Can I Play? Using Play Therapy for Children and Adolescents With Disabilities

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1 Suggested APA style reference: Lrenz, D. C. (2010). Can I play? Using play therapy fr children and adlescents with disabilities. Retrieved frm Article 7 Can I Play? Using Play Therapy fr Children and Adlescents With Disabilities Dawn C. Lrenz Paper based n a prgram presented at the 2008 American Cunseling Assciatin Cnference, March, 2008, Hnlulu, Hawaii Lrenz, Dawn C., is an adjunct prfessr at The Pennsylvania State University. Dawn has substantive experience cunseling children and adlescents with disabilities. Her primary research interest areas include clinical supervisin and cunseling self-efficacy, and effective cunseling interventins with yuth with disabilities. Traditinal mdes f cunseling require clients, even yung children, t verbally participate within the therapeutic prcess. Play therapy, ne f several mdalities f cmplimentary therapies (i.e., art therapy, sand tray therapy, music therapy) allws children t utilize tys (referred hereafter as materials) t express their wn stry and emtins withut necessarily using wrds t participate in the cunseling prcess (Carmichael, 2006). Play therapy has histrically been used in a myriad f interventins fr children with behaviral and emtinal needs. Beginning with psychanalytic play therapy interventins, Anna Freud realized that children have emtinal and behaviral needs much like their adult cunter-parts and that children culd be helped by mdifying available psychanalytic techniques such as free assciatin t better meet the needs f the child (Salmn, 1983, as cited in Landreth, 2002). Cmplimentary therapies such as play therapy have been shwn t prduce utcmes that are as effective as traditinal talk-therapy methdlgies cmmnly used with adult ppulatins (Leblanc & Ritchie, 2001). Carmichael (2006) explains play therapy as an interventin, based n theretical premises and recgnized as a therapy (p. 2). Needs that are ften addressed thrugh the use f play therapy include emtinal and behaviral adjustment needs f children related t acting ut aggressive behavirs, family and relatinship issues, dmestic vilence, abuse, academic perfrmance, and reductin f stress and anxiety as it is designed t prvide the child with skills and experiences that assist him r her in vercming such difficulties (Carmichael, 2006; Landreth, 2002). Fr these purpses, play therapy cntinues t be an effective means t facilitate the cunseling relatinship and prmte psitive change fr children (Leblanc & Ritchie, 2001). Given the flexible cnditins f play therapy and its uses, it can als be used t meet the needs f children with disabilities. Fr example, child life specialists already emply play therapy techniques t allw hspitalized children t adapt t their ften intimidating medical surrundings

2 (Landreth, 2002). Children with disabilities may face a variety f medical prcedures during their yung lives and may be particularly susceptible t feelings f inadequacy, lw self-esteem, and incmpetence (Williams & Lair, 1991) as well as feelings f anxiety, and lack f cntrl assciated with intense medical needs and demands. Given the pprtunity t wrk with play media and a trained cunselr, children with physical disabilities, cmmunicatin related disabilities, and chrnic medical illnesses may find slace in being able t express their emtins and tell their stries thrugh wrk with play therapy materials. Particularly, children with disabilities may find strength in develping a sense f self-esteem, autnmy, and cmpetency as well as mastering certain physical and scial skills thrugh the use f play therapy (Carmichael, 1993). Nn-directive and directive appraches t play therapy prcedures can allw the child with a disability t interact with his r her envirnment in a meaningful way, experience enhanced scial interactins, develp new skills, and be fully a child. Since childcentered play therapy is the mst familiar apprach t play therapy a mre detailed explanatin is prvided fllwed by a brief explanatin f the use f directive techniques. Basics f Play Therapy A brad set f theretical elements help t perpetuate play therapy prcedures. Fr example, a cunselr may seek t wrk frm their identified theretical basis (i.e., psychanalytic, Gestalt, Adlerian) thrugh their practice f play therapy. Each f these theretical cmpnents can be incrprated int three primary means f the play therapy envirnment. Althugh the mst well-knwn is a nn-directive, r child-centered apprach, cunselrs may als use a mre directive technique in selecting materials and facilitating the play therapy prcess, r may chse a prescribed apprach