Rima was a 5.5 year old ASD child when on gentle persuasion by a day care teacher her parents approached us for play therapy. Rima’s parents although both were paramedics, struggled to accept that their child was not normal. Initially they blamed themselves for the lack of time and hoped that their love and attention would reverse her ‘odd’ behaviours. The mother especially blamed her work hours or their decision to have another child (a normal 3 year old son) so soon for Rimas developmental issues.
When they first came to discuss Rima, they thought that the only issue with the child was that she was not very verbal. They claimed that although she was better than before after the day care center teacher spent extra time with her, they were worried how she would react to the big school which she would join in the 1st grade, next year. But as they talked they realized that the problem was far more complex and interlinked. They were able to identify other issues such as her hyperactivity, non communicative behaviour, usually preferring to play on her own, petrified of loud noises and animals, asocial by nature and find it difficult to share things. She also was easily irritated and was often teased and bullied by her cousins to whom she reacted by either crying or reacting violently. She loved to play in sand and go to the beach but didn’t much play with other toys. She was also at times mean and violent with the younger brother. She didn’t demand much, even in food and would be quite passive most of the times. She enjoyed watching television ads, and listened to religious mantras. She seemed to have an unusually bright memory in remembering lyrics of the songs / advertisement / mantras. Her favourite game with her father was to climb on him holding his hand and then throw herself backward head down. Although she does this regularly, the parents were very worried about this as she could seriously injure herself. They had tried to change this behaviour a number of times, but she would not pay heed to their warnings. Infact they thought that her risky behaviours such as this had increased and now she would take every opportunity to jump of the table or even fling herself suddenly at the opposite person, uncaring of how badly she might get hurt or hurt the other person. If shouted at or stopped, she showed an unusually strong temper and become very obstinate. Thus discipline and obedience or boundary setting were major issues with her. She would still wet the bed in the night although not regularly and at times soil her panties. The mother mentioned that Rima was very fond of sand; therefore they had made a sand pit in the balcony for her to play in. But her play in sand was pretty unusual. Instead of making something out of sand, she spent hours just sifting through sand humming to herself a tune. As we talked, the mother recognized other behaviours which although she had noticed, never paid much attention to it. Rima’s inability to generalize learnt behaviours to other similar situations, her inability to focus on two or more things at a time, her insistence of ritualistic actions, her inability to substitute one toy for another similar toy. She also realized that all these behaviours together indicated Autism, a neurologically based life long and severe condition and not merely a late developmental issue or an emotional problem.
The therapist helped them understand how play therapy can benefit an autistic child and how an autistic child’s play differs from that of other children. She also went on to explain how play is a complex phenomenon that occurs naturally for most children and how they move through the various stages of play development and are able to add complexity, imagination, and creativity to their thought processes and actions. However, for many children with Autistic Spectrum Disorder (ASD) various stages of play never truly develop or develop in a fragmented fashion. These skills which a ‘normal’ person takes so much for granted is actually an uphill task for an ASD child. An ASD child suffers at all three levels of understanding and mastering the skills, cognitive social and behavioural.
Initially it was believed that play therapy is not effective treatment for ASD, recent research has convincingly proved that it is one of the most effective forms of treatment when used at times in a structured manner and especially if it is taught to parents and incorporated in the daily routine by the parents. Extensive opportunities in play therapy for social skills and emotional development help the child by increasing his awareness of other people’s mental states and their intentions. Play therapy then becomes a safe practice zone for the development of these skills.
These play therapy skills can also be taught to the parent / care taker who can incorporate it as a part of the daily routine. Treatment of ASD is highly specialized and a life time task, therefore often very expensive. Play way parenting equips parents to incorporate these play sessions in daily routine of the child and drastically reduces the cost. Parents are also encouraged to introduce it to the rest of the family so that it becomes another support for the ASD child to learn and master the skills. It also indirectly helps the other family members cope with their emotions with regards to the ASD child in a constructive manner.
