Editorial, J Trauma Stress Disor Treat Vol: 9 Issue: 4
Incorporating Play in Cognitive Behavioral Treatment for Children with PTSD
Maayan Shorer1,2 and Alan Apter1*,2
1Department of Clinical Psychology, Ruppin Academic Center, Emek-Hefer, Israel
2Department of Psychological Medicine, Schneider Children’s Medical Center of Israel, Petach Tikvah, Israel
Received: September 14, 2020 Accepted: September 17, 2020 Published: September 24, 2020
Citation: Shorer M, Apter A (2020) Incorporating Play in Cognitive Behavioral Treatment for Children with PTSD. J Trauma Stress Disor Treat 9: e123.
Keywords: Cognitive Behavioral Therapy, PTSD, traumatic experience
Cognitive Behavioral treatments (CBT) for children and adolescents diagnosed with PTSD are considered effective and often serves as ‘first line’ treatments for this population [1-3]. Most of these protocols include modules of psycho-education, in-vivo exposures to trauma related triggers, stress management techniques, parent counseling, and some variety of narrative work or emotional processing of the traumatic experience [4,1]. CBT protocols for children diagnosed with PTSD, such as the Prolonged Exposure therapy for adolescents (PE-A; ) and the Trauma Focused CBT (TF-CBT; ) were adjusted to meet the developmental needs of children and adolescents. Some examples for such adaptations are using stories as a means for psychoeducation, using drawings to tell the traumatic experience, and involving the parents in the treatment course.
Despite the mentioned-above adaptations to pediatric population, CBT techniques, such as gradual exposure to trauma related triggers, or cognitive restructuring, are often difficult to carry out with young children [6,7]. The limited verbal and abstract thinking skills of young children might hinder the implementation of such techniques [8,9]. In addition, children and adolescents are likely to be impulsive and limited in their self-reflection , while an engagement in exposure tasks requires motivation, tolerance for frustration, and insight into one’s behavior .
The inclusion of play in CBT can enhance the child’s engagement and rapport during treatment. Integrating play elements into CBT has been suggested as a means of enhancing the utility of CBT for children diagnosed with anxiety disorders [11,12,10,7], and PTSD . Moreover, play itself can contribute to the child’s mental adjustment. In 2018, Schaefer and Drewes review different mechanisms through which play can ameliorate fears and anxieties . For example, play can evoke positive affect and reduce stress, which contradict the negative affect. Imaginative play provides the child a safe space and an opportunity to be gradually exposed to anxiety producing stimuli. Play may also afford the child a sense of control and competence. Through imaginative play and role play children can externalize their difficulties, thus feel less ashamed of it and more capable to overcome it. In addition, play is often a natural mode of self-expression for young children, whose language skills are yet developing.
These advantages of play may be particularly important in the context of traumatic experience. Greater resilience in children who have been exposed to terrorism has been associated with greater tendency to engage in play; a better ability to plan and play out a coherent, progressive, creative and satisfying narrative; a better capacity for self-soothing; and a greater tendency to engage in a relationship with an adult during the play .
Unfortunately, while play may be helpful in processing traumatic events, exposure to traumatic events may lead to a defensive reduction in children’s symbolic play [15-17]. When a child is under a threat condition, the sympathetic nervous system activates the fight or flight (F&F) response, or the freeze response. According to the Polyvagal Theory , an adaptive coping requires the ability to shift from these ‘survival’ modes into social engagement state. Play may be one way to activate the social engagement system. Therefore, incorporating play elements during an exposure to feared stimuli may help children to tolerate it and to be de-sensitized to it .
In our clinical experience, there are numerous options of integrating play into CBT with children diagnosed with PTSD. For example, play may be incorporated during the in-vivo exposure tasks . The therapist can design the exposure task as play or create a playful atmosphere during the exposure. By creating a playful atmosphere during the exposure task, the child can form new, competing, associations between the stressor and the feeling of enjoyment . An example for such playful exposure task is asking a child to re-visit the place where he was hit by a car as a journal reporter, who wants to write an article about the accident. The child can also be asked to take the role of a photographer, who wants to document the place where the accident occurred.
Play elements can also be incorporated while processing the traumatic memory. This treatment module usually requires an activation of the traumatic memory and re-telling its’ narrative. Reminding the traumatic experience might be painful for the child. Thus, many children resist participating in this therapeutic intervention. However, in our experience, when children are offered to construct their story in a playful and creative manner, their cooperation improves. For example, children treated at our PTSD unit are offered to build a three-dimension model of the place where their traumatic event happened, using blocks, clay, or miniature dolls. Each scene of the traumatic event is composed separately and then being pictured, to allow continuous exposure. The child is asked to view the pictures between the sessions, add verbal subtitles to it, or further elaborate on each scene. Other children choose to tell their traumatic experience by drawing a comic’s booklet, writing a book, or preparing a presentation. It is important to allow children to choose their preferred mode of expression, to ensure their engagement and rapport.
