The Function of Play for Coping and Therapy with Children Exposed to Disasters and Political Violence

Abstract

Purpose of review:
The objectives were to identify specific characteristics and patterns of children's play following events of political violence or disasters, examine their associations with risk and resilience, and explore their implications for preventive and therapeutic intervention.

Recent findings:
Patterns of individual, dyadic, and social play are associated with measures of children's adaptation following collective traumatic events. Modifying the traditional child-centered play therapy, by integrating CBT principles or including parents, may increase efficacy. Preventive interventions in the aftermath of collective traumatic events must address children's need to play in safe spaces, with the support of significant adults. Recognizing that posttraumatic play is a multifaceted phenomenon implies the need for more individualized play therapy models, varying in level of therapist's activity and techniques employed. Research is needed to clarify the validity of play measures for assessing adaptation and to study the effectiveness of integrative play-based models.

Full text

CHILD AND FAMILY DISASTER PSYCHIATRY (B PFEFFERBAUM, SECTION EDITOR)
The Function of Play for Coping and Therapy with Children Exposed
to Disasters and Political Violence
Esther Cohen
1,2
&Reuma Gadassi
3
#Springer Science+Business Media, LLC, part of Springer Nature 2018
Abstract
Purpose of Review The objectives were to identify specific characteristics and patterns of children’s play following events of
political violence or disasters, examine their associations with risk and resilience, and explore their implications for preventive
and therapeutic intervention.
Recent Findings Patterns of individual, dyadic, and social play are associated with measures of children’s adaptation following
collective traumatic events. Modifying the traditional child-centered play therapy, by integrating CBT principles or including
parents, may increase efficacy.
Summary Preventive interventions in the aftermath of collective traumatic events must address children’sneedtoplayinsafe
spaces, with the support of significant adults. Recognizing that posttraumatic play is a multifaceted phenomenon implies the need
for more individualized play therapy models, varying in level of therapist’s activity and techniques employed. Research is needed
to clarify the validity of play measures for assessing adaptation and to study the effectiveness of integrative play-based models.
Keywords Posttraumatic play .Play therapy .Play-based community interventions .Collective traumatic events .Risk and
resilience .Family-based play interventions
Introduction
Millions of young children around the world are exposed to
numerous traumatic events due to natural disasters, war, and
terrorism [1]. Recent reviews provide consistent evidence
showing that children exposed to political violence or disas-
ters are at high risk for posttraumatic stress disorder (PTSD),
psychosomatic symptoms, behavioral and emotional prob-
lems, sleep problems, and disturbed play [2,3].
Recent longitudinal studies examined long-term risk and
resilience trajectories of development in children exposed to
political violence and disasters. They showed that effects of
early exposure to prolonged or recurrent traumatic events do
not heal “naturally”and may exacerbate over time [4•].
Similarly, research suggests that exposure of pregnant women
to political violence and natural disasters may affect their
child’s future development [5,6]. However, robust findings
show that maternal posttraumatic coping is associated with
trajectories of risk and resilience in their children [4•,7].
It appears that special attention should be directed towards
young children, since they may be at particularly high risk for
developmental problems and psychopathology following
traumatic events, in comparison with older children and adults
[3]. Nevertheless, research on the coping mechanisms of pre-
school children and the effectiveness of preventive and thera-
peutic interventions is limited [2]. This is partly due to the
reduced reliability of young children’sself-reports[4•]. It is
therefore sensible to focus on children’s“natural language,”
namely, their play activity, in order to learn more about how
they process traumatic events and how they can be helped.
Events involving natural disasters or political violence (war
and terrorism) are collective and often affect the community
infrastructure [1]. Given the paucity of comparative research
on the play of children exposed to these types of events [8],
this paper links together studies related to these collective
traumatic events, often referred to as “mass trauma,”which
This article is part of the Topical Collection on Child and Family
Disaster Psychiatry
*Esther Cohen
Esther.cohen@mail.huji.ac.il
1
School of Psychology, Interdisciplinary Center, Herzliya, Israel
2
School of Education, Hebrew University of Jerusalem, Mount
Scopus, Jerusalem, Israel
3
Psychology Department, Yale University, New Haven, CT, USA
Current Psychiatry Reports (2018) 20:31
https://doi.org/10.1007/s11920-018-0895-x

differ from traumatic events involving child maltreatment and
family violence, which we did not include in this review.