Play therapy provides ample of opportunities to develop following skills in ASD children, necessary for their learning:
1. Imitation: imitation is a skill that is learnt very early in childhood. But the most crucial aspect of imitation is the ability to generalize these imitative behaviours to other situations. For example a child through imitation learns to smile and then uses cognitive and social skills to generalize smiling behaviour to situations requiring it. But ASD child find it difficult to generalize this to other situations. During play therapy, puppets, role enactment, make believe situations etc are used to increase the generalizations of these imitative responses.
2. Object exploration: children suffering from ASD find it difficult to initiate an exploratory play. This is because they get over whelmed with multiple stimuli and over a period of time, due to past experiences they learn to be socially reserved. In play therapy, the sensitive manner in which the therapist approaches the child establishes a safe and trusting environment for the child to attempt to explore. Then when the therapist incorporates some specific techniques such as restricting the space during play and giving them toy one by one the child finds it easier to learn them. A combination of skills and emotional support substantially increases these initiative responses in the child. It also helps to increase the child’s self confidence and self esteem.
3. Exploratory and Experimentation with play: Play therapy is often one of the first experiences of play without any target response goals for an ASD child. Being socially withdrawn they rarely take any initiatives to play on their own. Since play sessions are directed towards play only, it provides them with an opportunity to experiment and explore with play in a safe and trusting environment. Manipulation of toys in play session helps them to practice varying characteristics of toys, classification of toys such as sorting and matching, establish causal relationship between events and how to influence the world around them.
4. Communication skill: Communication skills such as expressing emotions, expressing specific needs, using gestures and joint attention are mastered during play sessions. Play therapists create surprise events during play sessions, using visual information to communicate verbally something that the child wants. This provides the child with ample opportunities to practice putting their emotions into gestures and words and thus reduces their frustration about not being able to get their needs met. It also reminds ASD children that communication and play involves another person and acts as a bridge toward more complicated or symbolic communication using words assessing not only their emotions and needs but also to match it with the other person. This is especially a difficult area for an ASD child as these skills are highly dependent also on social skills, both a problem area for the child. This skill can be taught using substitution of the play object (such as dolls), role enactment using various toys (puppets), recreating real life situations with numerous alternatives, helping the child to elaborate on intentions (involving verbal communication), helping the child to master ideas / themes, discussing with the child abstract themes and using obstacles to generate alternative solutions.
5. Signing or acting: Play sessions provide ample of opportunities to use a combination of gestures supported by verbal communication. This helps in the transition from no communication to gestures and then to verbal communication. This also helps to reduce the child’s frustration with people, usually strangers who are unable to understand their sign language. It thus increases their confidence socially and also boosts their self esteem. We often find a simultaneous reduction in anger in the child.
6. Peer Play: Peer play also relies on social cues which ASD child finds extremely difficult. Therefore we often find and autistic child unable to share, wait for turns, negotiate with another child, imitate other role models, ask for help, request for events / objects, initiate inviting another child for spontaneous play, all of which a necessity for any school going child. Through structured play sessions dealing with each of these skills and then slowly moving on to group play sessions or introducing it amongst the siblings the child gains enough confidence in these skills to be able to practice them at school or with other peers.
7. Increasing attention and concentration: also requires the child to comprehend the object and hold it in his thought symbolically. Play sessions intrinsically provide these opportunities to the child. It then becomes a practice field where the child learns to master these skills and then be able to use them outside.
8. Motor coordination also increases tremendously using play toys. The child learns to explore and experiment with different shapes, sizes textures and colours of toys in a non threatening, goal less, safe environment where the only goal is pleasure.
9. Parenting skills are also improved. Very often without realizing parents facilitate the learned helplessness in the child as he is unable to communicate. We often find the parent not being able to push the child to learn the above mentioned skills or become too harsh and frustrated. Neither of these behaviours are conducive for further development. During play sessions parents get an opportunity to examine their play deficits as well as express their own emotions and frustrations with the therapist. This kind of self exploration helps in dealing with parental anxiety of their child and his future in a manner which will help the child become independent.
Vineeta lost her mother when she was a young adult; she pined for years, unable to overcome her grief over the loss of her parent. But when she underwent divorce, she was unable to understand her own 8 year old son, who was grieving the loss of his father. She struggled to understand why suddenly he was getting into trouble at home and at school, why were his grades falling although he was an intelligent child, why was he back answering and blaming her. Nothing made sense, but a sense that everything falling apart for them both was experienced. Maybe that is what a child feels when parents divorce/ separate. His entire world seems to come crashing down.
