Abstract
Background:
Play is an essential parameter of children’s growth and expression and this is the reason of why the use of play therapy is considered as fundamental means of preventing and dealing with problems and difficulties presented to children.
Objective:
The aim of this paper is to review the parameters related to this issue, emphasizing the efficacy of this therapeutic approach to various problems of children.
Methods:
A review of the recent literature on the issue, searching through Greek and international databases (Medline, Heal-link), in English and Greek language.
Results:
The review shows that play therapy as a form of prevention and treatment is suitable mainly for preschool and school age children. It is addressed to children who are in a transition period of their lives (after a divorce, a loss), with difficulties in managing feelings, in socializing or children who have behavioral problems. It is also addressed to children who have been witnesses of domestic violence, who have suffered some form of abuse, children who are to undergo a major surgery or those who have speech disorders. Furthermore, it is suitable for children who have some kind of developmental disorder (autism or attention deficit / hyperactivity disorder). Its efficiency is demonstrated by numerous research papers reporting a significant decrease of negative emotions and behaviors by its use.
Conclusion:
Play therapy is an alternative proposal of intervention on important issues related to children. Its implementation and value is widely known and is constantly expanding. The only condition for its implementation is the correct theoretical training of the professionals and the proper diagnosis.
Keywords: play therapy, child and adolescent therapy, pediatric nursing, children, mental health
1. BACKGROUND
Play is at the heart of childhood. It is a dynamic process that enables children to express themselves in their own ways, to get in touch with other children, to become socialized. In contrast to adults, is not an easy task for the children to express verbally their thoughts, their problems, their questions. They usually use play to express their concerns, their fears, their desires and to communicate with their environment (1, 2). Play as a free and effortless expression of life, is of vital importance for the children, because they can develop their imagination through it. They are also guided to new ways of viewing every day’s life. It is a way of exploring and getting to know both the interior and the outside world. It is a basic part of children development and it is as important as the maternal hug (3).
Playing alone (as well as playing with his friends) differs from playing under the supervision of a therapist during a therapeutic process. In the second case, the play is a means of achieving a goal. The child is under observation, is receiving care, permission is given to him and he is supported to play (4).
Play therapy is defined as the systematic use of a theoretical model that establishes an interpersonal process, in which trained therapists use the therapeutic power of play to help children prevent or resolve psychosocial difficulties and achieve optimal growth. Play therapy is a form of psychotherapeutic approach of the children and a psycho-diagnostic tool (5).
Play therapy is a form of therapy that requires the therapist to come to the child’s level and speak in his own language. The most familiar mode of expression for a child is the play. In this therapy, therefore, toys are like the child’s words, through which the child is encouraged to explore his feelings, to understand and accept them and furthermore to process them using his innate imagination and the characteristic for his age creativity (6, 7, 8). It represents a unique form of therapy for children, and at the same time, is translated into a language that children can understand and utilize the language of play. Play therapy seeks to balance the symbolic play with the linguistic expression, in a way appropriate to the children age and beneficial for them (9). Play therapy is widely used to treat emotional problems and behavioral disorders of children because it fully meets their unique developmental needs. In most children under 11 years the capacity of abstract thinking, which is a prerequisite in order to express a word with meaning and understand complex issues, motivation and emotions, is not fully developed (10, 11).
Thus, in play therapy, play is treated as a vehicle for child-therapist communication on the basis that the child will use the play materials to express directly or symbolically his feelings, thoughts and experiences (12, 13, 14).
Historical data
The first known discussions on the subject of play refer to its relationship with education and date back to Greek philosophers Plato and Aristotle’s texts. (15). In the Middle Ages, theories about play are absent and the first actual theories are found in the 19th century by Schiller, Spencer, who mentioned that play is the result of excess energy of children and it simply gives fun (16).
