Theraplay

• A 2011 study evaluating its effectiveness in treating shy, socially withdrawn children found that children improved significantly on assertiveness, self-confidence, and trust
• Tact's "in-house" therapy service means adopters do not have to go to the local authority for assessment and referral

ACTION

Four years ago The Adolescent and Children's Trust (Tact) established a play-based therapy service called Power of Play. The "in-house" therapy service means adopters do not have to go to the local authority for assessment and referral to limited resource, nor wait for child and adolescent mental health services.

Julie McCann, who runs the service, says a relationship is established with all Tact adopters from the beginning of their preparation course and following them through approval, matching and early placement.

"In this way, I normalise therapeutic support and encourage our adopters to use therapeutic play skills from the beginning, hopefully avoiding too many crisis moments," she says.

Play is used as a means of observing the dynamic between adopters and their children with initial support tailing off in the first six months of placement. Where issues are identified, McCann embarks on a series of sessions, using play to analyse and address issues.

"What we try to do with therapy is enhance attachment between the parent and child," she says. "I will do an assessment of what is already happening to get a sense of where the strengths and challenges are in the relationship. In that sense it is relationship therapy."

Theraplay is based on four different determinations of the relationship:

• Structure - how they structure their time together
• Engagement - what the quality of the engagement is
• Nurture - who is nurturing who in the relationship. Is the child able to receive nurture? Can they be soothed and looked after?
• Challenge - some families set the bar really high, and the child is always way behind and trying to catch up. Some are over-challenged and don't let other people help them with lowering that bar sometimes. Some children don't give themselves any challenge and are hesitant and shy to try anything new.

"I look at those elements and structure sessions with those families to look at ways that might be strengthened," McCann says. "The child has come from their birth family and they [and the adoptive parents] don't know one another. The child brings with them previous templates of what a parent is, and, quite often, it is not a healthy template. Part of the work is to help them become a family by putting in a lot of early stuff."

The sessions are entirely based on games and activities such as singing and dancing.

The Theraplay therapist guides the parent and child through playful, fun games, developmentally challenging activities, and tender, nurturing activities. The very act of engaging each other in this way helps the parent regulate the child's behaviour and communicate love, joy, and safety to the child. It helps the child feel secure, cared for, connected and worthy.

McCann monitors the sessions and identifies behaviour and signals that can be acted on to improve the relationship.

"It can be the case that a child doesn't go to their parent to be soothed, they don't expect to be picked up, they may be reliant on themselves, or it could be a child who can't separate from parents - even to the extent of the parent walking into the kitchen," McCann says.

"Some children seek out other adults - they are very indiscriminate with their attachments. Parents will sometimes say they don't feel anything - they can look after the child but don't feel any emotion underneath."

Gradually, over the weeks the parents begin to take more of the lead themselves, McCann says.

"I video the sessions and look at them with the parents - reviewing them. We look at the cues that children are giving that they may not recognise - children subtly looking away, for example.

"We often look at the video with the sound off to see what is happening in their bodies."

The norm is for around 12 to 15 sessions with each family, which usually take place on a weekly or fortnightly basis.

IMPACT

As an intervention originally developed in the US, Theraplay comes with a degree of evidence behind it.

A 2011 study evaluating the effectiveness of Theraplay in treating shy, socially withdrawn children found that children improved significantly on assertiveness, self-confidence, and trust, while social withdrawal was also reduced and expressive and receptive communication improved. Improvements were maintained over a two-year period with no cases of relapse.

Tact has done its own survey of adopters and social workers, but has not commissioned a formal evaluation.

"It is difficult to evidence, because we don't have a control group, but families have said that if they hadn't done therapy the family would not have stayed together," McCann says.

"They had two children, and bonded with one, but didn't with the other. I worked with them for a year - they have just had the adoption papers through. They said that if it hadn't been for Theraplay, they wouldn't be a family of four."