The movie Bal Ganesha which got everyone in the theatre to tears of joy when Ganesha showed his superior intelligence and circled his parents three times instead of taking three rounds around the world, winning the race against his younger brother. Little do we realize that this mythology is not about superior intelligence, rather it portrays the child’s perception of his parents, his world. For him, parents are at the center of his existence and therefore separation from one or both is experienced like death and a threat to his own survival.
Like any one who is fighting for their survival, children try out various options to survive this trauma, and attempt to reunite their parents. Like the Vineeta, who grieved for years over the loss of her mother, children do not give up hope of reuniting their parents for years after the separation. Parents who are anyways struggling to deal with their own emotions find it extremely difficult to deal with the emotions of the children. Children ask questions which seem impeccably correct putting the parents in a spot. “But why does he not like you? Maybe if you work hard and become smarter and thin, the way he wants you to, we can be together,” says a 7 year old boy to his mother. Or a 10 year old girl to her father “Why can’t you forgive her, maybe she did not mean the things she said to you. You forgive me every time I have lied, can’t you forgive her? For my sake please?”
In most cases the children tend to feel responsible for the divorce and try to change the behaviour and actions to please the other parent, like this 6 year old boy pleads to his mother, “lets go back home, I promise I will not make him angry and bother him for toys ever again or change the TV channels.” At times, in their attempt to get back the parents together, they may even get into negative behaviours such as lying, running away from home, cooking up stories, poor academic performance, and bedwetting, being irresponsible and stubborn etc. This problem is exaggerated if the child is very young and unable to communicate; or if he is entering his teens and feels confused and threatened about the volatile emotions characteristic of this age. Unable to deal with this confusion and inability to express their distress, children learn to bottle up emotions and thoughts, making communication all the more difficult. There seems to be a glass wall around them where you cannot hear what they are saying nor can they seem to understand what you are trying to communicate. Nothing seems to penetrate and touch them through this wall.
But there is a non threatening way to communicate to them, through the language of play. Play is a natural mode of communication of children. They can better emote their feelings unconsciously through play and therefore play becomes a powerful cathartic medium. It also provides an emotional distance to the children necessary to express threatening and negative emotions and thoughts. They cannot say that I don’t hate you mom for getting divorce but they can definitely express the same using a doll set or by beating at clay incessantly. Thus through the use of play, we can reach out to both the younger children and the teenagers alike.
This play way is used by a specially trained therapist to help children and parents better understand and deal with each others thoughts, feelings and behaviours. Unfortunately this is a language that we as parents, have long forgotten and need to relearn it in order to understand what our child is feeling to help them. Sometimes the Play Therapist also involves the parent to some of the structured play techniques which can help them bond better. This is what we did with Vineeta and her son. Through play materials we helped the child emote his anger and frustration. Once he had a name for the feelings, he was able to express it verbally. Vineeta on the other hand, when she was involved in the Play Therapy sessions, learned to better understand his emotions and respond appropriately to his needs.
The drawing in the picture was drawn by the child demonstrating his pain at the divorce as is seen by the heavy clouds, scratched sun and the two rivers which run parallel to each other like tears from the eyes. A Play therapist uses numerous play materials such as this to make such interpretations and convey it to the child, equipping the child with the ability to choose his reactions appropriately. It aims to increase resilience and self esteem within each child. Making him confident to face the future and challenges in life.
It’s normal for children to occasionally forget their homework, daydream during class, act without thinking, or get fidgety at the dinner table. But inattention, impulsivity, and hyperactivity are also signs of attention deficit disorder ADD. ADD/ADHD makes it difficult for people to inhibit their spontaneous responses—responses that can involve everything from movement to speech and attentiveness. Having ADD/ADHD (for the child) can be just as frustrating as dealing with someone who has it. Kids with ADD/ADHD want to sit quietly; they want to make their rooms tidy and organized; they want to do everything Mom says to do, but they don’t know how to make it happen. They do not intentionally want to annoy you. If you keep this in mind, it will be a lot easier to respond to you child in positive, supportive ways. Like all kids, children with attention deficit disorder (ADD ADHD) sometimes make bad choices regarding their own behaviour.
