Children in today's world face a myriad shocking and disturbing events from war and natural disasters to terrorism and increased school shootings.  More personal traumatic events experienced by children include car accidents, physical and sexual abuse, and medical procedures.  Therefore, childhood trauma continues to be a growing area of concern for counselors and psychotherapists.  Trauma can be defined as "a sudden and extraordinary event that overpowers a child's ability to cope and to manage the reactions that are aroused by the event" (Dripchak, 2007, p. 125). 

According to Terr (1991), there are two categories of trauma experienced by children.  Type I is a sudden, unpredicted trauma that occurs as a single event in the child's life, such as natural disasters or automobile accidents.  Type II is recurrent exposure to trauma which the child learns to fearfully anticipate, such as chronic physical or sexual abuse, or living in a war-torn country.  A child who falls under the Type II category may develop symptoms that are more acute and severe than those children who experience Type I trauma (Ogawa, 2004). 

A child's ability to respond to trauma is dependent upon the age at which the trauma is experienced and involves multiple, subjective dimensions (Dripchak, 2007, p. 125; Subtance Abuse and Mental Health Services Administration, SAMHSA, 2011).  Young children up to the age of six years old have been observed through research to play out the traumatic event by recreating it in their imaginary play or by experiencing nightmares related to the event, in addition to being more likely to aggressively act out (SAMHSA).  Older children between the ages of seven and 12 "were most likely to report feelings of re-living the trauma and difficulty with expressing sadness or anger" (SAMHSA, p. 1). Previous research has also shown that adolescents between the ages of 13 and 18were more likely to report feeling isolated, guilty and fearful.

Play Therapy to Treat Childhood Trauma

Contingent upon the developmental level of the child being served, children do not possess the requisite verbal and reasoning skills to internally examine and then share their experience verbally; therefore, those who provide trauma counseling must look for other ways to assist the child with communicating their trauma.  One such way to do this is with play therapy, which recognizes that play is a child's natural form of communication and concedes that play is the most characteristic manner in which a child may process the traumatic event.  Children who have experienced a traumatic event will spontaneously and repeatedly play out the traumatic event with trauma-related play themes referred to by Terr (1990) as "traumatic play" or "posttraumatic play" (Cohen, Chazan, Lerner, & Maimon, 2010).  Terr reported that this type of play was noticed in both Type I and Type II trauma.    

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Play therapy allows the child to express deeply emotional concerns in a safe manner in a secure setting.  The Association for Play Therapy

(2012) defines play therapy as "the systematic use of a theoretical model to establish an interpersonal process wherein trained play therapists use the therapeutic powers of play to help clients prevent or resolve psychosocial difficulties and achieve optimal growth and development" (para. 3).  In general, the most prevalent theories (Gestalt, Cognitive Behavioral, Psychoanalytic, Person-Centered, etc.) utilized in the treatment of adults also have theories adapted to play therapy (Schaefer, 2003).  The two main types of play therapy are directive and non-directive.   

There are a few common modalities for treating children who have experienced trauma, such as creative arts and psychoanalytic, though only trauma-focused Cognitive-Behavioral Therapy has been empirically researched (Cohen, Mannarino, & Rogal, 2001).  The theories compared here are Release Play Therapy (RPT), Structured Play Therapy (SPT) and Child-Centered Play Therapy (CCPT).   RPT and SPT are directive approaches that utilize toys and objects most specific to the child's experience of trauma in an effort to encourage the child to process the experience through play (Ogawa,2004).  According to Ogawa, the therapist may, in an effort to prompt expression of the traumatic experience, recreate the experience with the child.  The therapist directs the session to first break down the child's defenses in order to provide the opportunity for the child to master their play, express deleterious emotions, and have successful play outcomes (Ryan & Needham, 2001; Schaefer, 1994). 

In CCPT, the therapist is non-directive and thus therapy relies on the child's natural ability to cope and process the traumatic event on their own (Ryan & Needham, 2001).  The child is in control of the session, the type of play utilized in the session (symbolic or realistic) and in control of the degree to which emotional distance is experienced, which prevents the child from becoming overwhelmed by emotions associated with the trauma (Ogawa, 2004).  The therapist provides unconditional positive regard, empathy, and congruence to the child and allows the child freedom to simply "be" in the session as they wish (Ryan & Needham).  While Child-Centered Play therapists attest to the effectiveness of CCPT with children who have experienced traumatic events, there are very few clinical examples in the literature (Ryan & Needham). 

In conclusion, children need a safe place to express themselves regarding a single traumatic event or one that has recurred frequently.  Directive and non-directive styles of play therapy allow the child to freely and safely explore the intense emotions surrounding their perceptions which they are unable to express verbally.  More research is needed to explore the effectiveness of both styles of play therapy for use with children who have experienced traumatic events with special attention given to single traumatic events versus recurring traumatic experiences.  

                                    References

Association for Play Therapy. (2012). Play therapy. Retrieved from http://www.a4pt.org/ps.playtherapy.cfm

Cohen, E., Chazan, S., Lerner, M., & Maimon, E. (2010). Posttraumatic play in young children exposed to terrorism: An empirical study. Infant Mental Health Journal, 31(2), 158-181.

Cohen, J. A., Mannarino, A. P., & Rogal, S. (2001). Treatment practices for childhood posttraumatic stress disorder. Child Abuse & Neglect, 25, 123-135.

Dripchak, V. L. (2007). Posttraumatic play: Towards acceptance and resolution. Clinical Social Work Journal, 35, 125-134.

Ogawa, Y. (2004). Childhood trauma and play therapy intervention for traumatized children. Journal of Professional Counseling, Practice, Theory, and Research, 32(1), 19-29.

Ronen, T. (2002). Difficulties in assessing traumatic reactions in children. Journal of Loss and Trauma, 7, 87-106.

Schaefer, C. E. (1994). Play therapy for psychic trauma in children. In K. J. O'Connor & C. E. Schaefer (Eds.), Handbook of play therapy, (Vol. 2, pp. 297-318). Chichester, UK: Wiley.

Schaefer, C. E. (Ed.). (2003). Foundations of play therapy. Hoboken, NJ: John Wiley & Sons, Inc.

Substance Abuse and Mental Health Services Administration. (2011). Helping children and youth who have experienced traumatic events. HHS Publication No. SMA-11-4642. Retrieved from http://www.samhsa.gov/children/samhsa_short_report_2011.pdf

Terr, L. C. (1990). Too scared to cry. New York: Harper & Row.

Terr, L. C. (1991). Childhood traumas: An outline and overview. American Journal of Psychiatry, 148, 10-19.