Creative Ways to Help Children Manage Anxiety by Fiona Zandt and Suzanne Barrett is packed with therapeutic activities to help children aged 4-12 years and their families to better understand and manage anxiety using CBT, ACT and narrative therapy approaches.
Read below an extract from the book to learn more about how to get the most out of an assessment with a child by using games and play.
Amy was an 11-year-old with anxiety and an intellectual disability. She was referred for therapy
in the context of increasingly unsettled behavior which began around the time that one of her
fathers became depressed. Amy’s family drawing depicted everyone looking happy and she
denied any worries or concerns. When playing with some family dolls, however, Amy enacted
a story in which one of the parents was sick and was administered magic medicine by some
supportive grandparents. Her spontaneous play conveyed more of her internal world than her
conversation ever could and gave the therapist some insight into what she was experiencing.
The assessment phase is one in which the importance of building rapport cannot be
overemphasized and finding the balance between connecting and assessing is essential.
Having playful assessment activities that are engaging for children yet also provide us
with essential assessment information is therefore crucial. Communicating through play
is natural for children and having something to do often helps them to feel less anxious.
Drawing and play activities may have a clinical focus, eliciting information about
feelings and thoughts; however, non-directed play is also useful. Themes often emerge in
a child’s spontaneous play. Further, children are often more comfortable talking while they
are playing and drawing. For example, research shows that children who are engaged in
drawing are more likely to provide clinically relevant information, even if the drawing is
not related to the topic being discussed (see Macleod, Gross and Hayne 2013; Woolford
et al. 2015).
In the assessment process we need to tune into both what a child tells us (the content)
as well as what we observe. A child’s free play is often very informative. It is useful to
notice any themes that emerge in the play as well as the feelings the child is conveying. It
is important not to overinterpret the play, and to watch for themes over time, interpreting
these in the context of what you know about the child. Children who are anxious will
sometimes play out themes around risk or danger, which can be useful to notice in the
assessment phase and to monitor for changes as therapy progresses.
In addition to watching for themes it is important to notice how children play. Children
who are anxious may be cautious and hesitant in their exploration of toys in the clinic
room, waiting for permission to be allowed to play and constantly checking in with the
therapist or their parents. They may be hesitant to initiate interaction and may retreat
if the therapist expresses an interest in their play. Alternatively, anxious children can
be overactive and impulsive, unable to sit still and moving about the room in a chaotic
manner. Noticing how the child’s play changes over time as they become more comfortable
in the therapy room is useful, as is observing how their play changes in response to what
is happening in the room. For example, a child may become frenetically engaged in active
play as soon as his parents begin to talk about their concerns.
Noticing how the child relates to you in play is also important. Some children will
want you to be engaged, whereas others will prefer to play alone. Some may be directive
of you in play, whereas others will seek your input and engage in a cooperative manner.
How a child plays with you may give you an insight into the way in which they relate to
others. It may also give you an insight into their internal world. For example, a child who
consistently takes toys from you and excludes you from the play may feel excluded by
their peers at school. A child who is particularly controlling of the play may be doing so
in an attempt to manage their anxiety.
In terms of directed play and drawing, there are many different ways of encouraging
conversation about worries. The following box contains some ideas for directed drawing
around anxiety. Puppet play where you enact a worried character is also useful for
understanding how the child understands and manages their anxiety. Animal and figurine
play can be used in a similar way.
Drawing ideas for assessing anxious children
Me when I’m worried.
My family when I’m worried.
My body when I’m worried.
My Mom/Dad/etc., when they’re worried.
Me when I’m not worried.
My worry as an animal.
My worry as a shape.
My worry as a color.
My worry as the weather.
The things that worry me.
“I just wanna play a game” is a refrain that you may hear in the therapy room. It can
be a good reminder that we have slipped into talking therapy and need to offer the
child something more developmentally appropriate and fun. There are a number of
commercially produced games that can be useful in this context. Alternatively, you might
like to make a game with the child in the session. A simple idea is to make a feelings die (a
die with a picture of a feeling on each side) and take turns to roll it and talk about a time
when you felt that way. Board games are also fun to make, allowing you to personalize
the game to match the interests and needs of the child you are working with. In the
assessment phase, discussion of feelings might be encouraged by making a simple board
game with pictures of different feelings in the spaces, prompting players to remember a
time they felt that way, or to describe something that happens when they feel that way.
Alternatively, a board game could incorporate “pick-a-card” spaces, with questions about
feelings, thoughts and memories. The following box includes some other simple ideas of
playful assessment activities.
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