Rima was getting ready to go for a swim with Akshay, her 10 year old son. Saturday morning is a planned outing with him and some of his school friends and their mothers and a special time for Akshay, something that he looks forward to the entire week. Rima asked Akshay to finish his breakfast, take a bath and pack his swimming bag while she went on hurriedly going about doing her household chores. Expecting Akshay to have finished at least with his breakfast and bath in the past half an hour, Rima went to check whether he needed anything. She found him sitting on the dinning table with the breakfast untouched and watching his favourite cartoon show. What is his problem? Yes, he has ADHD, but how hard is it to do three simple things? He loves to go to for the swim with his friends. Why is it such a struggle to get him to listen? As Rima hurries Akshay around, she is thinking of what her husband would say if he were around. ‘You are spoiling him by not being stricter with him and doing his work for him. He pays attention when he is playing with his video game, but not when we ask him to do his chores.’ Rima thinks that Akshay’s failure to comply is due to a lack of motivation – if he wanted to do it, he could. But Rima isn’t so sure. She’s been consistent with discipline. Rima also knows that Akshay feels bad about himself when he doesn’t succeed at school or when she constantly fusses at him at home. She knows that he has begun to compare himself to his peers. He seems frustrated with his inability to accomplish simple things that seem effortless for his friends. She has heard him refer to himself as “dumb.” She can’t understand why Akshay doesn’t comply with the instructions he receives from adults, but she doesn’t think it’s a lack of motivation. She knows in her heart that he would comply if he could. Rima has recently attended a talk by the school counselor on Executive Functions of ADHD. Equipped with this information she tries to understand what actually must be Akshay’s mental process.
Executive functions are mental processes that give organization and order to our behavior, allowing us to direct our actions through time toward a goal. Let us take Rima’s working of a single evening as an example of executive function. The previous evening, Rima left office for the weekend. She was tired and would have loved to go straight home especially with the heavy down pour since late afternoon. But she recalls that she needs to fill in some grocery first for dinner (working memory) and heads for the super market. She decides to pick up the lap top adaptor on the way to the grocery store (strategic thinking) so that she can work over the weekend and does not have to make another round this side of the town for the adaptor. She thinks of how comfortable her Sunday morning will be if she could in between the cooking do her work and then relax the entire day (internalized language). She begins to feel more energized as she weaves herself through the evening traffic (regulating motivation). As she reaches the grocery shop after picking up the adaptor, she makes a list of things that she would require to buy for the dinner (initialization action). Just as she gets her pen out, her cell phone rings, she checks the display and sees it is a friend who was returning her call. She makes a mental note of calling her later after dinner (strategic thinking) and chooses not to respond to the call right now (interference control). While entering the grocery store she sees that there are some attractive schemes on the 15 litre oil cans but decides to check on it the next week (interference control) as she is running late (a sense of time). As she heads for the vegetable section, she takes a quick look at her wrist watch. She has time to stock in the fruits and makes a bee line for section (self-monitoring). She decides to check on Akshay as she waits in the billing queue (shifting between tasks) so that his work is done by the time she reaches home. In the night before retiring in front of the television, Rima remembers to make the call to her friend (working memory) and calls her.