In this paper, we set out to identify specific characteristics
and patterns of children’s spontaneous play following collec-
tive traumatic events (CTE). We examined their implications
for assessing adaptation and for supporting children’scoping
via preventive and therapeutic intervention.
How Is Play Potentially Healing in the Aftermath
of Traumatic Events?
Free play may be viewed as a creative natural mechanism,
enabling children to gradually pace the revisiting of traumatic
memories and to process them. A basic function of play is to
afford engagement in a sphere removed from external reality,
thereby supporting the emergence of positive affect, shown to
benefit adaptive coping with acute and chronic stress [9,10].
Terr [11] specified that healing traumatic experiences in
children is aided by opportunities for emotional expression,
cognitive understanding, and behavioral or fantasized change.
Clinical reports and empirical research demonstrate that play
may be a natural medium for promoting these processes. By
playing, children organize their memories, integrate
fragmented sensory experiences, and reconstruct them to in-
crease comprehension. This allows the construction of a co-
herent and meaningful narrative that is satisfying and re-
assuring [12–14]. A major healing function of play involves
the ability to experience self-efficacy by changing the passive
victim role into an active one and by showing off in fantasy
one’s power and capabilities [14,15]. Additionally, Prichard
[16] argues that neuroscience shows that play and relation-
ships are major means of regulating arousal and coping with
fear. Thus, play allows trauma memories to be re-worked at
both a metaphorical and a neurobiological level.
On an interpersonal level, play provides opportunities for
sharing private subjective experience with othersand strength-
ening attachment and social bonds. Parental involvement in
play with their young children and mutual emotional availabil-
ity significantly contribute to children’s resilience in the face
of continuous exposure to traumatic events [17,18••].
Furthermore, research clearly supports the important function
of social engagement through play with family and peers in
protecting from developing psychopathology following expo-
sure to political violence [4•].
Posttraumatic Play—Characteristics, Risk,
and Resilience
Maladaptive Posttraumatic Play
Posttraumatic play (PTP) has been described in the literature
relating to changes observed in the play of young children
exposed to various traumatic events [15]. Few studies focus
specifically on exposure to disasters [19,20] or on war and
terror [13,21,22]. The PTP literature tends to emphasize its
abnormal aspects. Recognized descriptions of worrisome PTP
characteristics include: the serious, somber, driven quality of
the play activity; repetitive re-enactments of frightening
events with unresolved themes; increased aggressiveness; fan-
tasies linked with rescue or revenge; increased withdrawal;
and reduced symbolization and concretization here [13].
Use of Play for Assessing PTSD in Young Children
Exposed to CTE
Scheeringa [23] argues that given the limited reliability of
child or parent reports, the criteria for diagnosing PTSD
need to be more behaviorally anchored and developmental-
ly sensitive to detect PTSD in preschool children. Play ob-
servation can therefore aid in evaluating specific behavioral
features that are relevant to the diagnostic criteria for PTSD
in the DSM-5 [24].
The re-experiencing domain for PTSD may be observed
in young children through the expression of trauma re-
minders in words or gestures during play [22]. Re-
experiencing is further evident through unique repetitive
play in which themes from a traumatic event are re-
enacted [25]. Additionally, the criterion addressing a dimin-
ished interest in significant activities and feelings of detach-
ment may manifest behaviorally as social withdrawal from
playing with peers, preference for solitary functional or con-
stricted play, and increased interest in objects [23].