that allws fr cunselrs t select frm bth child-centered and directive techniques t best facilitate grwth dependent upn the child s develpmental, physical, and cgnitive needs. Fr a cmplete descriptin f theretical basis f play therapy, please see Carmichael (2006). Child-Centered Play Therapy Play is a child s natural means f cmmunicatin and self-expressin and can prvide an pprtunity fr the child t wrk thrugh a variety f emtins (Axline, 1947). In nn-directive r child-centered play therapy, the child is given the respnsibility f leading and directing the sessin (Axline, 1947; Landreth, 2002). Abve all the relatinship between the cunselr and the child is paramunt in the prmtin f psitive change (Axline, 1947). This apprach can be used t allw the child t express feelings r attitudes that may be t threatening fr traditinal mdes f cunseling by allwing the child t chse his r her materials in the play therapy setting (Landreth, 2002). The cunselr using child-centered play therapy remains nnjudgmental, accepting, respectful, and prvides the child with uncnditinal psitive regard, dignity, and self-wrth just as the cunselr wuld when wrking with an adult client frm a persn-centered perspective (Carmichael, 2006). The cunselr attempts t understand the child s internal wrld in her r his expressin f emtin thrugh the use f childselected materials. Thrugh reflectin f the child s affect, emtin, and activities the cunselr is able t prvide a vice fr ften very painful experiences fr the child (Carmichael, 2006). This develpmental apprach is funded in the idea that the child 2

3 has a natural tendency tward grwth and actualizatin (Landreth, 2002). Cmmn materials the child may chse frm in child-centered play therapy include nursing bttles, culturally diverse dll families, ty sldiers, ty animals, dll huses, puppets, and varius art materials (Axline, 1947). Fr a cmplete descriptin f child-centered play therapy and materials please see Axline (1947), and Landreth (2002). Fcused Play Therapy Depending n the child s therapeutic needs, a mre directive r fcused apprach in play therapy may be mre suitable. Directive explratin endrses the idea that selfefficacy can best be attained by either cllabrative selectin f materials by bth the cunselr and the child, r thrugh cunselr-selected activities and materials (Carmichael, 1993). Unlike child-centered play therapy, which allws fr free explratin, fcused appraches can als be utilized t teach alternative behavirs and new skills (Carmichael, 2006). While the relatinship between the cunselr and the child remains the mst essential cmpnent f directive appraches t play therapy (Nrtn & Nrtn, 2006), cunseling technique may incrprate theries utside f the traditinal child-centered, r nn-directive apprach. Since child-centered play therapy is child-led, the cunselr will adhere mst stringently t Rgerian stylistics withut directing the child. Directive appraches allw the cunselr t utilize Gestalt, Adlerian, Jungian, r relatinship play therapy techniques (Carmichael, 2006). Depending n the presumed basis fr emtinal r behaviral difficulty, cunselrs may assume different rles as a play therapist depending n their theretical rientatin. Cmmn directive appraches t play therapy include cgnitive behaviral play therapy, develpmental play therapy, and relatinship play therapy (Carmichael, 2006). Fcused play therapy can be utilized as a time-limited interventin in which cunseling wuld be limited t twelve structured sessins (May, 2006) whereas traditinal child-centered play therapy is mst effective when stretched ver 30 t 35 sessins (Leblanc & Ritchie, 2001). Prescribed Play Therapy Bth fcused and child-centered play therapy techniques can be easily adapted t meet the emtinal and develpmental needs f children with disabilities. Applicatin f either technique that is best suited t the child s needs is als knwn as prescriptive play therapy. Cunselrs wh use this methd are knwledgeable abut different appraches t play therapy and have skill in applying these strategies (Thmpsn, Rudlph, & Hendersn, 2004). Thrugh prescriptive play therapy the cunselr is able t identify bth shrt and lng-term needs f the child and understand the wrld f the child thrugh his r her play (Thmpsn et al., 2004). Due t the flexible nature f prescriptive play therapy, use f this apprach fr practice is best used t address the needs f children with disabilities as well as prmte psitive utcmes fr the child. Multicultural Cnsideratins In chsing a play therapy apprach fr a child with a disability, it is als imprtant fr the cunselr t be familiar with cultural cnstructs apparent within the family. Basic assumptins f play therapy include similarity f play acrss cultures and pen expressin f feelings thrugh play. This may make it difficult fr the cunselr t distinguish between cultural play variants as sme cultures place significant restrictin n 3

