One Therapist’s Journey as a Head Start Mental Health Consultant Integrating Child-Centered with Sensory/Theraplay-Based Approaches to Play Therapy with At-Risk Children

W. Barry Chaloner, M.Ed., LPC

I have been doing therapy with adults, teens, children, and families (and most recently infants and toddlers) for over twenty five years. Early in my career I assessed a 13-year old boy who had murdered his best friend’s older sister for less than $5.00 in her purse. He shot her point blank in the torso with a 38-caliber handgun when she refused to give up her purse. My recommendation was to incarcerate him until he could be tried as an adult. Instead he was put into inpatient treatment and released about a year later. Within six months he repeated the crime. After this experience I no longer felt I could work within the Juvenile Justice system, as the prognosis for this boy and other teens I was seeing there was very poor.

So I began to seek training and new venues to work with younger at-risk children with the hope of preventing such violence. This led me to explore play-based methods of therapy and apply them in school as well as clinical settings. Eventually, I became a provider at a Head Start in NW New Mexico where I applied symbolic play therapy (primarily Child-Centered Play Therapy [CCPT] and Filial Therapy [FT] approaches). I still work as a 0-5 mental health consultant/trainer nationally, a therapist/consultant for a SW Colorado Head Start, and maintain a part-time private practice in infant, toddler, child, and family therapy. I have more recently integrated a sensory/Theraplay-based approach into my work with individual children, families, and classroom groups, which I have found more effective than CCPT alone in about half of the cases. While I still have much to learn about Theraplay, I believe it has many advantages over symbolic approaches as the primary mental health intervention model in Head Start or other early childhood settings. This is because many children with the most significant self-regulation problems have sensory processing AND attachment issues which traditional behavior management and symbolic/language-based approaches like CCPT do not efficiently address. Theraplay is a developmentally appropriate method for both sensory dysfunction and impaired attachment which helps children learn self-regulation and empathic behavior. This article describes the process of my therapeutic transition and integration process and the reasons for it.

When I began seeing children individually, I used a child-centered approach to play therapy. The term CCPT is used here to describe any school of play therapy (such as Child Centered, Experiential, Filial, Jungian, Adlerian, and Thematic) where the therapist “primarily” lets the child lead the symbolic play with miniatures and dramatic props. In this approach toys are considered words and play with them language. The curative elements of CCPT are considered to be children’s symbolic expression of issues through child-centered play with toys, the therapist giving language to the themes expressed in the play, the therapist letting children lead the way, and the maintenance, by the therapist, of a deep trust in children’s ability to heal themselves. Filial Therapy is an extension of this approach where parents are trained to play in a child-centered fashion with their child. Many of the CCPT schools have a strong “Rogerian Client-Centered” slant but all seem to hold that direction or control of the play is considered counter therapeutic in most cases.

Even though I was using a play-based approach at Head Start, I realized that teachers would have to be trained as therapeutic partners to serve the many children who needed interventions for a variety of problems including aggressive, oppositional defiant, anxious, withdrawn, and impulsive behaviors. In other words, when I was primarily relying on individual CCPT, there was not enough of me to go around. So I began to develop a program initially called Play And Language to Succeed (PALS) that adapted FT for classroom use by Head Start teachers during centers or free play time. The initial results (measured by pre and posttests) were encouraging in that over half of the children improved without individual CCPT when teachers incorporated child-centered play into centers in the classroom. I could then coach the teachers of these children rather than do individual CCPT, which improved the efficiency of service delivery. By 1996 I had developed a teacher training and eventually a whole program that attempted to systematically implement CCPT into Head Start and Pre-K-2 classrooms.