Clinical Distinctions of Types of PTP
We believe that PTP is a multifaceted phenomenon allowing
differential considerations in planning therapy. In support of
this view, some of the clinical literature alludes to two kinds of
PTP: the positive and negative [26] or dynamic versus toxic
[15]. In the positive type, children re-enact the trauma but are
able to modify its negative components and gain mastery over
the experience. In the negative type, the repetitive play, al-
though driven, is unsuccessful in relieving anxiety, and fails
to help the child attain resolution or acceptance. The risk of the
negative type of PTP is that it may actually worsen the trau-
matic effects and cause developmental regression. Gil [17]
provides a summary of comparative criteria between dynamic
and toxic play, including differences in affect and in the struc-
ture, development, and creativity of the portrayed story.
The distinction between possible patterns of PTP is impor-
tant as it may help to evaluate the levels of children’sriskfor
posttraumatic distress and delineate the kind of support and
treatment they may require. Few empirical studies provide
data on the reliability of play assessments or their validity.
31 Page 2 of 7 Curr Psychiatry Rep (2018) 20:31

Research-Supported Patterns of Adaptive
and Maladaptive PTP
Cohen and her colleagues [13,14]employedreliableanalyses
of free play sessions with children directly exposed to inci-
dents of terrorism. Using the Children’sPlayTherapy
Instrument Adapted for Trauma Research (CPTI-ATR), they
found that exposed children showing the best adaptation
levels, according to their caregivers’reports, displayed more
positive affect and engagement in their play. Furthermore,
they showed a better ability to plan and play out a coherent,
progressive, creative, and satisfying imaginary narrative.
Their sense of self-efficacy was evident by displaying their
“awareness of oneself as player”(being both the director and
the actor in their play). They also revealed a better capacity for
emotion regulation and self-soothing.
The distinct ratings of PTP characteristics allowed re-
finement into three theoretically derived patterns of cop-
ing and defensive strategies observed in play. These
proved useful in predicting levels of adaptation and risk.
The first pattern—“re-enactment with soothing”—includ-
ed play activity characterized by re-enactment of aspects
or themes of the traumatic event, accompanied by free
expression of diverse feelings. The play narrative or ac-
tivity achieved a satisfactory ending, resulting in a sense
ofmasteryandrelief.Childrenratedhighonthispattern
displayed the highest level of post-trauma adaptation.
This pattern is similar to the clinical descriptions of adap-
tive or dynamic PTP.
The two other patterns of coping and defensive strategies
“re-enactment without soothing”and “overwhelming re-
experiencing”were significantly and negatively related to
the first pattern and were associated with higher levels of
posttraumatic symptoms. “Re-enactment without soothing”
is similar to the descriptions of toxic play [15]. It included
the repeated re-enactment of themes or aspects of the traumat-
ic event, often expressed in an aggressive or rigid manner. Re-
working of the traumatic event did not occur, and the child did
not gain relief from terror and fear.
“Overwhelming re-experiencing”involved the expression
of mental states lacking a coherent structure, resulting in over-
whelming the child. This usually manifested by an inability to
produce a coherent narrative and by disconnected, or tense
and hyper-vigilant behavior. At times, when a play narrative
was produced, it was chaotic and involved a loss of sense of
boundaries. The play activity did not diminish the child’sex-
treme emotional state; rather, it tended to prolong or intensify
it. Descriptions resembling this pattern are uncommon in the
clinical literature and may warrant special attention because of
its strongest associations with a PTSD diagnosis.
An adapted coding scheme of coping-defensive strategies,
the Children’s Play Development Instrument [27] includes
four play styles: adaptive, inhibited/conflicted, impulsive/
aggressive, and disorganized. These allow reliable tracking
of aspects of traumatic play over time in a single child.
Recent research further examines play from a more
interactive-interpersonal perspective. This new emphasis re-
flects the growing recognition of the importance of human
connections in coping with trauma and for healing in its after-
math [2,28]. In their study of risk and resilience trajectories in
young children exposed to political violence, Halevi and her
colleagues [4•] used a “child social engagement”measure
based on observations of young children during free play.
The measure included several codes: child gaze/joint atten-
tion, positive affect, alertness, social initiation, creative or
symbolic play, and competent use of environment. Lower so-
cial engagement increased the propensity for late-onset disor-
ders in exposed children.