Rima’s executive functions work smoothly and efficiently. Because this functioning occurs without her conscious awareness, she takes it for granted. But the development of these functions took place over time. Imagine Rima at the age of 10, would she be able to do all this planning simultaneously? She would probably be able to only concentrate on her chore of buying chocolate at the super market. It was a gradual process for her actions and sense of time to become internally directed. Researchers believe that this capacity for self-direction is neurologically based and concentrated in the pre-frontal region of the brain. Rima learns that current research regarding ADHD is moving away from an emphasis on impulsivity and inattentiveness and toward an emphasis on executive functions. Many experts in the field recommend that individuals with ADHD compensate by using tools that “externalize” the executive functions. is a natural form of integrating these skills and Play therapists are specially trained counselors who use play appropriately to help children regulate their behaviour. The school counselor suggested Play therapy for Akshay. In many children’s games –Froggie May I, Statues, Simon Says, Freeze, mountain and river, saakli–while fun, also provide an engaging external framework for children to practice behaviors that are central to executive functioning. The therapist lets both Akshay and Rima know that a large part of each session will be devoted to play, and that she will even give some home assignments that involve play. Rima relates the history of Akshay’s diagnosis and treatment over the past three years her own attempts to firm up discipline and provide extra structure and support in Akshay’s day to day life. Both Rima and Akshay are tearful as they describe their frustrations and guilt and an overwhelming sense that they are not good enough. The therapist comments that they might want to add to their treatment plan is for Akshay to become a working member of the “treatment team.” The following weekend Akshay has an assignment from his therapist. Chores are a sore point in their household. Rima has always been frustrated that she has to remind Akshay each and every step of the way. Akshay’s assignment is to use the time honored habit of making a list to supplement his working memory and free him from dependence on his mother’s reminders. To engage Akshay’s interest and sense of fun, the therapist has given this tool a playful spin. An hour later, chores done, Rima and Akshay are on their way to the swim. “That was fun,” Akshay says to his mother. “And I got all my chores done by myself! Let’s do that again next week.” Rima reflects that it doesn’t matter whether Akshay relies on his working memory or uses a list. The results are what she cares about. She is pleased that the chores got done but is even more pleased to see that Akshay himself is so pleased. She was right; Akshay is motivated to succeed. But she had been expecting him to succeed in ways that were not in line with his development. She has now seen that, with the right external support, Akshay can experience the success that he so much wants for himself.
As the new academic year sets in, it waits to be explored by your child. There are new goals to be achieved, new knowledge to be gained and new challenges to be faced.
One thing is certain. All children look for everything new… new books, new bags, new stationary etc. But does your child look forward to the new class which will bring a change in the classroom scenery? He/She will probably have new classmates, new teachers, new subjects etc.
Preparing your child for the new academic year is much more than equipping him/her with material requirements. If a child is not academically, socially and emotionally prepared, the disconcerting feeling may just last the whole year through.
Children often visualise about the year ahead based on the senior student’s experiences, which may be misleading and make your child anxious.
Some things to bear in mind when helping your child prepare for the fresh year…
• A higher class brings new challenges. Perhaps your child will be expected to do more homework or assignments. With fears of not measuring up academically, the best defence is a good offence. Getting organised and establishing reassuring routines can go a long way to making a child feel competent.
• Rumours of a particularly hard teacher may fuel fearing or disliking a new teacher. Do help your child keep in mind that one person’s dreaded teacher can also be another kid’s favourite. While it’s okay for your child to express his/her dislike of a teacher, he/she should be expected to remain respectful. You can encourage your child to be open-minded and approach this as an opportunity to help him/her learn how to deal with a person he/she finds difficult. Listen to his/her issues and plan to attend parent-teacher meetings to get your own take on the situation.
• A new class schedule can mean adjusting without friends, who have provided a social base in previous years. Try to present this as an opportunity for your child to widen his group of friends, rather than a tragic loss of familiar faces.
• If possible, get the class list and set up a play date before school starts, so that your child will have a new friend to look for on the first day. Establish time for him/her to catch up with old friends too.
• A new school or classroom may spark concerns about finding friends at all. An outside class or hobby such as dance or a sport can provide a conversation starter and the opportunity to meet kids outside your child’s usual circles. Talking to him/her about other challenging situations that he/she successfully navigated also boosts self-esteem.
Before Vishal came in for Play therapy sessions, Vishal, a 11 year old, often lied to his parents about school work and stole money. Hi s parents were unable to understand why he did so despite the fact that there were liberal and would never pressurizing him for school work. They tried to correct his behavior by first talking to him, then threatening him with dire consequences and occasionally using the rod, but to no avail. Vishal had, over the months got grumpier and was now not only avoiding school but he even refused to play with friends. The cousellor at school too was unable to bring about any improvements in his behavior, when he was finally referred for play therapy.
Within a few sessions of play therapy, there was marked shift in his demeanor as his willingness to do school work improved and was back to his normal playful self. Infact as Play Therapy continued there was a significant improvement in his academic performance.
How did Play Therapy help him to achieve this? How does Play Therapy Work?
