Faculty of

Nursing and Midwifery

Bachelor of Science
(Honours) Nursing- Post Registration

Academic Writing NBNS 2514

Student Name: Sia Ching Hung

Student Matrix Number: BNP 18046418
Course Title: Care of Sick Child
Course Code: NBNS 2514
Subject Leader: Dr. Umapathi Mariappan
Word Count: 2800 words
Date of Submission: 2 December 2019

I am a registered nurse with 5 years working experience and graduated with diploma in

nursing. I have been posted to intensive care unit in government hospital in my state.
Following my years of working experience in the area, therefore I decided to go deeper into

my profession. Currently I am attached to 17 bedded with 5 isolation room department.

In this academic writing, I am going to talk about reflect on assessment of a child between the

ages of two and twelve years old at practice area and critically analyse the role of play

therapy in enhancing child development and behavior modification with the integration of

concepts, theories, model related to play therapy for a chosen child.

Play has been defined as any activity freely chosen, intrinsically motivated, and personally

directed. It has no particular goal other than itself. Play is not a specific behaviour, but any

activity undertaken with a playful frame of mind (Jeffrey Goldstein 2012) . Psychiatrist Stuart

Brown writes that play is ‘the basis of all art, games, books, sports, movies, fashion, fun, and

wonder – in short, the basis of what we think of as civilization.’ (Brown 2009)

As the noted play theorist Brian Sutton-Smith remarked, the opposite of play is not work, but

depression. All the of play, from fantasy to rough and tumble, have a crucial role in

children’s development. Play is the lens through which children experience their world, and

the world of others. If deprived of play, children will suffer both in the present and in the long

term. With supportive adults, adequate play space, and an assortment of play materials,

children stand the best chance of becoming healthy, happy, productive members of society

(T.Manichander 2016).

Play therapy is a structured, theoretically based approach to therapy that builds on the normal

communicative and learning processes of children (Carmichael, 2006). The curative powers

inherent in play are used in many ways. Therapists strategically utilize play therapy to help

children express what is troubling them when they do not have the verbal language to express

their thoughts and feelings (Gil, 1991). In play therapy, toys are like the child's words and

play is the child's language (Landreth, 2002). Through play, therapists may help children

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learn more adaptive behaviours when there are emotional or social skills deficits (Pedro-

Carroll & Reddy, 2005). The positive relationship that develops between therapist and child

during play therapy sessions can provide a corrective emotional experience necessary for

healing (Moustakas, 1997). Play therapy may also be used to promote cognitive development

and provide insight about and resolution of inner conflicts or dysfunctional thinking in the

child (O'Connor & Schaefer, 1983; Reddy, Files-Hall, & Schaefer, 2005).

In my case, Warron was a 5 year old Malay child who was referred by his parents. Warron

came from an intact family with middle socioeconomic status. His mother had graduated and

worked as an employer, his father was a accountant at an company. They came from intact

families and did not report any specific traumatic events in their life. On present referral,

Warron was referred by his parents for speech difficulties, oppositional behavior and sleep

problems. During that occasion, only parenting support and advice were offered to help the

parents better understand and manage Warron’s difficulties.

First, I was met Warron’s parents without the child, to assess how they perceived his son and

their functioning toward the child, and the therapist adjourned the child’s anamnestic history.

Warron’s parents were particularly worried about their little son. Regarding Warron’s

language impairment, the parents reported Warron decrease in verbal ability such as

stuttering, changing letters in words and difficulties with naming objects along with a general

regression to baby talk. Warron oppositional behavior had also relapsed, as he often seemed

upset and had tantrums. In these situations, Warron’s parents felt that they were unable to

calm down and relax Warron, and they felt distressed, powerless, and inadequate. Moreover,

they reported a regression in several of Warron’s competencies, concerning feeding as he

wanted his mother to feed him, social inhibition Warron looked more isolated and less

interested in his peers than before and aspects of separation anxiety. He needed his parents to

play with and stay next to him most of the time. A psychodynamic assessment was done

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using Anna Freud’s developmental lines. In particular, difficulties and regressions were

found in many developmental lines at the beginning of the therapy. Following “from

dependency to emotional self-reliance and adult object relationships,” he showed a regression

to a more dependent phase of life and was unable to stay alone even for few minutes to play

or draw, and always asked for his mother’s presence. At the preschool, he asked for the

teacher’s company and showed more difficulties in behaving and playing with other children.

