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 International Journal of Pediatric Nursing
Vol. 1: Issue 1
www.journalspub.com

Play Therapy: An Approach to Manage

Childhood Problems
Achla Dagdu Gaikwad1*, K. Lalitha1, Shekhar P. Seshadri2
1
Department of Nursing, NIMHANS, Bangalore, India
2
Department of Child & Adolescent Psychiatry, NIMHANS, Bangalore, India

Abstract
“Birds Fly, fishes swim and children play” Landreth (1991:25) Childhood is the most
pleasurable period of one’s lifetime. During this period children undergo various changes in
areas such as physical, psychosocial, cognitive and moral development. Child learns to adapt
to these changes in various ways. Adaptation from fantasy to real world imposes a lot of
emotional ups and downs, which if left unattended, may turn in to emotional/ behavioural
problems. Play is a medium by which child expresses his/her worries and tries to address
their problems. Art, puppets and dolls, drama, songs, music are all common element of the
wonderful world of play and imagination for a child. It’s appropriate and therapeutic use can
help all professionals dealing with children, to understand children well and help them to
cope with and heal their internal trauma, manage their externalizing problems. Current
concept article on play therapy throws a flash light on play therapy as a therapeutic
approach to manage childhood problems.

Keywords: Play therapy, psychosocial difficulties, optimal growth and development

*Author for Correspondence: Email ID: [email protected]

PLAY THERAPY towards the end of more adaptive

The systematic use of a theoretical model, resolution [1].
to establish an interpersonal process
wherein trained play therapists use the Play increases in complexity and
therapeutic powers of play to help clients imagination from simple imitation of
prevent or resolve psychosocial difficulties common experiences to more extended
and achieve optimal growth and scenarios involving singular events, to
development- Association for Play creation of scenarios that have only been
Therapy. Play therapy promotes the imagined. With growing age child starts
working relationship between children and having cooperative play activities with his
therapist, and it allows for the friends and it also becomes increasingly
communication of wishes, fantasies and governed by rules, early rules about asking
conflict in ways the child can tolerate and sharing, to rules that change from
effectively and express at the level of his moment to moment [2].
or her cognitive capacities. The therapist’s
function is to observe, attempt to Theoretical Paradigm
understand, integrate, and ultimately Theoretical Basis of Play Therapy [3]
communicate the meanings of child’s play Play Therapy emphasizes the client as
in order to promote the child’s trustworthy. Play Therapy is based upon
understanding of his or her conflict three critical theoretical principles:

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Play Therapy Gaikwad et al.

1. Actualisation: Humans are motivated Major Functions of Play Therapy

by an innate tendency to develop • Play is a natural form of expression in
constructive and healthy capacities. children
This tendency is to actualise each • Play is as a vehicle for the occurrence
person's inner potentials, including of insight and working through.
aspects of creativity, curiosity and the • Play in therapy is that of providing
desire to become more effective and opportunities to practice with a variety
autonomous. of ideas, behaviours, interpersonal
2. The Need for Positive Regard: All behaviours, and verbal expressions.
people require warmth, respect and
acceptance from others, especially Biological functions
from 'significant others'. As children • Learn basic skills
grow and develop, this need for • Relax, release excess energy
positive regard transforms into a • Kinesthetic stimulation, exercise
secondary, learned need for positive
self-regard. Intrapersonal Functions
3. Play as Communication: Children use • Mastery of situations (exploration,
play as their primary medium of develop understanding of the functions
communication. Play is a format for of mind, body and world, cognitive
transmitting children's emotions, development
thoughts, values and perceptions. It is a • Mastery of conflicts (symbolism and
medium that is primarily creative. wish fulfilment)