4 direct expressin f emtin (O'Cnnr, 2005). Language may als be an imprtant cmpnent f the play therapy relatinship. If a child with a disability speaks a different language at hme than in the play therapy setting he r she may rely n tne f vice, facial expressins, and bdy mvements t understand what is being said (Sue & Sue, 1990, as cited in O'Cnnr, 2005). Culture may als play a key rle in cmmunicatin variatins: while sme families are mre directive, thers may tend tward nndirective cues such as bdy language and nnverbal cmmunicatin (O'Cnnr, 2005). T this end, cmmunicatin is als influenced by the cultural perspective f spntaneus exchange f ideas and statements abut difficulties within the family as sme may believe that prblems shuld be handled within the hme and sme families may be less likely t spntaneusly present this infrmatin unless directly questined abut it (O'Cnnr, 2005). Cunselrs seeking t use play therapy must als understand that families may feel sme shame in regards t having failed t address their child s difficulties (O'Cnnr, 2005, p. 567). Mdificatins fr Children with Disabilities Children with disabilities may be faced with a multitude f different experiences that are unique t having specific disabilities including expsure t medical prcedures, feelings f lss f autnmy and inadequacy that may lead t lw self-esteem and decreased independence. Children with cmmunicatin disabilities may als experience behaviral difficulties if they are unable t effectively cmmunicate with peers and caregivers. Addressing these cncerns in play therapy the child can express him r herself withut the need fr verbal explanatins. Having materials available that relate t the child s wrld is essential fr children with and withut a disability as it allws them t express their cncerns, fears, and emtins using cmmnalities frm their wrld as they see it. T allw fr this expressin it may be necessary t mdify prcedures used in play therapy and/r materials utilized in the play therapy setting. Prcedure Mdificatins Prcedural mdificatins are the first step in addressing the needs f a child with a disability in the play therapy setting. Inclusin f an interdisciplinary team as well as apprpriate family members will enable the cunselr prvide suitable accmmdatins within the cunseling envirnment bth thrugh implementatin f play therapy practice and use f any needed adaptive materials. The child is the mst imprtant cnsideratin when chsing the ptimal apprach t play therapy. The first recmmended mdificatin t prcedural practices in play therapy is the inclusin f a treatment team (Carmichael, 1994). An interdisciplinary team shuld cnsist f thse individuals currently prviding services t the child (Carmichael, 1994). Members f this team culd be medical specialists, ccupatinal and physical therapists, and ther persnnel invlved in the care f a child with a disability. Inclusin f the interdisciplinary team in prcedural cnstructs with a child with a disability will aid the cunselr in setting up apprpriate accmmdatins while als allwing them t becme familiar with realistic expectatins fr the gals f the family and a child with a disability (Carmichael, 1994). These members may als be able t 4

5 prvide the cunselr with feedback regarding the effectiveness f play therapy as it relates t behaviral, emtinal, and scial needs acrss settings (Carmichael, 1993). Inclusin f a treatment team can bring up sme ethical cncerns related t cnfidentiality f the child with a disability and f the family. Fr the cunselr it is essential t wrk with bth the child and the family t ensure that having a treatment team in place adequately meets the needs f the child with a disability. Given the sensitive nature f sharing infrmatin with individuals utside f the play therapy envirnment the cunselr shuld btain all apprpriate cnsent frms at the nset f cunseling and regularly meet with the family t discuss any cncerns prir t meeting with the treatment team. As always the cunselr shuld seek t disclse nly infrmatin necessary t the nging benefit f the child with a disability. The family shuld als be advised f their right t nt have infrmatin shared with the treatment team. A secndary cmpnent fr prcedural mdificatins fr play therapy fr a child with a disability includes the incrpratin f parents and caregivers in the therapeutic prcess (Carmichael, 1993, 1994; Cgher, 1999; Guerney, 1991). Althugh this is useful in wrking with children withut disabilities in treatment planning, it