Psychiatric Association, 1980) was published that research on traumatized children began in earnest (Fletcher, 1996).
The milestone work in the field of traumatized children was that of Terr (1979), who studied kidnapped children in Chowchilla, California, As a result offace-to-face interviews with the victimized children, Terr described the children's unique traumatic responses, including their tendencies Io relive their trauma through reenactments of significant parts of the experiences by either talking about the incident or though trauma-inspired play. Terr's findings revealed the limitations of applying adult assessment and treatment, methods to children and reestablished the importance of play and play therapy.
Similarly, Shelby and Tredinnick (1995), in their study of the survivors of the 1993 Hurricane Andrew in Florida, discussed symptomology oi'these traumatized children, as well as the importance of play as a means of expression and resolution of children's terrifying experiences.
Although play has been observed to be an effective treatment for traumatized children, the paucity of research on its therapeutic utilization with this population has prevented it from gaining recognition as an effective approach by mental health professionals. However, the terrorist activities of September 11, 2001, resulted in metre attention to play-therapy as a means of helping children cope with the trauma they witnessed and experienced. By using the child's universal language, play, play therapists, the author included, observed the effective and powerful use of play therapy in the lives of children at a New York City shelter for the victims of the World Trade Center terrorist attack.
Definition of Trauma and its Difficulty in Assessing Children
Terr (1991) defined psychological trauma in children as "'the mental result of one sudden, external blow or a series of blows rendering the young person temporarily helpless and breaking past ordinary coping and defensive operations'" (p. 11). According to the nature of the event Terr (1991) divided childhood trauma into two categories: Type I, which involves a single, sudden, unexpected, relatively timelimited, and public (i.e., affecting children from more than a single family) stresser, such as a natural disaster or school shooting; and Type II trauma, which refers to a stresser resiilung from a long-standing ordeal, such as repealed abuse.
The criteria for PTSD in the Diagnostic and Statistical Manual of Mental Disorders (4th Ed., Text Revision) (DSM-IV-TR) (American Psychiatric Association, 2000) is cfuite broad and includes direct experiencing of the event, witnessing the event, or learning about the sudden death, serious harm, or threat of death experienced by a family member or another close person. However, it is important to remember that the nature of the experience will affect the healing process. For example, the healing process for the people who physically escaped from the World Trade Center when the September llth attack took plane is different from lhe process of those who witnessed it.
Seheeringa, Zeanah, Drell, and Larrieu (1995) warned that the Diagnostic, and Statistical Manual of Mental Disorders (4th EA.)(DSM-1V) (American Psychiatric Association, 1994) criteria for PTSD are not sensitive enough to diagnose traumatized infants and young children. They point out that lhe PTSD criteria in lhe DSM-IV are largely dependent on the patients' verbal descriptions of their experiences and internal states, a major limitation when working with younger children who often possess limited cognitive, abstract thinking, and expressive language skills. Scheeringa et. al. (1995) developed an alternative set of criteria for assessing PTSD in children under the age of 48 months, which included many behavioral symptoms, such as nightmares, play reenaclmeiit, and separation anxiety. Ronen (2002) proposed the assessment of children's PI1SD symptoms be based on the context of normal childhood behavior profileras, as well as developmental considerations in addition Io the PTSD criteria in the DSM-IV.
Several authors of prevailing literature also discussed the importance of assessing a child's prior exposure to trauma, yet this has never been a component of the criteria in the DSM texts (e.g., Pfefferbaum, 1997; Pynoos, 1994). This is important, since multiple experiences of trauma affect a child's sense of control arid, as a consequence, increase the child's vulnerability and hopelessness. Therefore, a child with a history of numerous traumas may develop more acute and severe symptoms compared with a child who does not have prior trauma experience. Carrion, Weems, Ray, and Reiss (2002) slated that children's unique reactions to trauma indicate an increasing need for more elaborate PTSD criteria for children. They emphasize the, paucity of empirical data supporting the belief that clusters of symptoms that illustrate adult PTSD in the DSM-IV appropriately define pediatrie PTSD. This lack of PTSD criteria specific to children may result in professionals assuming that what is adequate for adults will also be adequate for children.
