Using Play Therapy to Address Behavior Concerns in Children

Play therapy can help young people cope with their emotions and find healthy, lasting solutions to their problems, including social, emotional, and behavioral concerns. There are many variations, including the use of arts and crafts, music, storytelling, board games, drawing, sand trays, role playing and drama, puppets or dolls, and other expressive activities.

Ahou V. Line, PhD, NCC, LPC, RPT, CSC, CCPT-S, is a play therapist for children ages 3–10 and adolescents in Dallas, Texas, where she co-founded Thread Counseling Group. Dr. Line is also a former middle school teacher. In her practice, Dr. Line regularly uses play therapy to address behavioral concerns within the young clients that she serves.

There are many approaches to this modality, but the most commonly used are child-centered play therapy (CCPT), cognitive behavioral therapy (CBT), and Adlerian therapy, Dr. Line explains, adding that there is an extensive body of research supporting it.

“Evidence demonstrates the efficacy of play therapy for behavioral issues with children,” she says. “In a 2018 study, Wilson and Ray completed a randomized control trial with 36 children in elementary school who received 16 sessions of CCPT. Pre- and post-test data measuring aggression, self-regulation, and empathy found statistically significant positive results. We also know that play therapy can decrease symptoms of depression (Burgin & Ray, 2022), reduce disruptive behavior (Cochran & Cochran, 2017), improve attention-deficit hyperactivity disorder (Ray et al., 2007), and support self-esteem and reduce anxiety (Post, 1999).” 

There are important factors to discuss with parents when determining whether a child is a good candidate, Dr. Line says. 

“I often advise parents that sometimes behaviors can be developmental or may pass on their own,” she says. “If they start to notice that ‘the issue’ is beginning to impact the child in school, their friendships, or daily living, it may be a good time to consider play therapy. The play therapist can discuss with parents at the intake appointment if the presenting concern may be a typical part of development. I have absolutely met with parents and let them know that their concerns, though completely valid, are part of typical development, and that even though play therapy won’t hurt, it may not be necessary. That is why the initial intake is so important.

“I spend time understanding the presenting concern, including when it began, when they see improvement, or when they see the behavior is worse,” she says. “This helps me begin to conceptualize the child and their perspectives of the world. I then co-create goals with parents in that initial intake. Often, in addition to ‘decrease aggression,’ I will include goals such as ‘increase emotional vocabulary,’ ‘engage in self-determined decision-making,’ ‘increase self-regulation,’ and other goals that I know are being addressed through CCPT.

“After I meet with the child, I may discuss with parents the need to shift some goals or add additional ones. It is helpful for me to use clinical judgment to determine if there are additional goals that could be helpful,” she continues. “For example, maybe the parent is most concerned about aggression, but they haven’t mentioned anything about wanting to increase self-confidence. However, when I meet with the child, I recognize that they may lack confidence or often put themselves down. This becomes a great thing to discuss in the next parent consultation and add to the goals. I like to think about goals being malleable especially since we set so many of them before ever meeting with the child.”

Goals should be clear and measurable, she says.

“For example, if parents attend the intake and tell me that their child is not doing as well as they expect in school, I may point out that though play therapy is not addressing academics, there may be social or emotional considerations such as lack of motivation, difficulty concentrating, or other concerns that may be impacting their school performance. I spend time in the intake understanding the concern and clarifying whether play therapy may be the best next step. Also, I always ask parents, ‘If play therapy was successful, what two or three things would be different for your child?’ Then, I help them clarify what that may mean. If they say, ‘I want my child to be happier,’ I may ask, ‘What would that look like?’” 

In subsequent parent consultations, she asks whether they’ve noticed changes in their child’s behavior at home or school, including aggression, outbursts, or other emotional regulations related to the goals they’ve established. Tracking this information helps her discern and communicate the child’s progress. 