Jean Piaget, Anna Freud, Melanie Klein, Donald Winnicott, Virginia Mae Axline are some of the scientists who studied the contribution and value of play in mental development. Piaget considers play as part of the whole intellectual development of the child. He classifies play into three types. Practice begins in the first months of life, symbolic begins when the child is about two years old, and social occurs in the 7-11 -year- old group (17). Piaget observed that most of the children, in the first decade of their life, did not have the ability to understand complex issues, motivations and feelings, because they lacked the ability of abstract thinking. As their cognitive horizon was expanding, play was becoming more complex and rules were added (9). Anna Freud developed a system that uses the play of children in a manner similar to the one that the dreams are used in adult psychoanalysis (17). She supported that the child’s ability to play is based on precocious interactions with his mother, where, playing with his own body and the body of his mother, learns to differentiate himself from others, and in extension, to differentiate reality from fantasy (18).
Melanie Klein stated that play therapy furnishes direct access to the child’s unconscious and the spontaneous play of the child is a substitute for the free association of the adults (17). Winnicott argued that the child’s task in the first three years of life is the development of the close relationship with his mother, then a move to separation and individualization. The process of individuation is developed through the use of transitional objects and transitional space between mother and child, and suggests that there is a direct development from the transitional object to playing. The play, according to Winnicott, is central to the therapeutic experience (17, 19). The relationship between child and mother is the foundation of the child’s emotional development, and the play is an important part of this relationship (19). Play is the main means of expression for the children, while for adults is the verbal expression (20).
In contrast to Anna Freud and Melanie Klein, who were seeing play as a psychoanalytic instrument, Axline was the one who saw the conceptual expression in the process of play and the one who introduced play as a form of therapy, as she believed that it was by itself a wound healing process (8, 9). Axline proposed eight key principles that she considered as necessary in play therapy (8):
Development of good communication / relationship,
Acceptance of the child as he is,
Provision of opportunities for the child to express his feelings,
Awareness of the feelings expressed by the child and their reflection,
Belief that the child has the ability to solve his problems,
Non-directional play,
No rush to the child,
Secure boundaries around the treatment, to maintain contact with reality.
There are many classifications of play in childhood, but the broader categories include (21):
Construction toys (lego blocks, puzzles).
Toys that help in learning the use of hands (toys with various buttons, sounds, lights).
Mimetic play.
Play of pretense (most common in preschool children and older in age-children -including creating scenarios).
Energetic play (physical activities, such as sports)
Exploration play,
Play with rules (especially sports).
2. OBJECTIVE
To review the parameters related to this issue, emphasizing the efficacy of this therapeutic approach to various problems of children.
3. METHODS
This is descriptive study based on searched and used literature data related to the issue derived from on-line databases: Medline, Cinhal, and Scopus (in English), using the following keywords: play therapy, play therapy techniques, child and adolescent therapy, pediatric nursing, children, mental health.
4. RESULTS AND DISCUSSION
Therapeutic nature of play
Play has some basic features that show its importance to the child’s development:
Play is fun.
Play diminishes anxieties, fears, and frustrations.
Transfer in the child’s play is functional.
The ability of the child to imagine during play is consistent with the development of his cognitive functions (22).
Play provides an excellent opportunity for the child to have fun, and during this time, the staff has the possibility to observe the child, taking care especially about the development of socialization and the creation of relationships with other children (23). Play is vital in order the child to understand the world around him, and to find his place in this world. The significance and the importance of play are often underestimated, although they are crucial in learning to appreciate ourselves. Through the play, we can imagine other possibilities and ways of being (17).
Play is the primary code of communication. Children discover the world, themselves and others through it. They broaden their imagination, they learn to co-operate and recognize their own limits. Through this dynamic process, the child feels free to express his concern, anxieties and the various difficulties that he faces in everyday life. Play, in other words, is his own language of communication (17). It is difficult for someone to be able to confront his own feelings, to recognize and give a name to them, especially for a young child who does not know them. This therapeutic approach enables children to understand mixed emotions and unpleasant events, which were not allowed to be solved in the past. Based on this therapeutic character though, play therapy has as main objectives (13, 17):
Child’s socialization,
Development of creativity and improvement of child’s functionality,
Understanding and expressing of feelings, difficulties and conflicts,
Management of “ego”,
Understanding of “ego” and “want”.
