Play Therapy and Cognitive Development in Children

Introduction
This essay will discuss how play therapy improves the cognitive and social functions of young children. A brief review of child development theories and how these underpin play therapy will be done. A critical analysis of published literature on play therapy and its impact on child development will then be presented. Finally, a conclusion summarising the key points raised in this essay will be presented.

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Child Development Theories and Play Therapy
Piaget’s theory proposes that cognitive development of children occurs in four stages: sensorimotor, preoperational, concrete operational and formal operational stages (Nevid, 2008). Piaget observes that very young children engage in general patterns of behaviour once they are at play. These include being fascinated with objects, covering objects, filling or emptying containers, transporting objects and connecting them together. Crowley (2014) explains that these behaviours are known as schemas. As children assimilate new experiences and accommodate learning, these schemas will help them to make sense of the world around them (Crowley, 2014). Hence, allowing children to play and explore will help them develop a schema of their environment (Keenan and Evans, 2009). Piaget’s theory helps to underpin play therapy since it acknowledges that play will help children to construct knowledge and develop cognitive abilities. For instance, in the sensorimotor stage, providing children with a treasure basket will expose very young children to a wealth of sensory stimuli (Shaffer and Kipp, 2009). In turn, this will promote cognitive development as children become acquainted with different sounds, shape, colour, taste and texture of toys. Children, according to Piaget, develop through assimilation or through using an existing schema to make sense of a new situation or object (Shaffer and Kipp, 209). This is then followed by accommodation when existing schema has to be changed in order to deal with a new situation. As children continue to develop, new information is quickly assimilated based on existing schema. Piaget explained that equilibrium is reached when children learn to deal with new information through assimilation. Meanwhile, Vygotsky’s theory proposes that social interaction is crucial in the cognitive development of children (Shaffer and Kipp, 2009). He suggests that social, linguistic and interpersonal factors all play a role in the mental development of children. In this theory, social interaction during play is critical in developing cognitive learning. It has been shown that during play, social skills are developed along with skills on problem solving (Keenan and Evans, 2009).
Critical Review of Play Therapy
Play has long been recognised as crucial in the healthy development of children (Ray, 2011). However, it was only in the 1900s when therapeutic settings began using play as a means for young children to express their emotions and feelings. Early proponents of play therapy include Melanie Klein and Anna Freud (Ray, 2011). They used play to help analyse childrens’ behaviour, feelings and responses to events or situations. Both early scholars used play to help children communicate non-verbally. Today, child-centred play therapy is widely accepted as a means of helping children resolve or prevent psychological and social difficulties and in helping them to achieve optimal development (Keenan and Evans, 2009). A meta-analysis (Bratton et al., 2005) on the efficacy of play therapy reviewed and pooled data from 94 studies that investigated play therapy outcomes. Forty-two of these studies were published in peer-reviewed journals while 50 were unpublished dissertations. Two of the articles were from the Education Resources Information Center (ERIC) database. Studies included in the meta-analysis utilised the comparison or control-group design or pre and post-treatment measures. Treatment effect was calculated after pooling data from these studies.
Findings of the study reveal that the effect of play therapy on different treatment outcomes ranges from 0.66 to 0.84. According to Cohen’s guideline for interpretation of treatment effect, a value of 0.80 suggests a large treatment effect (Ellis, 2010). This suggests that play therapy is effective in managing behavioural and emotional difficulties in children. Although duration of treatment varies, findings suggest that 35-40 sessions of play therapy significantly improved treatment outcomes. Findings also appear to suggest that positive outcomes declined with prolonged sessions. For instance, findings suggest that positive outcomes declined after multiple sessions (40 sessions). This suggests that findings should be taken with caution in determining whether long-term play therapy is effective.  In contrast, children ending play therapy prematurely or engaging in less than 14 sessions of therapy did not show positive treatment outcomes compared to children who completed 35-40 play therapy sessions. Meanwhile, investigators of the study failed to mention the average number of hours for each session. This could have provided important information on how long each session should last.  Findings also show that gender and age were not significant predictors of the treatment outcomes, suggesting that this type of therapy is equally effective for boys and girls and across all ages of the children. Although the study shows equal effectiveness of play therapy for different age groups, this intervention might be more successful in younger children. Since play therapy is considered as sensitive to the development stage of the children (Nevid, 2008), it is reasonable to apply this form of therapy to younger children while older children might benefit more from traditional talk therapies (Bratton et al., 2005). The study also suggests that when parents are trained to partner with healthcare professionals in conducting play therapy, the treatment effect of play therapy significantly increased when compared to therapy conducted by professionals alone. Hence, when supervised by healthcare professionals and therapists, the involvement of parents would result in the greatest benefit.