“For example, if the presenting concern is aggression or impulse control, I notice things such as the number of limits I set in each session and make sure to report to parents if I have seen a decrease,” she says. “I may also recognize increases in emotional vocabulary, or moments when I recognized self-regulation,” adding that clear communication is imperative and keeps parents engaged for the best outcome. “At each consultation, I also share one takeaway of something they can do at home to continue to support the progress through therapy.” 

Play therapy is more effective when parents are actively involved, Dr. Line says. She shares the following information as part of initially meeting with them: 

• Your child may vacillate between being timid to eager about attending session each week, and back to being resistant.
• Things may seem worse before they become better. Continue to communicate with your play therapist to let them know what you’re seeing at home and address any concerns.
• Your play therapist may not tell you every detail of your child’s behavior in the playroom. The therapist is working to create a safe environment where your child can work toward their own self-enhancement.
• Be transparent in each consultation. Your play therapist relies on you to provide clarity on how you are experiencing your child at home, what you are hearing from school, etc. Be open and honest about concerns you have or progress you see.
• Play therapy may not always seem fun. Just as sessions in adult counseling may be difficult and stir strong emotions, children may have particularly emotional sessions. Recognize that they are just as important as the “fun” ones.

Play therapists are poised to change lives by engaging with children and their parents to foster healing, and the outcome can be remarkable, Dr. Line says.

“It’s magical seeing what happens when you trust children. It is so neat to see how they gravitate toward things that they may need,” she says. “For example, children struggling with school may ‘play’ school with the board in our office and tell me to act like a student. When they play the role of the teacher, they may yell at me and tell me I am not doing things well enough. This isn’t a denouncement of their teacher—rather, it demonstrates their perception of how they feel in school. Even through the act of playing this out, there is a semblance of control. They may do so week after week and may change the ending by praising me as the child, telling me I finally got it right. Again, when I meet with parents, it’s so great to hear that many of their behavior concerns at school have dissipated, or that the child has begun to name their emotions by saying they are frustrated or upset, rather than hitting another child.” 

She recommends the website of the Association for Play Therapy (NBCC Approved Continuing Education Provider No. 5636) for a variety of resources for interested counselors, emphasizing the necessity of proper training and continued learning. 

“The Association for Play Therapy really stresses the importance of quality training and education for play therapists. They also clearly point out that play therapy is not just therapy that uses toys and is not to be used by anyone who simply has an interest in working with children. Just as I would not venture into family or couples counseling without adequate training, I believe it is inappropriate—and can be detrimental to our profession and to children—to engage in the play therapy modality without proper education and training. 

“Play therapists can work toward additional credentials to become a Registered Play Therapist or Registered Play Therapist Supervisor,” Dr. Line continues. “Moreover, theoretical approaches have their own trainings, such as Child Centered Play Therapist (CCPT) or Child Centered Play Therapist-Supervisor (CCPT-S), which require many hours of training and experience. I believe that in order to be grounded in theory and trust in the work that you are doing with children, a clear theoretical orientation and intentionality is a requirement. I also believe that it is up to the counselor to engage in those additional trainings to continue to hone their craft.”

Ahou Vaziri Line, PhD, NCC, LPC, RPT, CSC, CCPT-S, is the co-founder of Thread Counseling Group in Dallas, Texas, where she works with children, adolescents, and adults. She is a National Certified Counselor, Licensed Professional Counselor, Certified School Counselor, Registered Play Therapist, and Certified Child-Centered Play Therapy-Supervisor. Dr. Line has authored several peer-reviewed journal articles and book chapters on working with parents, supporting Middle Eastern children and families, and in training preservice educators to consider counseling skills in their work as teachers. She has also presented at many local, state, national, and international conferences on various topics, including teacher and parent support and multicultural considerations in play therapy.

**Opinions and thoughts expressed in NBCC Visions Newsletter articles belong to the interviewees and do not necessarily reflect the opinions or practices of NBCC and Affiliates.