Cohen and Shulman [18••] used dyadic mother-toddler
free-play observations to systematically analyze emotional
availability in mothers and toddlers exposed to political vio-
lence. Emotional availability [29] refers to the degree to which
each interacting partner expresses emotions and is responsive
to the other’s emotions. Cohen and Shulman found that higher
exposure was associated with lower emotional availability,
and that the dyadic emotional availability was associated with
the mother’s perceptions of her child’s behavior problems.
Additional studies are needed to document associations be-
tween play measures relating to the child’s interactions with
parents and peers and measures of risk and resilience.
Intervention and Therapy
There is a growing awareness of the need for community-
based interventions especially in the first stages following
CTE, mainly because it impacts multiple systems [30].
Community interventions are usually more feasible than ad-
dressing individual needs and may decrease stigmatizing and
increase social support [31]. Later changing circumstances
usually allow for additional interventions on small group, fa-
milial, and individual levels [3,32,33].
Community-Level Interventions
Creating Infrastructure and Promoting Psychoeducation In
their review of children in war and disaster, Masten and her
colleagues [1] conclude that the research supports the impor-
tance of normalizing everyday life for children and families by
resuming school and providing opportunities to play and so-
cialize. This is not a simple recommendation, because play-
grounds and play spaces are often destroyed, or become un-
safe in CTE. Therefore, recreating the infrastructure enabling
children to play safely becomes an important community-
level intervention. Facilitating opportunities for play may
Curr Psychiatry Rep (2018) 20:31 Page 3 of 7 31

improve play quality and quantity for resettled refugee chil-
dren and strengthen positive resettlement outcomes [34].
Often, when the impact of the traumatic event is severe,
and resources are depleted, psychological needs cannot be met
without the intervention of organizations and volunteers from
outside the community. This requires heightened cultural sen-
sitivity and cooperation with local personnel [35••,36]. Thus,
Kinoshita and Woolley [37] described how following a series
of 2011 mass disasters in Japan (an earthquake followed by a
tsunami and a nuclear power station malfunction), many chil-
dren had little opportunity for free play. Moreover, the percep-
tion of play as important for children following disasters was
low and play was even considered disrespectful and inappro-
priate in the context of grieving. The intervention involved
creating playgrounds, mobile play vehicles, and indoor play-
grounds, and educating the community regarding the impor-
tance of children’splay.
Another intervention that involved creating the infrastruc-
ture required for play is the “Child Friendly Places”interven-
tion [32]. This intervention targeted children, considered high
risk due to their exposure to traumatic experiences in war
zones (including sexual exploitation, trafficking, and HIV).
The goal of the intervention was to create a safe, supervised
space to support the children’s use of play, and to create op-
portunities for peer social support. Evaluations from children’s
teachers demonstrated their greater school readiness and so-
cial competencies.
Vanfleet and Mochi [20] describe a different type of play-
based community program that is multi-level, which they ini-
tiated following earthquakes in Tahiti and Iran. They maintain
that even at an early stage of mass trauma, it is possible to
attend to psychological needs by engaging children and adults
of the community in play-based activities; these help release
tension and create positive relationships between the commu-
nity and mental health professionals. At a later post-event
stage, they select sub-groups of identified distressed children
for group play therapy adding cognitive skills training.
Child-Focused Collective Play Interventions An exceptional
community-based intervention, aimed at strengthening chil-
dren’s sense of agencyby enlisting their imagination and play-
ful caregiving abilities, involves an adaptation of the “Huggy
Puppy Intervention”(HPI) [38]. The adapted version was im-
plemented in shelter homes for children who were orphaned
following a natural disaster or domestic violence in
Bangladesh [35••]. This play-based intervention originally in-
cluded giving children a stuffed puppet of a puppy and asking
them to care for the animal. In their adaptation in Bangladesh,
Deeba and Rapee [35••] chose to replace the puppy with a
teddy bear, since dogs are not pets in Bangladesh. One of
the intervention groups received in addition to HPI cognitive
training by practicing positive statements regarding them-
selves, the world, and the future. The data showed a reduction
in symptoms of PTSD, anxiety and depression, and increased
positive thoughts.