Children's Characteristic Reactions to a Traumatic Event
In her extensive study of traumatized children, Terr (1991) observed four common responses of child victims of catastrophes and stated that these four symptoms can be manifested both in children with Type I and Il traumas. First, similar to the well-known symptom of flashbacks reported by traumatized adults, traumatized children also re-experience the event that caused them turmoil through intrusive and repetitive thoughts (Pen-in, Smith, & Yule, 2000). However, unlike adult flashbacks, children seldom suffer from visual flashbacks (Terr, 1985) and are more likely to exhibit this reexperience in their drawings, stories, and play (Scheeringa et al., 1995). Furthermore, children's re-experiences tend to occur during relaxing times, for example, at night before they fall asleep or while they are watching television (Perrin el id., 2000: Schaefer, 1994: Terr, 1991). Adults, on the other hand, generally experience revisualizalion in an abrupt, sudden, and very intense way.
Repetitive behavior is a second common symptom in traumatized children. This is called reenactment or abreaction. Abreaction, a concept proposed by Sigmund Freud, is "based on the strong inner drive in all human beings to recreate their experiences in order Io assimilate them" (Schaefer, 1994, p. 301). For many traumatized children this process of abreaclion takes place in their play. Terr (1991) noted that traumatized children are usually unaware that they are repeating something that is related to the original set of thoughts or feelings about the trauma. The absence of their realization of abreaction could be attributed to the unconscious nature of the urge or to symbolic expression that allows them to maintain their emotional distance from the traumatic event.
For example, several children whom the author encountered in play therapy sessions at a shelter for the victims of the World Trade Center attack exhibited the compulsive repetitiveness of creating the traumatic scene, However, contrary to Terr's description, many of these children utilized very direct play expressions and seemed to be aware of the relationship between their play and their actual experiences. Even the children who initially refused to talk about their experiences when they are directly questioned started narrating their painful stories once they started playing, as if toys and the therapeutic environment defrosted frozen feelings.
A third symptom, trauma-specific fear, which is a fear toward an exclusive stimulus highly associated with the traumatic event (Schaefer, 1994), is another common symptom in traumatized children (Terr, 1991). This symptom may cause other symptoms, such as avoidance leading to social phobia, generalized anxiety disorder, or panic disorder (Penin el al., 2000). Perrin et al. (2000) stated that children under the ages of 5 or 6 may exhibit less specific fear and present fears for more mundane things, such as the darkness or a monster.
Finally, an often-observed symptom in traumatized children is futurclessness, where children, after experiencing a traumatic event, develop a tendency to have limited future perspectives and expectations. They seem to live their fives transiently, having a sense of a foreshortened future (Vogel & Vernbcrg, 1993), believing that more calamities are likely to occur. This leaves them with feelings of powerlessness, hopelessness, and loss of control.
Other Typical Reactions of Traumatized Children
In addition to the four paradigmatic symptoms in traumatized children suggested by Terr, other authors have described other characteristic reactions of this population. The DSM-IV-TR (American Psychiatric Association, 2000) lists persistent avoidance of stimuli related to the trauma as one of the criteria for the diagnosis of PTSD. However, avoidance criteria are the most difficult to diagnose in children, since assessment of some criteria of avoidance largely depend on children's verbal communication skills (Green, 1991). Developmentally, some children may not be able to talk about a traumatic event directly, but adults may interpret this inability as avoidance. Although children may not verbally communicate their feelings and thoughts about the event, they may communicate their experiences in another way-by playing them out. For children, play is their language, and toys are their words (Landreth, 2002).
Although not listed as a criterion in PTSD, the DSM-IV-TR (2000) describes the traumatized child's tendency to believe in omens in the form of his or her ability to foresee or read some sign of an upcoming traumatic, event. Terr (1991) noted that this symptom is especially typical in children with a Type I trau ma experience. Children tend to belatedly seek and make up reasons why the trauma took place or alternative courses of action they could have taken in order Io prevent the event. As a result, children msiy develop a sense of gui.lt, Warning themselves for not taking alternative actions they believe could have prevented the traumatic event's occurrence.
Salmon and Bryant (2002) attribute this to the development of children's abstract thinking skills, in which they are able to formulate hypothetical or imaginary outcomes. In younger children, their sense of egocentrieity may account for their unrealistic positive selfevaluations in order to protect them from negative self-appraisal after a trauma experience. The child's egoeentricity could also result in children blaming themselves for the trauma occurrence (Salmon & Bryant, 2002).
Shelby (2000) explained this tendency from a child development perspective. Around the age of 7, children begin to evaluate themselves based on their own perspectives instead of relying so heavily on external evaluation. Their self-perceptions become more accurate, and their grandiose self-perceptions become weaker. Therefore, children at this age become more susceptible to internalizing negative experiences, which leads to the development of the concept of guilt. Another characteristic of children at this developmental age is the acquisition of retrospective viewpoints. These developmental characteristics help explain the child's formulation of omen thought. For example, Wehb (2001) described a hoy who felt that Ws absence at a fund-raising party for his classmate's medical expenses was related to the classmate's subsequent death. Children who are suffering from omen-type thoughts may be scared to express their feelings of guilt, because they are afraid of being accused or blamed for not taking an action.