may be mre beneficial t cunselrs wrking with a child with a disability as it will allw them t have further insight int the child s immediate needs and hw t best address them within the play therapy setting. Parental invlvement can be implemented in several ways depending n the specific needs f the child. Filial play therapy, r child relatinship enhancement family therapy (CREFT), allws the cunselr t train parents t prvide play therapy sessins while they are away frm the cunseling setting (Carmichael, 2006). The cunselr may als chse t incrprate the use f hmewrk assignments fr the parents t cmplete with the child. These can include setting a date with the child, structured play activities, and the use f ntes, cards and phne calls t let the child knw that they are being thught abut (Mcguire & Mcguire, 2001). Parents shuld als be invited t attend a weekly 15-minute parent meeting arranged either at the beginning r the very end f the play therapy sessin (Mcguire & Mcguire, 2001). This meeting wuld allw parents t share weekly highlights and infrmatin abut the week s hmewrk assignments, and it wuld allw the cunselr t share sessin themes and t make new hmewrk assignments (Mcguire & Mcguire, 2001). This cllabrative wrk between the parents r caregivers in play therapy and the cunselr may assist in linking individual play therapy with parental empwerment practices t transference f psitive change int ther arenas utside the cunseling ffice (Thmpsn et al., 2004). Parental training will intrduce parents t methds f play therapy and encurage a cllabrative wrking alliance between the cunselr and the family. Material Mdificatins T prvide an apprpriate play therapy envirnment fr a child with a disability the fllwing factrs must be taken int cnsideratin: specific disability, physical accmmdatin, material mdificatins r adaptive tys, develpmental level, and experiences that may be unique t a child with a disability. Ability t mdify play therapy techniques and materials t suit bth the child and the child s supprt system will yield mre successful therapeutic utcmes (O'Cnnr, 2005). The play therapy envirnment prvides a child with a disability with freedm, acceptance, and permissiveness (Jnes, 5

6 2001) characteristics that may have been limited in nature in their yung lives given the fact that many children with a disability may have experienced a brad range f medical situatins (Kunkle-Miller, 1990). Children with a disability may have experienced a lss f cntrl, lss f freedm, and lss f chice (Jnes, 2001). Fr this reasn the first suggested material mdificatin is the inclusin f bth real and pretend medical equipment (Kunkle-Miller, 1990). Incrpratin f materials fund in the child s envirnment will allw the child with a disability t wrk thrugh feelings abut being hurt and pwerless and having a disability that cannt be fixed (Kunkle-Miller, 1990, p. 5). Cunselrs may als wish t include items that wuld be disability-specific fr dlls such as wheelchairs, braces, crutches, and hearing aids. Secndary material selectin may be made based n specific disability needs. This can include the adaptatin f play therapy materials already available r the additin f ther materials that allw fr a child with a disability t easily manipulate the item. It is als necessary fr the cunselr t determine whether t use a child-centered apprach r a fcused apprach fr play therapy. This determinatin will dictate whether r nt the child with a disability is able t chse frm the entire ty library r frm a few selected materials. This decisin shuld depend n the develpmental level f the children, and whether they have the requisite skills needed t explre their envirnment (Bradley, 1970, as cited in Carmichael, 1993). If a fcused apprach is decided upn the cunselr must chse which materials and fr what reasn they wuld like fr the child t begin wrking with. Depending upn the gals fr play therapy, inclusin f materials that allw a child with a disability t master physical skills, such as finger dexterity, may be apprpriate (Carmichael, 1993). Items like hmemade play dugh and activities such as macramé, msaic tiles prjects, string art, and sculpturing may als prvide physical benefits t a child with a disability alng with the emtinal and behaviral benefits f play therapy (Carmichael, 1993). Mdificatins t current materials already in the ty library may be needed fr specific needs. Fr example, traditinal art supplies such as crayns, paint brushes, and pencils can be easily adapted by slipping the fam cushin frm hair rllers ver them t allw fr easier manipulatin by a child with a disability (Musselwhite, 1986, as cited in Carmichael, 1993). Fr dramatic play, cstume