School-Based Intervention Over the past decade, an increasing
number of studies show the beneficial effects of teacher-
delivered interventions for children facing CTE. However,
very few reports address programs for children in preschool
or kindergarten [3]. Betancourt and her colleagues [40]de-
scribe a manualized group treatment delivered in schools to
war-exposed children in Indonesia. The program encouraged
cooperative play, creative expression, and trauma-processing
activities. This intervention reduced PTSD symptoms and in-
creased functioning, especially for girls. The authors reported
that similar school-based interventions were beneficial for
teenage war-exposed children in Gaza and Bosnia.
Adopting a more individualized focus, Bateman, Danby,
and Howard [39] introduced a play-based intervention in a
school setting following an earthquake in New Zealand.
There, teachers helped pre-schoolers to process the event by
creating a “Learning Story Book”for each child, reflecting the
child’s play, while describing their traumatic experience.
Individual Child Play Therapy Models
Child-Centered Play Therapy Child-centered play therapy
(CCPT) is a classic form of non-directive play therapy with
young children [41] considered among the treatments with
confirmed effectiveness for traumatized children[3]. A review
of CCPT studies with disaster-exposed children provides sup-
port for this treatment [19]. A randomized controlled trial
comparing CCPT with trauma-focused CBT for refugee chil-
dren [42] further demonstrates its benefits.
The clinical literature on traumatized children increasingly
reports the necessity to incorporate play, art, or other expres-
sive therapies in the assessment and treatment of young chil-
dren. Several case studies demonstrate that play therapy is
effective with CTE [43]. Play therapy and play techniques
are especially suitable for young children with PTSD who
are not able to deal with the trauma directly [44].
Integrative Play Therapy Some additional versions of play
therapy, developed over the years, specifically target children
exposed to CTE. Baggerly [45] developed an integrative ap-
proach called Disaster Response Play Therapy, which consists
of a combination of CCPT with 15 min of CBT at the end of
every play session. In her view, the CCPT portion of the ses-
sion establishes in the child a sense of safety and encourages a
re-enactment of the traumatic event. In the CBT part, the child
is actively encouraged to develop coping strategies.
Ohnogi and Drewes [46], using their experiences in work-
ing with children affected by natural disasters, propose an
integrative and personalized approach to individual play ther-
apy with posttraumatic children. They demonstrate how they
31 Page 4 of 7 Curr Psychiatry Rep (2018) 20:31

attempt to match elements from directive play therapy and
CBT to the specific symptom presentation by the child.
They also propose to introduce relevant specific toys in the
playroom (e.g., toy boats and sea creatures for tsunami
survivors).
This personalized approach is very much in line with the
argument presented by Gil [43] and by Cohen and her col-
leagues [12–14] that therapeutic interventions should be
adapted to the different patterns of the child’s observed play.
Gil emphasized that therapists must respond to toxic posttrau-
matic play in a much more active and directive manner than
they might respond to dynamic play. She describes a contin-
uum of interventions, ranging from less to more disruptive to
the child’s play, designed to change the play’s rigid pattern.
Similarly, Cohen and her colleagues maintain that while chil-
dren who display “re-enactment with soothing”may only
need opportunities to play safely in the presence of a support-
ive adult, children who display “re-enactment without sooth-
ing”may need the active intervention of the therapist in pro-
posing alternative hypothetical consequences or outcomes to
their “stuck”and morbid narrative. Children with overwhelm-
ing re-experiencing may need gentle encouragement and sup-
port to stimulate their playfulness and to begin to engage in
play. Additionally, they may need pacing by the therapist
when they lose boundaries and help in introducing coherence
in their attempts to create a narrative.