In summary, young children may have difficulties in adhering to trauma focused interventions, as these interventions require exposure to painful memories and to frightening situations. We suggest that the integration of playful elements into these interventions may enhance the child’s engagement and rapport, activate positive affect, and improve the child’s tolerance for stress.
- Lenz AS, Hollenbaugh KM (2015) Meta-analysis of trauma-focused cognitive behavioral therapy for treating PTSD and co-occurring depression among children and adolescents. Couns Outcome Res Eval 6: 18-32.
- Scheeringa MS, Weems CF, Cohen JA, Amaya‐Jackson L, Guthrie D (2011) Trauma‐focused cognitive‐behavioral therapy for posttraumatic stress disorder in three‐through six year‐old children: a randomized clinical trial. J Child Psychol Psychiatry 52: 853-860.
- Schottelkorb AA, Doumas DM, Garcia R (2012) Treatment for childhood refugee trauma: a randomized, controlled trial. Int J Play Ther 21: 57-73.
- Gilboa-Schechtman E, Foa EB, Shafran N, Aderka IM, Powers MB, et al. (2010) Prolonged exposure versus dynamic therapy for adolescent PTSD: a pilot randomized controlled trial. J Am Academy Child Adolesc Psychiatry 49: 1034-1042.
- Cohen JA, Jaycox LH, Walker DW, Mannarino AP, Langley AK, et al. (2009) Treating traumatized children after hurricane Katrina: project Fleur-de lisTM. Clin Child Fam Psychol Rev 12: 55-64.
- Schaefer CE, Drewes AA (2009) The therapeutic powers of play and play therapy. In Drewes AA (Ed.) Blending play therapy with cognitive behavioral therapy: evidence-based and other effective treatments and techniques. John Wiley & Sons, New Jersey, USA, 3-15.
- Weisman Kra-Oz O, Shorer M (2017) Playful exposure: an integrative view on the contributions of exposure therapy to children with anxiety. J Psychother Integr 27: 495-507.
- Schaefer CE, Drewes AA (2018) Play-Based approaches for treating childhood anxieties: basic concepts and practices. In Drewes AA and CE Schaefer (Eds.) Play-based interventions for childhood anxieties, fears, and phobias. Guilford Press, New York, USA, 3-12.
- Reynolds S, Wilson C, Austin J, Hooper L (2012) Effects of psychotherapy for anxiety in children and adolescents: A meta-analytic review. Clin Psychol Rev 32: 251-262.
- Podell JL, Martin ED, Kendall PC (2009) Incorporating play within a manual-based treatment for children and adolescents with anxiety disorders. In Drewes AA (Ed.) Blending play therapy with cognitive behavioral therapy: Evidence-based and other effective treatments and techniques. John Wiley & Sons, New Jersey, USA, 165-178.
- Kendall PC, Hedtke KA (2006) Cognitive-Behavioral Therapy for anxious children: Therapist manual. Workbook Publishing, Ardmore, PA, USA.
- Knell SM, Dasari M (2009) CBPT: Implementing and integrating CBPT into clinical practice. In Drewes AA (Ed.) Blending play therapy with cognitive behavioral therapy: evidence-based and other effective treatments and techniques. John Wiley & Sons, New Jersey, USA, 321-352.
- Green EJ, Fazio-Griffith L, Myrick A (2018) Play psychotherapy with children traumatised by caregivers with alcohol abuse disorder: integrative interventions. Commonwealth Youth and Development 16: 1-14.
- Cohen E, Chazan S, Lerner M, Maimon E (2010) Posttraumatic play in young children exposed to terrorism: An empirical study. Infant Ment Health J 31: 159-181.
- Drewes AA (2001) Developmental considerations in play therapy with traumatized children. In Drewes AA, Carey LJ, Schaefer CE (Eds.) School-based play therapy. John Wiley & Sons, New York, USA, 297-314.
- Dugan EM, Snow MS, Crowe SR (2010) Working with children affected by Hurricane Katrina: two case studies in play therapy. Child Adolesc Ment Health 15: 52-55.
- Feldman R, Vangrober A, Hallaq E (2007) War and the young child: mother child relationship, child symptoms, and maternal well-being in infants and young children exposed to war, terror, and violence. Paper presented at the European Society for Child and Adolescent Psychiatry 13th International Congress, Florence, Italy.
- Porges SW (2001) The polyvagal theory: phylogenetic substrates of a social nervous system. Int J Psychophysiol 42: 123-146.
- Glibota LC, Lindaman S, Coleman AR (2018) Theraplay as a Treatment for Children with Selective Mutism. In Drewes AA and Schaefer CE (Eds.) Play-based interventions for childhood anxieties, fears, and phobias. Guilford Press, New York, USA, 124-143.