While using play therapy as a therapeutic Interpersonal Functions

tool to manage childhood problems, it is • Develop social skills
very important to consider developmental • Separation-individuation: play can
processes in child’s play. Table no: 1 serve as distraction when significant
shows, developmental transformations in others are absent; it can be used to
play throughout the span of childhood. master the anxiety associated with
Play during initial period (0-1year) of life separation and can utilize objects
is specifically solitary; self (body) centred symbolically to replace significant
i.e. exploring themselves by sensory motor others who are absent.
activities. • Socio-cultural: imitate desired
roles(adults)[4, 5]
Later, children (1–3 year) explore the
world around them by imitation of actions Indications of Play Therapy
of caregiver. During this period child’s  Children who have been traumatized
interest moves from self to others and toys. by actual or witness (sexual, physical
Child by age 3 year enjoys symbolic/ or emotional abuse), domestic
pretend play, where he focuses on people violence, child sexual abuse,
around him by parallel play with mutual natural/manmade disaster victims.
regards and simple social activities.  Children who have been adopted or are
Thereafter by age of 4–5 year, child learns in foster care with emotional
sharing, team work, and cooperative play disturbances.
activities. In later period (i.e. after 5 years)  Children who are dealing with issues
along with cognitive development, child of loss, such as illness or death of a
learns to play games with simple rules, loved one.
which later turns to games with complex  Children who have been hospitalized
rules. due to any physical/psychological/
developmental problems.

IJOPN (2015) 22-28 © JournalsPub 2015. All Rights Reserved Page 23

 
11 10 9 8 7 6 5 4 3 2 1 0 Child’s Age

Cognitive Piaget
Formal Operations Concrete Operations Pre operational Sensori-motor (1952, 1962,
1967)
Trust
esteem etc.

therapy such as:

Identity vs. Autonomy Vs Vs Psychosocial
Industry vs. Inferiority Initiative Vs Guilt
Conformity Shame and doubt Mistrus Erikson 1950
t
Psycho sexual
Genital Latency Phallic Anal Oral Freuw (1905

Types of Play Therapy [5]

/1953)

Sensori Piaget
Games with rule Symbolic (pretend) Practice/solitary
-Motor 1962

Autoco
smic Ericks
Microsphere (Toy
Macrosphere (Other Focused) (body on
Centered)
Childhood emotional and behavioural

Several classifications are seen in play

problems, build confidence, self-

centere 1950
d)

Solitoa Parker
Organized Cooperative play Shifting group play Parallel
ry 1977




IJOPN (2015) 22-28 © JournalsPub 2015. All Rights Reserved

2)Use
Symbolic Sensor
Body Pulask Play
3)Dramatization 1)Project in to Practice y
symbol i 1974 Develo
environment Motor
ically pment
Parallel Stage
with
Reciprocal mutual Howes
Reciprocal Social Parallel
complimentary regard, 1980
simple
social
Peller
Sibling Oedipal Pre-oedipal Body
1954

play vs. controlled play.

Conditi Pre Linfor
Table1: General Developmental Stages versus Play Development. [4]

oned Play d Jean

Creative play
respon explora renaud
skill, communication skills etc.

ding tion 1968

Games with “it” requiring
Elaborate Sutton

Nondirective and directive/unstruct-

cooperation (frozen tag) Imitati

Page 24
International Journal of Pediatric Nursing
Vol. 1: Issue 1
www.journalspub.com

cooperation (Kick Games with Powerful “it” (tag) Exploratory -Smith

Cooperative games (Red ve Play

ured vs. structured play therapy/free

Teach specific skills such as social

the Can) 1967

Rover)
Play Therapy Gaikwad et al.

