In the article by Parker et al. (2021), “Exploring Child-Centered Play Therapy and Trauma: A Systematic Review of Literature,” the authors conducted a systematic literature review of research on child-centered play therapy (CCPT) and Adverse Childhood Experiences (ACEs). The intent was to explore the effectiveness of CCPT as a therapeutic treatment for children with a history of trauma including poverty, systemic discrimination, attachment difficulties, abuse, and/or parental incarceration. As Felitti et al. (1998) developed, Adverse Childhood Experiences explore the prevalence of traumatic events in childhood including physical or sexual abuse, neglect, and household dysfunction, and Cronholm et al. (2015) expanded upon the ACEs sample to include new community-based ACEs like living in an unsafe neighborhood, witnessing violence, experiencing discrimination or bullying, and living in foster care.
Chronic stress and childhood exposure to ACEs can negatively impact internalizing and externalizing behaviors such as emotional regulation and anxiety or aggression and risky behaviors respectively. These negative impacts on mental and physical health carry into the individual’s adulthood with higher rates of depression, alcoholism, domestic violence, suicidality, etc. Play therapy has been developed as means for children to process their emotions and experiences through symbolic expression. Even when a child is exhibiting defensive or closed off behaviors due to their experienced trauma, a play therapist responds with openness and empathy allowing the child to potentially override their pain-based trauma response learning.
Of the studies in the systematic review, 32 met the full criteria for inclusion; and across the 1,207 participants in all the studies, 87% lived in the US, 13% lived internationally, and age ranged from 3.5 to 11 years old. The studies included focused primarily on the impact of CCPT amongst children who live in poverty, identified as minority or immigrant, and witnesses or experienced abuse. Outcome variables across the studies included children’s internalizing behaviors, children’s externalizing behaviors, children’s stress, parental empathy, parental stress, child self efficacy, self concept, anxiety, attachment, self esteem, and parental acceptance. Although CCPT has demonstrated promising results as an effective intervention, it has largely been excluded from studies of interventions for children after traumatic events. Additionally, even though the criteria for participants in the studies aligns with ACEs as previously identified, none of the studies actually used the Adverse Childhood Experiences Questionnaire.
Most of the studies examined childhood behavior problems as manifested in externalizing or internalizing behaviors that occur due to the hyperarousal. The literature included identifies how behavioral problems in children who experienced trauma may function as a coping skill that the child develops to protect themselves from trauma. Of the studies included, 60% demonstrated statistically significant decreases in children’s externalizing behaviors after CCPT, 64% demonstrated statistically significant decreases in children’s total problem behaviors after CCPT, yet only 36% demonstrated statistically significant decreases in children’s internalizing behaviors after CCPT. The internalizing behaviors may be comorbid with anxiety and depression, difficult to isolate, and more difficult to identify in their presentation.
Because a child who experienced trauma may experience hyperarousal and difficulty regulating their emotions, they might distance themselves from caregivers, withdraw from social interactions, thus reinforcing rejection and decreasing attachment opportunities. Studies included in the review demonstrate that CCPT has significant impact on the child’s relationship with their caregiver(s) when the caregiver is engaged in the CCPT by decreasing parental stress and increasing parental empathy.
The findings from this systematic review are applicable to the toolkit we are working on for our NPO because they link the use of play therapy to improvements specifically in problematic behavioral outcomes seen in children who have experienced trauma. Although, the large majority of studies in this paper were located in the United States, the concept of expressive play as a therapeutic tool to regulate internalizing and externalizing behaviors can be widely understood even if it may manifest with slight differences across cultures.