Through the therapeutic relationship in play therapy, children may be able to reveal these feelings of self-blame. Additionally, they can play out scenarios as if they took an action and prevented the trauma in their fantasy, which may serve Io assuage lheir feelings of guilt. Additionally, James (1989) took the position that therapists should tell children unequivocally lhat the reason for lhe occurrence of the traumatic event had nothing to do with them.
The loss of a sense of security is another common symptom in traumatized children, which may increase their feelings of separation anxiety. In order to deal with these feelings, traumatized children use their parents as secure bases when faced with fearful and stressful situations (Vogel & Vernberg, 1993). Gleitman, Fridlund and Keisberg, (1999) explained this separation anxiety from the standpoint of Bowlby's attachment theory. From birth, a baby possesses a built-in fear of the unfamiliar or unknown, and it is this fear that produces attachment with a caretaker, mainly a mother, for security. A traumatic event magnifies this children's. built-in fear. Consequently, they stay closer to an adult, a secure base, in order to feel protected and eventually gain the inner strength to master the trauma.
However, if children witness parents being distressed or panicked by experiencing the same trauma or being overwhelmed by a sense of guilt for having exposed their children to a traumatic situation, children may lose confidence in their parents' ability to manage events and, as such, may themselves feel more unprotected and vulnerable. Shelby and Trediimiek (1995) mentioned lhat after experiencing Hurricane Andrew, the anxiety level of children seemed to be accelerated by the shattering of their illusion of parental control. Schaefer (1994) pointed out that the reactions of a child to a traumatic event are often subjective and relative to those of the parents. Seheeringa and Zeariah (2001) reviewed 17 studies of parent and child adjustment following traumatic event and found that those studies indicated thai the parental avoidance, inducing guilt and anxiety, and perceived rejection by the parents were associated with more negative child outcomes. Scheeringa and Zeanah (2001) also discussed the compound effects of parent and child trauma, in which the symptomology of a traumatized caregiver exacerbates a traumatized child's symptoms, or vise versa.
One characteristic frequently observed in the children whom the author met at the shelter in New York was their strong desire to accumulate possessions. Many children asked to take playroom toys home with them, or they tried to eat as many snacks as they could. This may have been because they had unconsciously or consciously felt the need to be prepared for some future calamity. Another possible explanation for this behavior is that the children may have thought that if they could have a toy or some items from the playroom, they could bring a sense of security home with them.
Curative Factors of Play Therapy for Traumatized Children
Play is children's way of expressing their whole experience of the trauma, often resulting in a cathartic experience. However, the postlrauniatie play itself does risk aggravating, instead of lessening, anxiety and increasing fear and helplessness provoked by the traumatic event. INader and Pynoos (1991) suggested that the outcome of posttnuiniatic play depends on several factors: (a) the amount of security and freedom a child possesses in order to express inhibited feelings, (b) the degree of control a cliild perceives, (e) how well cognitiveJy reworking or the event is facilitated, and (d) the child's satisfaction with the ending of the play. If these conditions are not met satisfactorily, the child may be retraumatized or fixed on the trauma. An effective play therapist will help a child regain or strengthen these factors, so that the child's adjustment is facilitated.
Sense of security
After a tratimatie event, children lose their sense of security and experience the world as a fearful and unpredictable place, furthermore, if a child sees his or her parents in a state of desperation due to the experience of a traumatic event, the child may feel weaker and defenseless. Therefore, a sense of security is one of the most important factors that a play therapist strives to create in the relationship with the child. This sense of security is provided through several key conditions in play therapy, including the therapist's confidence in the child, a therapist's confidence in him or herself, a therapist's eagerness to be fully with the cliild, and consistency and predictability in the relationship between the therapist and the child. On occasion, limit setting on a child's behaviors in a session may he necessary in order to facilitate these conditions. By having a sense of security the child is empowered and is better able to gain a sense of control (Nader and Pynoos, 1991).
Sense of Control
Mueh of the literature about traumatized children advocates that helping children regain a sense of mastery or control is the primary curative factor (Nader & Pynoos, 1991; Shelby & Tredinnick, 1995; Schaefer, 1994; Vogel & Vernberg, 1993). As Shelby and Tredinnick (1995) suggested, in play children act as if an external happening that is realistically beyond their control is under their control. Fantasy in play allows children to change (he story, so that they become empowered and strong enough to overcome their feelings of helplessness and lack of autonomy. In doing so, they finally regain their sense of control. Freud (1967) referred to ibis powerful phenomenon as denial in fantasy. It is a child's way of compensating for the expression of disequilibrium in their inner world by employing fantasized or imagined actions through play.