 Individual versus group play therapy. Virginia Axline has given the principles of
 Psychoanalytical play therapy. play therapy which a therapist needs to
 Miscellaneous play therapies: free follow.
play, cognitive behaviour play therapy,
affect in play therapy, sand play Virginia Axline’s Eight Principles of Non
therapy etc. Directive Play Therapy [6]
1. Develop a warm and friendly
Nondirective and directive is the relationship with the child.
commonest classification used in play 2. Accept the child as she or he is.
therapy. 3. Establish a feeling of permission in the
relationship so that the child feels free
Nondirective Play Therapy to express his or her feelings
Nondirective play therapy is a non- completely.
intrusive method in which children are 4. Recognize the feelings the child is
encouraged to work toward their own expressing and reflect these feelings
solutions to problems through play. It is back in such a manner that the child
typically classified as a psychodynamic gains insight into his/her behaviour.
therapy. It also called as client-centered [4] 5. Maintain a deep respect for the child’s
and unstructured play therapy, is guided by ability to solve his/her problems and
the notion that if given the chance to speak gives the child the opportunity to do
and play freely under optimal therapeutic so. The responsibility to make choices
conditions, troubled children and young and to institute change is the child’s.
people will be able to resolve their own 6. Should not direct the child’s actions or
problems and work toward their own conversations in any manner. The child
solutions. In other words, nondirective leads the way, the therapist follows.
play therapy is regarded as a method by 7. Do not hurry the therapy along. It is a
which child is allowed to freely explore his gradual process and must be
world, without any instructions, in the way recognized as such by the therapist.
he want. This therapy originates from Carl 8. Establish those limitations necessary to
Rogers's non-directive psychotherapy and anchor the therapy to the world of
in his characterization of the optimal reality and to make the child aware of
therapeutic conditions. Virginia Axline his/her responsibility in the
adapted Carl Rogers's theories to child relationship.
therapy in 1946 and is widely considered
the founder of this therapy [6]. Different Directive Play Therapy
techniques have since been established that Directive play therapy, as name suggests,
fall under the realm of nondirective play the therapist gives directions to child in
therapy, including traditional sand play order to achieve certain therapeutic targets
therapy, family therapy, and play therapy such as anger control, attention
with the use of toys. Though non directive enhancement etc. It is guided by the notion
play therapy suggests child has freedom to that using directives to guide the child
play the way he want, but certain through play will cause a faster change
limitations are imposed, as and when than is generated by nondirective play
necessary. therapy. The therapist plays a much bigger
role in directive play therapy. Therapists
Nondirective play therapy is well may use several techniques to engage the
described with an example in Virginia child, such as engaging in play with the
Axline’s “Dib’s in search of self”. child themselves or suggesting new topics
instead of letting the child direct the
conversation himself. Stories read by

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 International Journal of Pediatric Nursing
Vol. 1: Issue 1
www.journalspub.com

directive therapists are more likely to have 4. The Mastery Stage: In this stage
an underlying purpose, and therapists are children work on issues related to
more likely to create interpretations of competence and self-mastery and work
stories that children tell. In directive on integrating the gains of earlier
therapy games are generally chosen for the stages into their personality structures.
child, and children are given themes and
character profiles when engaging in doll or The mastery stage is also a period of
puppet activities. This therapy still leaves signalling readiness to conclude play
room for free expression by the child, but therapy. It is a stage in which play
it is more structured than nondirective play becomes age appropriate, non-conflictual,
therapy. non-disturbed, and much less central for
children, meaning that although children
There are also different established may want to maintain contact with their
techniques that are used in directive play therapist, they become more motivated for
therapy, including directed sand tray age-appropriate play with peers than for
therapy and cognitive behavioral play therapeutic play in counselling.
therapy.
The aggressive and regressive stages are
Example: balloons of anger, beat the often collectively referred to as
clock, soda bottle games etc. ‘aggressive-regressive or working stage
play’.
Stages of Play Therapy
Briefly, the Nordling and Guerney (1999) Issues in Using Play in Therapy
stages of play therapy are as follows: A number of practical issues arise in
1. The Warm-Up Stage: It is the stage in working with children in play therapy.
which the therapeutic working Ideally, a psychological assessment should
relationship is formed, including an have been carried out so that the therapist
understanding of the child's and has identified treatment goals and has
therapist's roles, the unique potential developed a treatment plan. The therapist
and possibilities of the playroom, and a should have determined how much play
feeling of safety and security allowing will be utilized in the therapy, as well as
full and free expression and shared the nature of the play to be encouraged.
experience. Usually, play approaches should be
2. The Aggressive Stage: In this stage considered for children from 4 to 10 years
children work on issues related to of age [7].
exerting control over others and
accepting limits placed on them, and in How to Get Started
which children often express deep- Many children need help initiating the play
seated aggressive tendencies or process. The therapist usually starts by
thoughts through characters or actions telling the child that they can play or talk,
in play. and shows the child the toys and play
3. The Regressive Stage: In this stage materials that are available. Although
children explore issues related to many children go right to it, many others
attachment and nurturance, and often are reticent. The therapist might tell the
play in ways less mature than would be child to pick one thing, and start with that
expected for their chronological age, or the therapist could pick something for
and in which themes of giving and the child. Clay and drawing material are
receiving nurturance predominate. good starters. As a last resort, the therapist