Inclusion of Significant Adults in Child Therapy
Recent reviews and studies provide robust research evidence
demonstrating how parental posttraumatic coping and psycho-
pathology are risk factors for their child’s mental health, and
how parents can mediate the effects of traumatic exposure on
their children. The reviews and studies consequently highlight
the importance of engaging attachment figures in helping trau-
matized children [2,3,4
•
,7] and in contributing to the thera-
peutic process. Pfefferbaum and her colleagues [31]reported
in their review of early child disaster mental health interven-
tions that almost 40% of the interventions studied involved
parents, a strategy that was associated with success. The min-
imal level of parental involvement in play-based child therapy
involves their inclusion as observers in some of the sessions,
or requesting them to ensure that the child implements the
intervention at home (e.g., [35
••
]). Other interventions include
psychoeducation for parents related to recognizing the impor-
tance of play for children (e.g., [33,37]).
Filial/Family Therapy The impact of CTE on the individual
child is embedded in its impact on the family as a whole.
Therefore, interventions focusing on the family and its resil-
ience make theoretical and clinical sense [3,47]. Sories,
Maier, Beer, and Thomas [48
•
] present the theoretical rational
and some evidence for using family play therapy for bereaved
children of military families. The intervention involves both
joint and separate sessions for the surviving parent and the
child. The therapist helps the surviving parent to process the
child’s traumatic play, which can be challenging when both
suffer loss. Similarly, Vanfleet and Mochi [20]demonstrated
the use of filial therapy as an intervention aimed to strengthen
the family as a whole following the 11 September terrorist
event in NYC. Their intervention included both joint play
sessions (child-parent) supporting the use of CCPT principles
by the parents and separate sessions with the parents in order
to prepare them for occasions in which the traumatic event
will be reenacted in play.
Dyadic Play Therapy Dyadic therapy usually focuses on the
interaction between a caregiver and a child, while engaged in
play. Research shows its contribution to increasing parental
sensitivity to the child and improving mutual communication
and interaction. Harel and Kanner [49] describe the Haifa
Dyadic Therapy (HDT) model and its adaptation for the treat-
ment of children traumatized by war. The major focus in this
model is enhancing the dyad’s mentalization, facilitating the
co-construction of the trauma narrative, and infusing their ex-
periences with new meanings.
A promising pilot intervention is the NAMAL (acronym in
Hebrew for “Let’s make room for play”) program targeting
dyads of mothers and toddlers exposed to recurrent terror at-
tacks in a group setup. The program focuses on improving
parent-child relationships, supporting the child’scopingwith
the traumatic events, and promoting play and playfulness.
Various evaluations showed the beneficial potential of the
program for helping mothers enhance their enjoyment and
understanding of their child, improving mutual emotional
availability and reducing child behavior problems [17,18
••
,
50]. Further dissemination and studyof these dyadic programs
is recommended.
Conclusions
Accumulating and new research clearly demonstrate the long-
term developmental risks for children exposed to collective
traumatic events. The effects of traumatic exposure are evi-
dent in changes in children’s play. Clinical experience and
research suggest that play observation and analysis may serve
as important tools for assessing posttraumatic adaptation and
for the choice of appropriate interventions.
Both individual and social play activity are helpful sponta-
neous natural vehicles for children to process traumatic events
and promote resilience. Therefore, basic interventions in the
aftermath of CTE must address children’s need for safe spaces
to play. This activity needs to be encouraged and facilitated by
significant adults, including parents, teachers, and community
center personnel. However, certain types of spontaneous PTP
Curr Psychiatry Rep (2018) 20:31 Page 5 of 7 31

may be unhelpful or insufficient for child coping and recovery
and may signify the need for personal play therapy.
We suggest that the growing recognition that the phenom-
enon of PTP is complex and multilayered implies the need for
more individualized types of play therapy models, varying in
level of the therapist’s activity and in the techniques
employed. Recent modifications of the CCPT model indeed
involve differential use of techniques based on the child’splay
patterns and the integration of CBT principles into the play
sessions. Additional promising modifications involve the in-
clusion of parents in the play-based therapy process.
Research is needed to support these recommendations,
mainly to clarify the associations between play patterns of
children exposed to CTE with measures of risk and resilience.
It is also needed to examine the effectiveness of the integrative
play-based models, to fine-tune the differential choice of indi-
vidualized therapy techniques, and the use of varying levels of
parent involvement.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
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