items like purses, hats, and scarves may prve simpler fr a child with a physical disability t manipulate and utilize in their play (Salmn, 1983, as cited in Carmichael, 1993). Children wh have a hearing disability and use sign language fr cmmunicatin may find that having puppets placed n jars will allw them t cntinue t cmmunicate while still manipulating the puppet (Kunkle-Miller, 1990). Fr sme children a glve that is fashined with Velcr r magnetic strips may allw them t handle metal r textured items easily (Carmichael, 1994). Items that can be added t the play therapy library include activity bards, pegbards with yarn, and large beads with yarn fr stringing (Musselewhite, 1986, as cited in Carmichael, 1993). Other adaptive tys that have been used successfully with children with disabilities include sliding panels, bells, wheels, and lights; a rummage bx with tys f varying textures, sizes, and shapes; sand trays, and musical instruments (Darbyshire, 1980, as cited in Carmichael, 1994). Prviding small bean bags in different shapes and sizes is an alternative t balls that rll away r that may be difficult t grasp (Salmn, 1983, as cited in Carmichael, 1993). Sme materials traditinally used fr play 6

7 therapy may need t be altered t effectively make the play therapy envirnment user friendly (Carmichael, 1994, p. 53). Fr example, Kunkle-Miller (1990) suggests using plasticine instead f ceramic clay because the slip frm ceramic play impairs the ability t sign and the alternative leaves hands free t cmmunicate. Adaptive play materials such as rundheads and rundkids (pseable fam figurines that are easily manipulated and hld their shape), tactile discs, and adaptive art materials are nice additins t the play therapy library and are available at Cunselrs may als find adaptive materials at and can search several adaptive ty vendrs thrugh disability-resurce.cm/tys.html. Setting Mdificatins Mdifying the play therapy setting is the third cmpnent f prviding services t children with disabilities. Depending upn the specific needs f a child with a disability several things can be dne t adapt the envirnment t facilitate prductive play therapy. Fr instance, fr children wh have a disability that inhibits their mbility the use f wedge pillws, and bean bags placed in different places thrughut the rm encurages different psitins and independence (Carmichael, 1994). Large stuffed animals may als be an effective supprt fr a child with a disability (Carmichael, 1994). Fr children wh have a limited range f mtin, c-clamps can be used t stabilize a dllhuse n a table and items can be arranged n an elevated tray (Carmichael, 1994). Other cnsideratins must be taken in regards t the lighting and the general arrangements f the rm. Particularly with children wh have a hearing impairment and use sign language t cmmunicate, apprpriate lighting is essential t understand what the child is saying (Kunkle-Miller, 1990). Arrangement f the play therapy rm in such a way that allws the cunselr t see the wrk f the child with a disability may als enable cmmunicatin. Anther aspect is t ensure that children with a physical disability that inhibits mbility have enugh rm t maneuver their wheelchair thrughut the space, and that children wh are able t stand with assistance have plenty f places thrughut the rm t lean and brace themselves. Apprpriate mdificatin f materials and the play therapy envirnment can encurage children with a disability t achieve independence and cmpetence nt always available elsewhere (Carmichael, 1994). Implicatins fr Cunselrs and Cunselr Educatrs Cunselrs utilizing play therapy fr children with disabilities must be prepared t implement apprpriate mdificatins in technique, material selectin, and setting. Unlike ther treatment mdules in traditinal play therapy the inclusin f an interdisciplinary treatment team as well as cncurrent invlvement with the parents r caregivers in the therapeutic prcess is essential t prmte psitive change fr a child with a disability. By creating a safe envirnment fr the child with a disability the cunselr can encurage the expressin f psitive and negative emtins and help the child t develp refined cping and scial skills as well as assist them in attaining a level f autnmy and cmpetency. Prir t explring wrk with a child with a disability the cunselr shuld als becme aware f any dual diagnsis the child may have that wuld indicate the need fr further accmmdatins in play therapy. Fr example, a child with spina bifida may have a physical disability as well as a cgnitive disability. Parental input 7