IJOPN (2015) 22-28 © JournalsPub 2015. All Rights Reserved Page 26

Play Therapy Gaikwad et al.

might start with something themselves, expression through play should be

and have the child join in [8]. facilitated. For example, the child can be
encouraged to verbalize anger at the
Kinds of Play Materials therapist or to have the puppets fight it out
Most therapists agree that unstructured in a pretend mode [11].
play materials that can encourage the use
of fantasy and imagination are ideal. Toys Applications of play therapy in Nursing
that leave much room for individual Play can help all professionals dealing
expression are most appropriate for play with children in various settings such as,
therapy. Examples of relatively Hospitals, community centres, schools,
unstructured toys and material are: clay, foster care centres etc.
crayons, cars, trucks, puppets, dolls, doll
houses, and legos. Games such as checkers General Application: Rapport building,
do not encourage free expression, and are developing interpersonal relationship,
not ideal for traditional play therapy. The early diagnosis and management of
child is often asked for suggestions of childhood problems.
other toys that might be useful and
encouraged to bring toys in from home. Specific Applications: In Hospital
Different children use different media for Settings: Paediatric Nurses working with
expression and it is important to have a children can use play for reducing child’s
variety of items and to individually tailor anxiety while conducting several
what is available [9]. procedures such as, giving medications,
doing and invasive procedures etc,
How Much to Engage in Play alleviating pain of diseases/ surgeries etc.
One recurring dilemma is how much the
therapist should engage in the child's play. Child Psychiatric Nurses can use play
The amount of direction and activity by therapy for rapport building, develop
the therapist depends upon the general interpersonal relationship, explore child’s
theoretical approach. In more traditional problems, help them in handling their
client-centered and psycho-dynamic problems, teach newer skills such as anger
approaches, the therapist tries not to play control, social skill etc., and using play
with the child, but rather to observe and therapy with children and their families in
comment on the child's play. Many order to improve child- parent relationship.
children will eventually become
comfortable playing in this way. Some In Community Settings: Nurses working in
children need more engagement by the community at different levels such as sub
therapist. With those children, the therapist centres, PHC’s can use play to understand
tries to follow the lead of the child. The child’s developmental transformation and
therapist might put on one of the puppets detect any developmental delay in children
and play, but follow the lead of the child in at grass root level, educate them about
choosing the topic and setting the early interventions training and refer them
dialogue[10]. to appropriate health services. School
health nurses can identify child’s problems
How to Set Limits at school and help them accordingly[12].
For play to be a safe mode of expression,
limits about how to play are essential. If CONCLUSION
rules need to be set, then they should be Children have innate ability to solve their
set. Toys cannot be broken and the problems in their own ways. Play is a
therapist cannot be a target for affective medium through which child learns to
expression. Alternative modes of manage difficulties in day today’s life,

IJOPN (2015) 22-28 © JournalsPub 2015. All Rights Reserved Page 27

 International Journal of Pediatric Nursing
Vol. 1: Issue 1
www.journalspub.com

acquire various skills, ventilates his/ her 7. Axline VM. Dibs in Search of Self.
feelings, emotions, wishes and wants. Paperback Publication. 1964.
Being a professional in child care 8. Dogra A, Veeraraghavan V. A Study
management if we know these of Psychological Intervention of
transformations in child’s development of Children with Aggressive Conduct
play, we can use it as a therapeutic tool to Disorder. Indian J. Clin. Psychol.
early diagnose and manage these 1994; 21: 28–32p.
problems, faced by children. 9. Springer J.F., Phillips J, Phillips L, et
al. CODA: A Creative Therapy
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