During the mid-to-late nineties, my paradigm of why CCPT works changed dramatically due to my exposure to research on brain development, attachment, emotional intelligence, sensory integration, and other exciting new work. This work raised the question of why CCPT works: Is it because of the symbolic processing during symbolic play with toys and/or letting the child lead the way; or is there some other explanation altogether? Many of the young children we worked with in Pre-K-2 settings appeared to have impaired attachments. Therefore, I reasoned that CCPT worked, at least in part, because it was a medium for facilitating a more secure attachment with at least one caring adult during a prime window for neurodevelopment of a “good enough” internal working model of attachment. By the late nineties it was evident to me that establishing an attachment with a teacher was a primary healing component in PALS at Head Start and Pre-K-2 settings as well as in individual CCPT or FT. So I began to view CCPT and the PALS intervention model as relationship-based and to add other elements to CCPT and PALS such as movement and music and silly games to facilitate more positive relations between caretakers, teachers, and at-risk children. This appeared to improve outcomes and support my hypothesis. At that point I changed the PALS name to “Positive Attachments & Learning to Succeed.” I can still remember the therapy session around 1999 when I realized that it was the joyful spark that ignited intense laughter between a 3-year old boy and me that became the conduit for a secure attachment and a powerful curative element in his therapy process. Subsequent experimentation led to what I called then “sensory/relationship-based” strategies. For instance, I would engage a child and his teacher in an interaction like pitching a foam ball to the child who would hit it with a bat and each time he did we would yell “Yeah!” loudly and break into joyful laughter that reached deep into our bellies. Since that time I have trained with, been exposed to, and/or influenced by the Developmental Play Therapy work of Viola Brody, the “I Love You Rituals” work of Becky Bailey (in part derived from Theraplay), the Theraplay work of Ann Jernberg, the relationship-based sensory integration work of Maria Anzalone and Georgia DeGangi, the Thematic Play Therapy work of Helen Benedict, the “Watch, Wait, and Wonder” (WWW) Infant-led attachment work of Mirek Lojkasek, and the brain development and interpersonal neurobiology theories of Daniel Siegel.

At the same time I noticed that certain children did not respond to CCPT even with a more relationship-based approach. I know now that these children were much more likely to have both sensory/regulatory and attachment issues that manifested before age two and/or were traumatized or neglected usually in the first 24-months of life when their sensory systems and internal working models of attachment were developing. In contrast, a 3-to-4 year old child who has reached relatively normal levels of development (capacities for self-regulation in all areas are viewed here as neurological in their basis) is much better suited to symbolically process subsequent trauma and/or neglect using a CCPT approach. Specifically, to make use of symbolic processing in non-directive CCPT, a child will need to have achieved some degree of Erikson’s stages of basic trust, autonomy, and initiative and Piaget’s stage of preoperational processing. Relatively normal brain stem and limbic system development would therefore have occurred in the first 24-30 months of life allowing the child to focus and function in a non-directed manner and lead the way in CCPT. Inter-hemispheric integration of the traumatic material is likely the neural mechanism for therapeutic change and is probably why some practitioners have found symbolic play therapy to be effective for these children.

If a child has been abused, traumatized, neglected, and/or has a poor temperament fit with his caregiver in the first 24-months, it is likely that an impairment in the development of basic trust, a “good enough” internal working model of attachment, and related brain development will not occur normally. It is important to note that what is meant here by building basic trust is the establishment of a neurological foundation for attunement, self-regulation, and self-soothing to mutually occur between the adult and the child (otherwise known in neuroscience as limbic resonance), a precursor to judging trustworthiness, which develops later in childhood. It follows then that the development of autonomy and initiative would also likely have been disrupted. So if the development of autonomy and initiative is missed or disrupted, it is unlikely that CCPT alone will be adequate as it does not provide enough structure so the child can let her control down enough to reestablish basic trust, essential to attachment. In fact, I have seen some of these same children use CCPT to sustain control and avoid building attachments during the therapy process. The Theraplay method is well suited to this therapeutic task as it focuses on the development of basic trust and attunement while the adult remains in “loving” control directing the process much like a mother does with her 6-12-month old child. At a neurodevelopmental level what is likely happening during Theraplay is that neural connections and integration between the brain stem and limbic system are developing sequentially much in the same way they do in the first 8-24 months of life. This is assuming the child’s brain is still plastic enough to develop appropriate neural connections in a sequential fashion. This is not to say that CCPT cannot achieve positive results with these children but when it does, in my experience, it is because the therapist has used the play as a “relationship-based” treatment medium where attachment is the curative element not symbolic processing.

Carol Kranowitz, a well known expert on dysfunction of sensory integration (DSI), cites numbers ranging from 12-30% of all young children have DSI, depending on how you define it. This may in turn contribute to or cause impaired attachments according to experts in the field of regulatory disorders. Regulatory disorders in infants have been shown in studies to be associated with a host of later problems especially social, emotional, and behavioral ones. So if these children have a regulatory or sensory processing problem in conjunction with an impaired attachment then they would need an approach to therapy that has a sensory component, addressing issues related to sensory modulation and learning to self-regulate and attune to their caregiver and, therefore, attach. At a neurodevelopmental level what is likely happening is that the sensory component of Theraplay is organizing the brain stem and building connections between the brain stem and lower regions of the limbic system so that sensory modulation, self-regulation, limbic resonance (attunement), and attachment can occur. Again, Theraplay is well suited to the task, and CCPT would not likely be the treatment of choice initially.