He had previously developed the ability to eat using a spoon and a fork, but at the moment of

the assessment, he seemed unable to eat alone and was always asking for maternal care and

help. At the same time, at the age of three, he had begun to wash his face, prefer and choose

her clothes and try to dress alone, but at the moment of assessment, his regressive behavior

showed he was unable to do anything in autonomy. Most children this age begin to develop

greater independence, self-control, and creativity. They are content to play with their toys for

longer periods of time, are eager to try new things, and when they get frustrated, are better

able to express their emotions. Most children at this age enjoy singing, rhyming, and making

up words. They are energetic, silly, and, at times, rowdy and obnoxious (WebMD 2016).

I observed that the parents were only able to report negative descriptions when talking about

their little girl. There was no pleasure or positive affection to share about their son. To the

therapist, they appeared quite anxious and rigid about the adequacy of Warron’s behaviors

and requests, and to not always be able to understand or support he developmental needs or

understand their child in connection with his real age and developmental stage. They tended

to consider their son as a “little adult” whose behaviors were too “childish.” Typically, their

interactions with him were about normative conduct: “You are a grown-up boy. Help

yourself. Behave yourself. Keep sitting in a good manner.” The interactions surrounding the

play were like, “You are playing too much; now, try to draw something nice for your mom.”

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During the assessment phase, Warron showed the impairment her parents had declared,

highlighting a state of emotional distress and a sense of emptiness and loneliness. He looked

sad, showed poor facial expressions, showed no interest in exploring the room or in playing

with toys and did not talk to the therapist. However, he was able to stay alone and was eager

to stay with the therapist and to follow her suggestions for interaction. According to the

therapist, he showed a disposition to “use” the therapeutic space and the therapeutic

relationship for his developmental issues, and to use the therapist as a “real relational object”

to identify and interact with. He absolutely needed his own space to find a new model of

relationship in which to express his developmental needs and emotions, without rigid

requests of adjustment to be a well-behaved “grown-up boy.”

I thought about what would be the best way to help this family, especially Warron, and

decided to offer a parallel path: to continue working with parents and, at the same time, to

offer personal individual treatment to Warron. The latter was motivated by his

psychodynamic assessment, which highlighted both Warron’s indication for psychological

support and quite a stable sense of self to gain better adjustment throughout individual

psychoanalytic “developmental help,” as suggested in psychoanalytic training schools for

children aged 3 to 5 years old. This double therapeutic intervention was accepted by the

parents, and they started to have regular meetings twice a month and to support a weekly

individual treatment with their child.

The aim of working with Warron’s parents was to help his parents to support their parenting

function during Warron’s therapy. I worked hard to create and improve on his strong working

alliance with his parents, never making them feel inadequate while at the same time

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increasing their parenthood abilities to give meaning to Warron’s behaviors and to keep him

needs in mind, to help Warron reach better adjustment and wellbeing. The therapeutic goals

for his focused on behavioural regulation, decreasing inhibition and separation anxiety

symptoms as well as modulating her oppositional behaviour and increasing her emotional

expression. The therapy was also aimed at helping he to acquire relational skills and interest

in others to allow he to face new situations more adequately. As in every psychodynamically

oriented psychotherapy, the therapeutic relationship played a basic role in the therapy

process, play and dialog were used to support the quality of the therapeutic relationships and

motivation as well as to reach the therapy goals.

Model of play therapy that I had chosen for Warron was child-centered play therapy (CCPT).

This is a form of therapy that involves children engaging in enjoyable activities of their

choice, which symbolically and metaphorically allows them to address their emotional and

behavioural distress (Guerney, 2001). This therapy draws on Axline’s (1969) early work and

is based on the Rogerian principles of unconditional positive regard, empathy, congruence,

and self actualization (Rogers, 1976). When applied by the astute therapist, these principles

provide a climate that enables the child’s innate drive toward optimal functioning to unfold

(Wilson & Ryan, 2005). Overall, the therapy process is aimed to improve self-concept and

support children to realign themselves, psychologically and behaviorally (Guerney,2001).

CCPT has proven an effective intervention for children across a broad spectrum of social,

emotional, and behavioral challenges. To date, studies have demonstrated that CCPT

interventions result in desirable social behaviors increasing conjointly with improved self-

concept and emotional regulation (Cochran et al., 2010). Moreover, CCPT has been found to

support children with behavioural concerns, including reductions in aggressive occurrences

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(Schumann, 2010), attention problems (Bratton et al., 2013), and undesirable social behaviors

(Cochran et al., 2010).