Play therapy indications
This treatment is suitable for preschool and school age children and involves a wide range of difficulties that may occur during their development. It can help children who are in a transition period in their lives, after a divorce, a loss, a change of place of residence or school environment, or after the arrival of a new member in the family.
It is suitable for children with difficulties in managing their emotions, in socialization or children who have behavioral problems (eg aggressive behavior, temper tantrums in the classroom). It involves children who may be related to bullying phenomena, whether they are in the position of the victim or of the perpetrator (sleeping or eating disorders). It also concerns children who have been witnesses of domestic violence, who have suffered some form of abuse (social withdrawal), children about to undergo a major surgery (preoperative anxiety and fear) or those who have speech disorders. Furthermore, it is suitable for children who have some kind of developmental disorder such as autism or attention deficit / hyperactivity disorder (9, 24). Children, who have been experienced such situations and problems, can be helped substantially by the use of play therapy. Play is a form of natural and effortless learning process, the most direct way for a child to release his tensions, while it also facilitates adult’s communication with the inner world of the child (25).
Types of play therapy
Play has various features that help in the development and improvement of child’s functionality, when they are used as part of a treatment. The recognition of the value of a strong therapeutic relationship, the need of working with the child-patient differently than the adult patient, the need to examine the child from a developmental perspective, and the acceptance of play as the child’s language, are of great importance (26).
Adler’s therapy is based on people’s need for a sense of belonging. Its goals are to meet the particular needs of each child, giving them a sense of control. During play therapy, the therapist is more active and directional and tries, after building an equal relationship with the child, to explore ways of life, thoughts and feelings, to help the child understand them and to re-educate him. As a method, it seems to be quite beneficial for children with learning disabilities, autism, and attention deficit / hyperactivity disorder (27, 28, 29).
Child-centered play is based on the theory that the child’s development is a dynamic journey and a process of becoming (awareness or self-awareness). Carl Rogers (client-centered therapy) and Virginia Axline were giving emphasis to face-to-face process of coping with the child by encouraging the creation of a climate that helped him to grow up with his own rhythms (30). In non-directional or child-centered play, child is the one who directs the session, and his relationship with the therapist is the key of promoting a positive change (31). Cognitive-behavioral play therapy uses play in making cognitive changes. It introduces children to different, more adaptive responses to their difficulties, which are then used as models utilizing developmentally appropriate tools (32). Group play therapy also focuses on coping with behavioral problems, habits or mental disorders of children, who are playing in groups with the presence of a therapist, whose role varies from meaningful leadership to that of a simple observer (33).
How does play therapy work?
The child has the ability to choose what to do from a wide variety of materials and toys such as sand, clay, dolls, puzzles, etc. The therapist encourages him to experiment and express himself freely. The child is under observation, he gets attention, he is given the stimulus and he is helped to play. During the play, the child creates a safe environment where he can indulge in something difficult, “bad”, dangerous, without actually being threatened, because this is part of the play’s contract. Play therapist facilitates child’s play, enables him to get into roles, develop standards and explore alternatives. Play therapy and special interventions clarify, interpret child’s behaviors that are considered problematic, and impede his normal intellectual and mental development. Goal of play therapy is to alter these behaviors, eliminate them or even make them getting a less dysfunctional form. Play therapist works in collaboration with a team of therapists. As the child grows within the family, in which the emotional climate is determined by the quality of relationships, it is imperative that parents co-operate with a specialist adult therapist. Play is preferable to take place in child’s home, but it can also take place in therapist’s environment, even in the hospital, in a special place during his treatment, for example, during the treatment of fractures (34). The basic condition of play therapy is that it can be implemented only with the consent of the child and not because it was decided by his parents. Furthermore, its duration depends on child’s needs (35, 36, 28).
Play therapy Effectiveness and Research Data
Play therapy as a form of intervention for children has attracted the interest of modern researchers, who have tried in their studies to highlight the value and effectiveness of this method.