8 fr this reasn is essential at facilitating play therapy and can prvide cunselrs with needed infrmatin t supply needed accmmdatins fr a child with a disability. Cultural expectatins shuld als be addressed at this level as it may effect the parents expectatins f treatment as well as their level f invlvement. Cunselr educatrs shuld be acutely aware f the specific needs that children with disabilities may bring t play therapy. Cunselrs in training are best served by a variety f field experiences that allw them t wrk with children with disabilities. Cursewrk shuld als incrprate different theretical appraches t play therapy s that future cunselrs may be able t draw frm a prescribed methd f play therapy that is best suited fr bth the child and the family. Multicultural implicatins shuld als be addressed thrughut the cursewrk, and fieldwrk. Since mst masters level cunseling prgrams d nt include cursewrk r fieldwrk in play therapy, cunselr educatrs shuld cntinue t encurage cunselrs-in-training t seek ut cntinuing educatin thrugh apprpriate avenues prir t practicing play therapy with children with a disability. Cunselrs seeking additinal training fr play therapy can cnsult the Assciatin fr Play Therapy (APT) nline at fr cntinuing educatin, readings, and cnference infrmatin. Ethical cnsideratins regarding the limits f cnfidentiality in play therapy as discussed earlier particularly as it applies t the invlvement f an interdisciplinary team and the inclusin f filial play therapy shuld als be cnsidered. Cnclusin Play therapy prvides hlistic cunseling and is an effective means f wrking with children with a disability. Systemic appraches that identify the child s family, cmmunity, and sciety allw the child t interact with play therapy materials in a meaningful way. Chsing the apprpriate medium f interventin aids children with a disability in free expressin and helps them t establish sme cntrl ver their envirnment. While a brief utline f mdificatins t play therapy techniques, materials, and settings is prvided here, future research culd lk at the efficacy f needed mdificatins fr specific disabilities. Fr example, addressing accmmdatins needed fr cgnitive based, physical based, cmmunicatin based, and sensrimtr based disabilities may allw cunselrs t emply different mdificatins t best serve the children they wrk with. References Axline, V. M. (1947). Play therapy. New Yrk: Ballantine Bks. Carmichael, K. D. (1993). Play therapy and children with disabilities. Issues in Cmprehensive Pediatric Nursing, 16(3), Carmichael, K. D. (1994). Play therapy fr children with physical disabilities. Jurnal f Rehabilitatin, 60(3), Carmichael, K. D. (2006). Play therapy: An intrductin. Upper Saddle River, NJ: Pearsn Merrill Prentice Hall. Cgher, L. (1999). The use f nn-directive play in speech and language therapy. Child Language Teaching and Therapy, 15(1),

9 Guerney, L. F. (1991). Parents as partners in treating behavir prblems in early childhd. Tpics in Early Childhd Special Educatin, 11(2), Jnes, E. M. (2001). Play therapy fr children with chrnic illness. In G. L. Landreth (Ed.), Innvatins in play therapy: Issues, prcess, and special ppulatins (pp ). Philadelphia, PA: Taylr & Francis Grup. Kunkle-Miller, C. (1990). Ptentials and prblems in establishing an art therapy prgram in a residential schl fr children wh are deaf. The American Jurnal f Art Therapy, 29(2), Landreth, G. L. (2002). Play therapy: The art f the relatinship (2nd ed.). New Yrk: Brunner-Rutledge. Leblanc, M., & Ritchie, M. (2001). A meta-analysis f play therapy utcmes. Cunseling Psychlgy Quarterly, 14(2), May, D. (2006). Time-limited play therapy t enhance resiliency in children. In C. E. Schaefer & H. G. Kadusn (Eds.), Cntemprary play therapy: Thery, research, and practice (pp ). New Yrk: The Guilfrd Press. Mcguire, D. K., & Mcguire, D. E. (2001). Linking parents t play therapy: A practical guide with applicatins, interventins, and case studies. Lillingtn, NC: Taylr & Francis. Nrtn, C. C., & Nrtn, B. E. (2006). Experiential play therapy. In C. E. Schaefer & H. G. Kadusn (Eds.), Cntemprary play therapy: Thery, research, and practice (pp ). New Yrk: The Guilfrd Press. O'Cnnr, K. (2005). Addressing diversity issues in play therapy. Prfessinal Psychlgy: Research and Practice, 36(5), Thmpsn, C. L., Rudlph, L. B., & Hendersn, D. (2004). Play therapy. In Cunseling children (6th ed., pp ). United States f America: Brks/Cle. Williams, W. C., & Lair, G. S. (1991). Using a persn-centered apprach with children wh have a disability. Elementary Schl Guidance & Cunseling, 25(3), 194. Nte: This paper is part f the annual VISTAS prject spnsred by the American Cunseling Assciatin. Find mre infrmatin n the prject at: 9

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