A meta-analysis allows pooling of data from studies with small sample sizes and hence, insufficiently powered (Polit et al., 2013). It should be noted that small studies are often rejected for publication due to sample size or once published, have limited applicability due to insufficient treatment effect (Polit et al., 2013). Hence, a meta-analysis would be able to address this issue since findings are pooled (Ellis, 2010). A review of the study of Bratton et al. (2005) reveals that all resources for both published and unpublished studies were exhausted to avoid publication bias (Burns and Grove, 2013). Further, investigators only included studies that reported statistics and have sound methodological procedures. Further, the study was able to establish that play therapy could be an agent in changing children’s behaviour, help them adjust socially and adapt to a group in order to fit in. Likewise, play therapy also appears to be uniquely responsive to the children’s developmental needs. However, play therapy was compared only to no intervention, making it difficult to establish if play therapy is the most effective intervention for children’s behavioural, social and cognitive difficulties. Comparing play therapy with other form of interventions might help to provide more information on its effectiveness in improving the behaviour of children.
Apart from promoting positive treatment outcomes, play therapy also facilitates social competence and problem solving skills in preschool children (Stone and Stark, 2013; Chinekesh et al., 2014). Stone and Stark (2013) reveal that short-term therapy groups were shown to facilitate development amongst 3-5 year old preschool children. Findings are noteworthy since it has been suggested that very young children are not yet developmentally prepared to engage in a group process (Stone and Stark, 2013). However, findings of the study suggest that very young children are able to participate in structured play therapy. Further, they benefit from these structured plays as evidenced in improvements in their social skills. Meanwhile, Chinekesh et al. (2014) investigated the effects of play therapy on children’s emotional and rational skills. A total of 372 pre-school children were recruited in the study and randomly assigned to the group play therapy and control group. Pre and post-tests were done to compare the children’s self-regulation, self-awareness, empathy, social interaction and adaptability before and after the intervention. Findings between case and control groups were also compared. Results of the study suggest that play significantly improved the children’s social and emotional skills (p0.001). Further, Chinekesh et al. (2014) observe that play therapy could help improve the children’s ability to learn problem-solving skills and communicate with other children. Providing an environment where children are engaged in unstructured play would help them develop their social skills as they learn to interact with other children (Chinekesh et al., 2014).
Play therapy has also been shown to improve outcomes among children with disabilities. For instance, the studies of Abdollahian et al. (2013); Kasari et al. (2012); Wilkes-Gillan et al. (2014); Cantrill et al. (2015) have similar findings and suggest that play therapy is effective in improving social play skills of children with attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). For instance, Kasari et al. (2012) suggest that play therapy could help improve the language skills and communication of children with ASD. This was a longitudinal study and followed preschool children who received early play therapy intervention. During the 5-year follow-up, children who received play therapy were more likely to have better language skills. The strength of a longitudinal outcome is its ability to show patterns regarding how play therapy improves the social and cognitive skills of children over time (Ellis, 2010). However, panel attrition might affect the findings of a longitudinal study (Gray, 2009). Panel attrition could occur if several members of a cohort decide to drop out or are unable to participate during the last stages of the study. In addition, play therapy (Abdollahian et al., 2013) has been shown to be effective in reducing symptoms associated with ADHD. Abdollahian et al. (2013) emphasise that play therapy would be effective in managing symptoms associated with ADHD. Meanwhile, Cantrill et al. (2015) point out that children’s social play skills are further enhanced when parents are involved in the delivery of the therapy. A third study (Wilkes-Gillan et al., 2014) suggests that social play outcomes of children with ADHD significantly improved following play therapy. Although this study has a small sample size (n=5 children with ADHD), it was able to demonstrate preliminary efficacy.