Shelby and Tredinnick (1995) mentioned that children who re-obtain the sense of empowerment at an earlier stage of their recovery from a traumatic event are more likely to be better equipped to provide the necessary energy to understand and adapt their experience, and restart age-appropriate behaviors. This type of empowerment may be manifested in play that takes the form of revenge, rescue, nurturing, or fantasy play. For example, a girl whom the author encountered at a shelter in New York one month after the attack on September llth, built two tall buildings with blocks. She then put toy shoes on holh buildings so that they could run away in the case of an emergency.
According to child-centered play therapy, given a therapeutic relationship, children become more able to express and accept themselves (Landreth, 2002). They come to feel free to be fully who they are, no matter what feelings they bear. This stale of being real and independent stimulates the child's ability to constructively self-direct. As a result, children gain the sense of control while making a shift toward self-actualization,
Freedom of Expression
One of the misunderstandings among many adults is that dealing directly with a traumatic event with children, either by letting them playit out or talk about it, increases children's anxiety and confusion. As a result, many adults avoid the traumatic topic. This avoidanl attitude of the caretakers may suggest to children that it is taboo to talk about the trauma and thus may rigidly decide not to talk about it. Lack of information, due to the inhibition of expression or communication about a traumatic event, can cause children to feel uncertain or anxious and also be complicated by the child's own imagination (American Counseling Association, 2001), where they oftentimes imagine something worse happening in the future, thus strengthening their apprehension.
If children's parents are distressed by a traumatic event, children will sense it arid ihink that it is better not to show or talk about their fear or helplessness so as not to exacerbate the parents' distress. Although communication of a traumatic event between a child and a parent is often encouraged, Huzziff and Ronan (1999) stated that upsetting talk of a traumatic incident by a parent might be detrimental to a child's ability to cope. For example, in a formal assessment situation, children are apt to minimize the personal impact of a traumatic event it) the presence of their parents but later disclose distress in the absence of the parents (Ronen, 2002), Considering this tendency of traumatized children, an intervention by a third person who is able to provide an emotionally and physically safe environment can be significant in helping them release their intense and confined feelings, especially by a person who understands their language, that is play. Play allows children to use symbolic expression, so that they often feel safer to reveal difficult feelings. Nader and F'ynoos (1991) rioted that the use of symbolic play is more effective in alleviating children's traumatic memories than a purely verbal approach. Children who are considered to have avoidance symptoms may he more able to articulate their traumatic experiences in a play therapy setting.
Directed and Non-directed Play Therapy Approaches with Traumatized Children
Release Play Therapy
Release Play Therapy, developed by David Levy, and Structured Play Therapy, developed by Gove Hambidge, are frequently used, directed psychotherapeute treatment approaches with traumatized children, (e.g., Schaefer, 1994; Terr, 1994; Gaensbauer, 2000). In these approaches, the therapist encourages a child "to create or facilitate the creation of the situations by the use of play methods in which the anxiety of the child is given expression" (Levy, 1939, p. 141). The therapist chooses a few toys that seem to be highly related to the traumatic event in order to induce the child to play out the experience. On other occasions, the therapist may recreate the situation that seemed to precipitate the child's difficulties and encourage the child to express what he or she experienced. However, the release play therapist rarely interprets a child's piay. Kaduson (1997) stated that although a therapist directs a child's play to focus on the core of the problem that the child is struggling with, the approach slill remains nonthreatening to a child, since the play that the child engages in is symbolic and intrinsically furi.
Schaefer (1994) supported this type of brief and directive play therapy as a crisisoriented intervention for children of Type I psychic trauma. He valued release play therapy as an effective approach to working with traumatized children and believed that therapists are too passive or wait unnecessarily for tilings to happen (Solomon, 1938; Schaefer, 1994). Solomon (1938) established a more active play therapy, in which the therapist's role is more directive in the child's play.
In the directive approaches described above, it is assumed that "the cycle of retraumatizing play must be broken by active intervention from a therapist who directs the trauma play so as to create a sense of mastery" (Schaefer, 1994, p. 308). Ryan and Need h am (2001) stated that traumatized children with PTSD who are referred for therapy are, in general, assumed to be unable to utilize their own potential healing reactions. Therefore, it is important that a therapist actively intervene to help children re-acquire a sense of control.
