Play therapy can be an effective tool to aid in assessment and diagnosis for children and adolescents. Using play themes, play observations, clinical assessments and information from both the child and important people in their lives, can help a mental health professional create the most accurate diagnosis and treatment goals as possible.
It is important that mental health professionals are mindful of racial stressors in children of color and how that may negatively affect moods and behaviors. Ecosystemic play therapy is an important play therapy seminal theory that can be utilized to make clinicans are considering all of the people, experiences and stressors that may exist in the systems interacting with the child.
Important Factors to Consider
In applying the basic tenets of Ecosystemic Play Therapy, the play therapist must be aware of the social realm in which the child functions, including all of the systems they encounter. These includes gathering important information such as:
Cultural factors: It is important to gather important cultural factors about the child and their family that could be protective and/or risk factors. This can include race/ethnicity, sexual orientation, gender orientation, religion, values, beliefs and socioeconomic status are all important details that can provide further insight into the child's moods and/or behaviors.
Family dynamics: Exploring the family composition and dynamics can include using play genograms to gather more information about family structure and perceived relationship. It is also important to include any influential adults that may operate within the family system like aunts, uncles, grandparents and friends of caregivers.
Peer groups: Another factor to consider during assessment is the child's level of socialization. Do they have any close friends? How are their interactions with peers? How are their interpersonal relationships in school and other social settings? These questions will help the therapist determine if there should be treatment goals addressing interpersonal relationships and skills like conflict resolution, anger management, social skills and more.
School settings: There are a variety of educational settings for children including public schools, homeschooling, charter schools, private schools and gifted/independent schools. Additionally, the COVID-19 pandemic has virtual school to the list. Therefore, mental health professionals should inquire about the child's school setting, along with their behaviors and interactions with other peers and teachers in that setting. It is also important to find out if the child is receiving mental health services from school support staff, and if so, get the contact information of that professional. It also will be important to get the teacher's information, as it may be important to talk to the teacher as part of the assessment and/or treatment of the child. They may also need to complete clinical assessments as part of the process.
Other environments surrounding the child (i.e. church, sports teams, etc): It will be important to gather more information around the child's behaviors and interactions in other settings, and possible talk to the adults in those systems. This can be helpful when the therapist is trying to determine the most accurate diagnosis, as some diagnoses like ADHD require symptoms to be present in more than one setting.
Identification of client & clients needs: When working with kids, professionals will often hear the perspective of the child and their needs from the adults in their lives; parents, teachers, other clinicians. Mental health professionals should also ask children and adolescents how they identify and what goals they would like to address in treatment. Doing so can allow the therapist to gain more insight into the child and their needs, which can help contribute to more accurate diagnosis and treatment planning.
Clinical assessments: Although clinical assessments are subjective and there is a risk of underreporting or over reporting, it is another important piece of the puzzle to determine the best approach to addressing the child's presenting issue(s). ACE screenings like the Childhood Trust Events Survey can allow the therapist to assess for trauma and stressor-related disorders like PTSD. For children of color, using race-based assessments like the Philadelphia ACEs will help screen for race-based experiences that may aid in clinical diagnosis.
Play as a Tool for Assessment & Diagnosis
Appropriate diagnosis is based on the client's complete clinical presentation at the time. The diagnosis may change once treatment begins and as the therapist gains further insight into the child. The clinician must compare the cognitive, behavioral, emotional and interpersonal symptoms that the client presents with the criteria for diagnosis in the DSM-5, while also being mindful of cultural considerations.
The play therapist can also use play-based assessments using toys, games, art, music and sand, as a tool to further support their mental health diagnosis and assessment of the child's needs. Observing play and sand tray interactions in the playroom can alert the clinician to play themes that can gain insight into the child's presenting issue and progress in treatment.
The types of toys children play with and the energy/emotions expended during their play can communicate the child's wants, needs, desires and concerns. We refer to these as play themes. Play themes can develop across sessions or within one session. These play themes can aid in assessment of the child, as well as serve as a tool to measure progress in treatment. Below are some common play themes that I use in my practice:
Anger- Seen when a character is frustrated by an action from an another in role playing activities
Aggression- The use of aggressive toys like toy guns, army men, toy swords, etc. (Note: the use of aggressive toys does not mean the child is physically or verbally aggressive towards the therapist)
Chaos- Exhibited when children create a mess in the playroom
Connection- Can be seen when child says “look” or “watch this” or asks client to engage in play
Fear-Can be represented by the child shrieking and backing away from items in the playroom (i.e. spiders, snakes, etc)
Grief and Loss- Acting out scenes of dying, funerals, etc
Guilt- Can be exhibited in play through a child repeatedly saying “sorry” to a mistake they made
Limits & boundaries- When a child does not respect the limits set by the play therapist
Nurturance- Engaging in domestic play (i.e. giving baby a bottle)
Power & control- Can be shown through child telling therapist what do or play
Perfectionism- Displayed with a child making sure things are “just right” (i.e. setting up furniture in a doll house)
Protection & safety- Can be demonstrated by child using prison or net to contain characters/toys
Regression- Child using “baby talk” or using a bottle like a baby
Self-esteem- Child being proud of something they accomplished or created at the end of the session
Trust & betrayal- Can be demonstrated when a child does not feel comfortable telling the therapist a secret
Independent play- When a child plays on their own without inviting the therapist to join in their play
Play Themes & Diagnosis
There are several play themes that are associated with common mental health issues in children. They can include:
ADHD: Limits & boundaries, guilt, aggression, chaos, power & control, self-esteem, guilt, connection
ASD: Independent play, protection & safety, nurturance, anger, aggression, chaos, fear, perfectionism
Anxiety disorders: Chaos, connection, fear, grief & loss, guilt, perfectionism, self-esteem, independent play, protection & safety, power & control
Depressive disorders: Guilt, anger, aggression, self-esteem, grief & loss, independent play, trust & betrayal, regression, protection & safety
Disruptive & impulsive disorders: Anger, aggression, power & control, limits & boundaries, chaos
Trauma and stressor-related disorders: All of the play themes may be present, as trauma can often present as ADHD, anxiety, depression and impulsivity
Want to learn more? Check out our training calendar for our workshop "Play Therapy Assessment. & Diagnosis" as a live webinar or contact workshop near you!