In summary, recent literature has shown that play therapy consistently promotes positive outcomes for children with or without disabilities. Specifically, it promotes social and cognitive skills in very young children and could be used as a method to prepare these children for transition from kindergarten to infant school. The effectiveness of play therapy is also not influenced by gender and age, suggesting its effectiveness for both boys and girls and those in the younger or older age group. However, the impact of play therapy appears to be greatest amongst younger age children. This form of therapy could also be used to improve language skills in children suffering from autism (Kasari et al., 2012). Literature also demonstrates that the participation of parents significantly enhances the effectiveness of play therapy. This suggests that parents should be involved to facilitate sustained positive outcomes in children.
Conclusion
Play therapy could help to improve both social and cognitive functions of children with or without disabilities. Hence, there is a need to provide children with a safe environment that would allow them to play and interact with other children. While most studies reviewed in the present essay used play therapy as treatment for behavioural and social difficulties, play therapy could also be used for children without disabilities. Specifically, it can be used for preschoolers to help them develop their social and cognitive skills. As Vygotsky’s theory suggests, social development would help children develop mentally. Hence, promoting play therapy amongst young children with no disabilities would not only help to develop their social skills but also their cognitive skills. Finally, play therapy could also promote social and cognitive skills in children with disabilities such as ADHD and ASD. It is recommended that play therapy should be introduced into preschool settings for better outcomes for children. It is also recommended that parents should be involved in order to enhance the impact of play therapy. Hence, there is a need to train parents on how to deliver this type of therapy on their children.
References:
Abdollahian, E., Mohkber, N., Balaghi, A. & Moharrari, F. (2013) ‘The effectiveness of cognitive-behavioural play therapy on the symptoms of attention-deficit/hyperactivity disorder in children aged 7-9 years’, Attention Deficit and Hyperactivity Disorders, 5(1), pp. 41-46.
Bratton, S., Ray, D. & Rhine, T. (2005) ‘The efficacy of play therapy with children: A meta-analytic review of treatment outcomes’, Professional Psychology: Research and Practice, 36(4), pp. 376-390.
Burns, N. & Grove, S. (2013) The practice of Nursing Research: Conduct, critique and utilisation (7th ed.). St. Louis: Elsevier Saunders.
Cantrill, A., Wilkes-Gillan, S., Bundy, A., Cordier, R. & Wilson, N. (2015) ‘An eight-month follow-up of a pilot parent-delivered play-based intervention to improve the social play skills of children with attention deficit hyperactivity disorder and their playmates’, Australian Occupational Therapy Journal, 62(3), pp. 197-207.
Chinekesh, A., Kamalian, M., Elternasi, M., Chinekesh, S. & Alavi, M. (2014) ‘The effect of group play therapy on social-emotional skills in pre-school children’, Global Journal of Health Science, 6(2), pp. 163-167.
Crowley, K. (2014) Child development: a practical introduction. London: Sage Publications.
Ellis, P. (2010) Understanding research for nursing students. Exeter: Learning Matters.
Gray, D. (2009) Doing research in the real world. London: Sage.
Kasari, C., Gulsrud, A., Freeman, S., Paparella, T. & Helleman, G. (2012) ‘Longitudinal follow-up of children with autism receiving targeted interventions on joint attention and play’, Journal of the American Academy of Child and Adolescent Psychiatry, 51(5), pp. 487-495.
Keenan, T. & Evans, S. (2009) An introduction to child development. London: SAGE.
Nevid, J. (2008) Psychology: Concepts and applications. London: Cengage Learning.
Polit, D., Beck, C. & Hungler, B. (2013) Essentials of nursing research, methods, appraisal and utilization (8th ed.). Philadelphia: Lippincott Williams & Wilkins.
Ray, D. (2011) Advanced play therapy: Essential conditions, knowledge, and skills for child practice. London: Taylor and Francis.
Shaffer, D. & Kipp, K. (2009) Developmental psychology: Childhood and Adolescence. London: Cengage Learning.
Stone, S. & Stark, M. (2013) ‘Structured play therapy groups for preschoolers: Facilitating the emergency of social competence’, International Journal of Group Psychotherapy, 63(1), pp. 25-50.
Wilkes-Gillan, S., Bundy, A., Cordier, R. & Lincoln, M. (2014) ‘Eighteen-month follow-up of a play-based intervention to improve the social play skills of children with attention deficit hyperactivity disorder’, Australian Occupational Therapy, 6(15), pp. 299-307.