Child-Centered Play Therapy
In child-centered play therapy, the therapist has "a basic pliilosophy of the innate human capacity of the ehild to strive toward growth and maturity and an altitude of deep and abiding belief in the child's ability to be constructively self directing" (Landreth. 2002, p. 65). Self-actualization, which is facilitated via the therapeutic relationship between a child and a therapist through the therapist's genuineness, unconditional positive acceptance and empathy, is the core concept of child-centered play therapy.
Few research studies have measured the effectiveness of child-centered play therapy for children with PTSD (Ryari & Needham, 2001). This lack of research has prevented child-centered play therapy from being seen as a qualified, efficacious approach to working with traumatized children. Cohena, Mannarino, and Kogal (2001) conducted a survey on treatment approaches to children with FTSD thiit are utilized by both child psychiatrists and non-medical therapists. Among thirteen types of therapy, non-physician therapists rated nondirective play therapy second as the first-line treatment choice, following cognitive behavioral therapy as the most effective and preferable approach to this population.
Shen (2002) was the first to conduct a statistical study on the effectiveness of childcentered play therapy with Asian children who had experienced trauma. The Taiwanese children were victims of an earthcfuake that took place September 21, 1999. By using short-term child-centered group play therapy with the children, Shen (2002) demonstrated significant reduction in the children's anxiety and suicidal risk, thus supporting the effectiveness of child-centered play therapy with this population.
The effectiveness of child-centered play therapy for children who have witnessed domestic violence has been demonstrated in several studies (Flick-Helms, 1997; Tyndall-Lind, 1999; Kot, Landreth, and Giordano, 1998; & Smith, 2000). These studies validate the positive influences of child-centered play therapy on children's internal and external problems.
In child-centered play therapy, the duration of therapy is subjective to the needs of the child and is often dependent on the dynamic relationship between the therapist and the child (Landreth, 2002). According to the severity of the traumatic event and the intensity of the subjective experience of a traumatized child, a play therapist needs to be flexible and creative in order to provide therapy that meets a child's needs instead of strictly adhering to the traditional framework of a once a week, 45-minute play session. Landreth and Sweeney (1997) mentioned that a play therapist may need to meet traumatized children two or three times a week or even daily at the beginning of therapy, eventually shifting to once-a-week sessions. For example, Ryan and Needham (2001) presented a case study of brief, noridireclive play therapy with a child suffering from a single traumatic, event. The first meeting with the child was held at the child's house in order to reduce the child and the parents' anxiety, and accelerated the establishment of the relationship between the therapist and the child. They concluded that by conducting the first session at the child's home, the number of sessions was shortened.
The basic belief behind child-centered play therapy is that children have an innate selfdirected ability to adjust and grow as they choose how to deal with their experiences. Only the child knows how much emotional distance he or she needs in order to process his or her experiences without being overwhelmed. Consequently, children decide what kind of play, from very symbolic to realistic, they will use for personal expression. This approach allows the expression of children's subjective reactions to an event rather than reactions to the actual severity of the event (Street & Sibert, 1998). Bettleheim (1987) stated, "play is also a 'royal road' to the child's conscious and unconscious inner world; if we want to understand his inner world and help him with it, we must learn to walk this road"(p, 35).
Children who experience trauma are often abruptly deprived of the sense of security and control that are crucial to healthy emotional growth. Their feelings of fear, armer, and helplessness are often expressed differently from that of adults due to their limited development in the areas of cognition, verbalization, and abstract thinking. Due to these limitations, new PTSD criteria and treatment designated specifically for traumatized child fen are needed. A number of case studies have shown that play therapy is an effective treatment for traumatized children. Two types of play therapy, Release Play Therapy and Child-Centered Play Therapy, are often used to help children cope with trauma. However, due to the nature of traumatic events, such as a sudden onset and its chaotic aftermath, the efficacy of play therapy with this population has not been fully explored. Further research into effective interventions for children who have experienced trauma are needed, especially in the use of play therapy, which clinically appears to be helpful.
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University of North Texas
Yuiniko Ogawa, MS, M.Ed, NCC, RPT, LPCI is a doctoral student in Counseling at the University of North Texas.…
Questia, a part of Gale, Cengage Learning. www.questia.com
Publication information: Article title: Childhood Trauma and Play Therapy Intervention for Traumatized Children. Contributors: Ogawa, Yumiko - Author. Journal title: Journal of Professional Counseling, Practice, Theory, & Research. Volume: 32. Issue: 1 Publication date: Spring 2004. Page number: 19+. © Texas Counseling Association Fall 2008/Winter 2009. Provided by ProQuest LLC. All Rights Reserved.
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