In a study of Danger and Landreth (2005), (37) which was aimed to determine the effectiveness of child-centered group play therapy in children with speech difficulties, it was found that children were greatly helped in the improvement of both their expressive and perceptual skills related to their speech, while it seemed to have a mixed effect on their anxiety. In another study that was aimed at examining the effect of child-centered play therapy on the stress of the teacher-student relationship, in which 58 pre-school and school age students were involved, it was found that the sessions of this treatment significantly improved the stress of both teachers and students (38).
Play therapy intervention for children with chronic illnesses was also an important field of action for researchers. Thus, in a study of 15 children with Type 1 diabetes mellitus (IMMD), in which the aim was the reduction of anxiety symptoms, the decrease of overall behavioral difficulties and the adaptation and compliance with the instructions of doctors after an intensive individual play therapy program, it appeared that this intervention had a positive effect on the overall objectives originally set (39).
The effect of play therapy on the development of emotional and communicative skills of 372 pre-school children was at the heart of another study. The results showed that children’s socio-emotional skills, in particular, communication and problem-solving skills were greatly enhanced (22).
Another field of research that attracted the scholars’ interest is that of the relationship between play therapy and problematic behaviors of children. In a study conducted in Iran that concerned the effect of play therapy on children with Attention Deficit Hyperactivity Disorder (ADHD), it was found that the application of the above-mentioned therapy resulted in a reduction of disobedience in the experimental group (40). The application of Adler’s group-based play therapy to children, who could not complete their homework (off-task behavior) and they had disruptive behavior, has also resulted in a reduction of problematic behaviors (41). In a third survey of 60 displaced orphaned children from Uganda in which the effect of GAPT (Group Activity Play Therapy)on them was investigating, it was found that there was a significant reduction in behavioral problems of the experimental group compared with the control group (42)
Parents of children who had undergone liver transplantation were included in the research population of a study, in which their views about the effect of play therapy on coping strategies of problems arising from transplantation were examined. The findings suggest that the children were substantially helped during their hospitalization in the expression of their concerns and fears, fact that led them to reduce stress and increase their self-esteem (43).
Another interesting survey was aimed at studying the effect of pre-operative play therapy on 203 children undergoing surgery. The results showed that there were no significant differences between the two groups in the perception of postoperative pain, but the children of the experimental group experienced less stress both preoperatively and postoperatively (44). Similar were the results of a study in which after the intervention of a clown preoperatively, a significant reduction in children’s and parents’ concerns was observed (45). A reduction in anxiety, fear and other negative emotions resulting from the hospitalization, was also confirmed by a recent survey conducted in 304 children in Hong Kong (46).
Play therapy when applied within a family therapy framework has proven to be particularly important for both adults and children, because it helps in a better communication with each other, especially in difficult situations such as parental divorce (47). A study in school counselors has shown that just a 12-hour workshop was enough for them to understand and realize that they can easily apply the basic CCPT (Child Centered Play therapy) principles (48)
Finally, in a survey that studied nurses’ opinions on play therapy, it was found that although nurses agreed that the use of play therapy might have positive results, they mentioned that they don’t use it in everyday practice, mainly due to lack of time and knowledge (49).
5. CONCLUSION
Nowadays, play therapy is an important alternative for effective intervention in major child-related problems. Its implementation principles and the value of its use are known and accepted by all professionals in the field, regardless if its application has not been widely disseminated. The solid theoretical knowledge of this treatment and its application to appropriate diagnosis are essential prerequisites for its correct and effective implementation, since any difficulties reported by health professionals (lack of time) can be eliminated. Play therapy is also a huge field of research and study of all those involved in pediatric care.
Author’s contribution:
K.K, T.A. gave substantial contributions to the conception or design of the work in acquisition, analysis, or interpretation of data for the work and drafting the article, T.L. ( Contribution to analysis and data interpretation, drafting the article), I.C and F.A ( Drafting the article, critically revising), K.A (Drafting the article, critically revising, approval final version ) K.L (critically revising, approval final version)
Conflicts of interest:
There are no conflicts of interest.
Financial support and sponsorship:
Nil.
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