As mentioned earlier, CCPT maintains that a major curative element is letting the child lead the way where the adult remains non-directive, respecting the child’s ability to heal himself, and gives language to the themes in the symbolic play. Some CCPT practitioners have criticized Theraplay for being too directive and some Theraplay practitioners have criticized CCPT for being too non-directive; but here is where the paradigm of directive and non-directive as a model to guide therapeutic interventions fails. It is not whether the therapists are too directive or not, as much as what level of “attunement” they bring to the interaction with the child and what level of neurodevelopment the child has achieved as described above, especially in regards to the child’s ability to act autonomously in his own best interest. The ability to accurately reflect upon what the child feels, needs, and believes is critical to the attunement process. So one can be quite directive, but not insensitive as long as one remains “exquisitely” attuned and has the capacity to reflect accurately what the child feels, needs, and believes. Approaches to therapy such as Greenspan’s “Floor Time” and the “Watch, Wait, and Wonder” (WWW) model of infant-led psychotherapy, while non-directive, focus almost exclusively on helping the caregiver develop attunement and reflective capacity, not on themes in children’s play. These “reflective” approaches are usually best applied while children are 8-to-30 months of age and the brain and internal working model of attachment are still evolving. Children who have sensory/regulatory and attachment issues tend to develop defense systems that can interfere with building basic trust and therefore a “good enough” internal working model of attachment and related neural connections. So Theraplay attempts to replicate relations typical of the first 2-years of life with a focus on a playful diet of sensory/relational activities which challenges the child to learn to accept the adult’s nurturing and develop the capacity to modulate sensory-relational input without becoming over stimulated or threatened. This makes Theraplay ideal for children whose attachments and sensory/regulatory development were derailed before age two, have defense systems against building basic trust, and ideally still have the neural “plasticity” to change their brains. Children who have achieved relatively normal attachments and brain stem/limbic system development by age 3-4, and must process subsequent trauma (that does not rupture their internal working model of attachment), will likely respond well to CCPT in most cases. Different stages of neurodevelopment require that caregivers provide differing levels of structure and control, which is also true in therapy.

Therefore, accurately assessing the child’s neurodevelopmental level can indicate which intervention is needed. I recommend that Head Starts adopt a neurodevelopmental perspective that looks at self-regulation in a more holistic fashion, screening for delays at the sensory, attachment, social-emotional and behavioral levels. Then, interventions can be designed that begin at the level of neurodevelopment where the derailment originally occurred, and progress through the intervention process in a neurodevelopmental sequence from the sensory/brain stem to attachment/limbic to symbolic/inter-hemispheric levels.

Two additional advantages to the use of Theraplay are the ease of teacher training and the efficiency and benefit of Group Theraplay sessions. Because Theraplay’s consistent, playful diet of sensory/relational activities is similar to the way a mother teachers her infant/toddler, many Head Start teachers already intuitively understand the process; this reduces training difficulties related to concepts foreign to their field. The Theraplay dimensions of Structure, Engagement, Nurture and Challenge can be learned relatively easily by most Head Start teachers and provide a useful, easy to understand structure to organize a variety of interventions that can include many activities they already know and use, such as music and movement exercises that facilitate the development of sensory modulation. Group Theraplay integrates more easily with fewer classroom routine changes than symbolic methods. For instance, group Theraplay reduces classroom management problems associated with utilizing CCPT individually in centers because it engages the entire class at once. Theraplay groups have the potential to rapidly make a family out of a Head Start classroom at a level comparable to a real family. This allows the classroom environment, peer relations, and the teacher-child relationship to potentially all help meet the attachment and basic trust needs of at-risk children. This in-turn helps heal the attachment-based aspects of neurodevelopmental behavior problems. In addition the sensory aspects of Theraplay groups help children learn to transition between and modulate different types and intensities of sensory input as well as increase their capacities to self-soothe. Finally, group Theraplay utilizes materials readily available in the early childhood environment and thereby eliminates the problem and expense of obtaining and maintaining large numbers of relatively expensive symbolic play miniatures and dramatic play items.

While I believe that CCPT should be a part of all early childhood programs as a symbolic level of intervention, Theraplay offers the Head Start mental health consultant an alternative to CCPT that more directly addresses and efficiently resolves the two most common causes of self-regulation problems in early childhood settings: impaired attachment and regulatory/sensory integration dysfunction.

The author can be contacted by email at pals@frontier.net or at www.pals4schools.com. Barry is licensed as a professional clinical counselor and school psychologist specializing in early childhood consultation, training, assessment, and therapy and is the director of the Center for Early Intervention in Durango, Colorado. He is currently under contract with the publisher W. W. Norton to complete a book related to the material included in this article entitled: The Brain at Play: Unifying Play Therapies and Early Intervention through Neuroscience.