Play Therapy helps to unmask the unconscious motives & feelings which are the primary drivers of the majority of our maladaptive behaviors. These behaviors (which have their roots in the unconscious motives) resist any change brought about by our conscious decisions and bringing them into awareness is the only way to bring about sustainable change.
For example, Vishal’s tendency to lie is his unconscious need to get attention from his parents. Although, consciously he understands that his parents love him and provide him the best, unconsciously he detests the little time he gets to spend with them. His conscious reasoning fights this hurt and anger and it is pushed down into the unconscious. These emotions, although not available to his conscious mind, continue to operate and determine his behaviour.
During play therapy, a child enacts these unconscious conflicts and the therapist helps the child understand them. In Vishal’s case it provided him with the freedom to communicate this need for attention verbally in a healthier manner than his current negative attention seeking ‘acting out’.
Play is one of the primary activities of childhood. Although adults brush it off as a ‘time pass’ activity, it is a very meaningful activity for the child. It is through play that the child learns to explore, understand and develop an array of skills to deal with the social, emotional and physical challenges that are constantly thrown his way in his initial learning years. Play therapy utilizes play, children’s natural medium of expression, to help them express their feelings more easily through toys instead of words. Play therapy is to children what counseling is to adults.Whereas most adults may find relief in talking over problems, children often have difficulty in expressing thoughts and feelings in words, and play can serve as a medium for them to express themselves.
It is common for children to experience occasional problems as they grow and mature. They experience conflicts at home over such issues as toilet training, bedtime and homework. They encounter problems with parents and peers as they attempt to establish a personal identity and practice relating to others. They experience conflict with teachers as academic and behavioral demands increase. As a child is faced with new situations, demands and expectations, it is common for the child to experience emotional ups and downs characterized by feelings of sadness, fear and anger. These reactions tend to be short-lived, however, and usually do not significantly interfere with the child’s life. However, occasionally a child’s response to life’s pressures may become severe, and the parents’ attempts to help their child may be unsuccessful. At times such as these, professional assistance may be warranted.
Psychological treatment may be warranted when a child’s difficulties interfere with normal family functioning, even though the child is not upset by this circumstance. Children may also benefit from psychological treatment when the problems they face are complicated and beyond the range of normal daily experience. For example, children who suffer from serious or life-threatening medical problems, the death of a loved one, an accident, children whose parents are undergoing divorce or families who are shifting to a new city. The psychologist focuses on helping these children develop coping skills to deal with their unique situation and advises parents regarding how best to support their child.
The least common but most serious indication that psychological treatment is needed is when a child’s symptoms are severe or the behavior is extreme and potentially life threatening. This would include situations in which a child is experiencing false auditory or visual sensations, setting fires, assaulting others, or is severely depressed and making remarks about committing suicide.
Parents react in varied ways when faced with the idea that their child needs psychological treatment. Some parents tend to feel guilty and blame themselves for their child’s problem. Other concerned parents may experience confusion or uncertainty regarding their child’s need for treatment. A teacher, for instance, may describe the child as evidencing emotional or behavior problems in the classroom, while the child appears to behave normally at home. Parents who receive this type of feedback often have difficulty reconciling their own perception of their child with those of the teacher.
Most parents can and should attempt to help their child cope with problems before consulting a psychologist. However, as with all areas of life, there are some situations where outside help is warranted. The average parent is not reluctant to consult a physician for their child’s medical needs. In fact, parents who do not obtain appropriate medical care for their children are considered negligent. I believe the informed parent also recognizes when their child may need or benefit from psychological treatment and understands that such intervention is not in any way a sign of parental failure.
Children’s reactions to stressful life circumstances range from mild and short-lived to severe and long lasting. When a child’s problems do not resolve within a reasonable time-frame psychological intervention is recommended. Therapy offers children the opportunity to identify, discuss and understand problems and to develop necessary coping skills. Therapy also provides the opportunity to address parental concerns, educate parents regarding their child’s unique needs, and assist them in meeting these needs in an appropriate, effective fashion. Finally, it is important to recognize that without appropriate and timely treatment a child’s problems may become severe and lead to more serious, long-lasting difficulties.