The child was invited to play with a set of plastic and stuffed toys, including animals e.g.

bear, shark and objects e.g.car, small cups, a “hairy” rubber ball intended to elicit a range of

emotional expressions such as aggression e.g., a shark . With regard to cognitive scores,

organization assesses the quality, complexity, and coherence of the play narrative, with

scores ranging from unrelated events, no cause and effect, to integrated plot with a beginning,

a middle part and a conclusion. Elaboration refers to the variety and complexity of elements

used in the story themes, such as facial expressions, sound effects and characters’

development, from very few details and simple themes with no embellishment, too much

embellishment across many dimensions such as details, sound and voice effects and facial

expressions. Imagination assesses fantasy and the number of transformations e.g., using one

thing as another in the play, ranging from no symbolism, no fantasy, to many transformations

and fantasy themes. Comfort measures the child’s ability to get involved in the play task and

his or her enjoyment of the play, ranging from reticent, distressed, to very involved and

enjoying the play. The expression of affects was coded as regarding the Frequency of Affect

Expression, which was used during the play session. Affect is scored when an affect theme is

expressed in the play. Affect scores can be positive e.g., nurturance/affection or negative e.g.,

aggression, and they can be summed to form the total affect.

The treatment lasted for 3 months and consisted of 12 once-a-week sessions, which were

audio-recorded and fully transcribed with the parents’ informed consent. Each play therapy

session varies in length but usually last about 30 to 50 minutes. In the present work, 12

sessions were scored and analysed: 4 from the first phase (T1), 4 from the central phase (T2),

and 4 from the last phase (T3) of therapy. During the assessment and outcome phases, the

Affect in Play Scale—Preschool version (APS-P; Russ, 2004) was administered to Warron at

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the beginning of, about halfway through and at the very end of the therapy, respectively, to

assess his cognitive and emotional expression and to observe his level of pretend play.

Warron’s Affect in Play Scale affect scores were assessed by comparing his results with

normative scores of the Italian sample (children between 4 and 5 years; Mazzeschi et al.,

2016). His assessment scores were very low – within the first quartile (between the 10th and

20th percentiles). However, Sarah’s scores increased after therapy, reflecting relevant

improvements in her emotional understanding and expression.

In order to analyze Warron’s activities during therapy sessions, three categories were

separately counted in terms of “time” dedicated to: (a) play, in terms of Warron’s verbal and

non-verbal expression during play with toys, using an adaptation of APS-P; (b) dialog, or

Warron’s speech during activities that were different from play; and (c) drawing/other

activities, such as book reading and storytelling. Play, dialog and drawing/other activities

were measured as percentages regarding the three considered therapeutic periods (T1, T2, and

T3). More specifically, drawing/other activities and dialog progressively became more

frequent during sessions with Warron, whereas play decreased .

At the end of the therapy, another developmental evaluation was done using Anna Freud’s

developmental lines. Warron reached normal development in all of the developmental

dimensions that were compromised at the beginning of the therapy. The present work

analysed a good treatment outcome in a 5 year old child, in terms of symbolic play changes.

At the beginning of therapy, Warron was not comfortable with play thus, during T1, the

therapist aimed to make Warron feel more comfortable with playing in the therapy room.

With children who are not able to play, the therapist’s goal is to help them use play as a

means of self-expression and as a way of create meaning in the presence of another (Yanof,

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2013). T2 represented an important phase in Warron treatment. This is probably due to his

acquisition of higher comfort in therapy. Due to the therapy, Warron’s play progressively

improved from exploratory to symbolic play. Moreover, Warron’s affect expression

increased, particularly negative emotions, which did not disappear but strongly decreased in

the middle and then re-increased at the very end of the therapy.

Warron learned to explore and affirm the expression of his negative affect in the therapeutic

setting, increasing the “bad feelings” in the middle of the clinical work. Then, he learned to

manage and cope with such emotional expressions: the quantity decreased, but more

importantly, the quality of the negative affect became more “workable,” and he was more

prone to explore and elaborate upon these feelings in his play. Progressively, Warron

expressed aggressive affects through fantasy and cognitive elaboration, which allowed an

adequate expression of aggressive emotions in much more of a holding setting like the

therapeutic one that, in contrast with his parents, recognized his developmental gains. This

was confirmed by Warron’s assessment and outcome results on the APS-P scores: the

percentiles showed that his’s results were not in the normative range for his age at the

assessment phase, but at the end of the treatment, the percentiles showed that Warron had

reached the range of normal development in symbolic play. This positive psychotherapy

outcome was also confirmed in the analysis of Anna Freud’s developmental line at the end of

the therapy: Warron was less disharmonic that was in line with the developmental stage he

was in.

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