Lesley University

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Graduate School of Arts and Social Sciences

Expressive Therapies Capstone Theses (GSASS)

5-16-2020

Using Child-Centered Play Therapy as an Intervention to Reassess

ADHD Diagnoses and Trauma in Children: A Literature Review
Bethany Gibbons
[email protected]

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and Trauma in Children: A Literature Review" (2020). Expressive Therapies Capstone Theses. 358.
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Running Head: PLAY THERAPY AS DIAGNOSTIC REASSESSMENT 1

Using Child-Centered Play Therapy as an Intervention to Reassess ADHD Diagnoses and

Trauma in Children: A Literature Review

Capstone Thesis

Lesley University

May 5, 2020

Bethany Gibbons

Expressive Arts Therapy

Professor Kellogg
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Abstract

Although it is difficult to assess, attention deficit hyperactivity disorder (ADHD) is a

prevalent diagnosis that exists among children. A major factor that contributes to the complexity

of this disorder is the parallel symptoms presented in other diagnoses. Post-Traumatic Stress

Disorder (PTSD) in children has been identified as being either comorbid with ADHD, or

sharing similar symptoms, which can produce potential misdiagnosis and ultimately lead to

ineffective or impertinent treatment. To better determine a child’s diagnosis and plan of

treatment, an approach can be implemented to assist in distinguishing between the two disorders.

Child-centered play therapy (CCPT) may serve as a significant intervention to re-assess trauma

versus misdiagnosis of ADHD. CCPT has shown to be highly effective in treating traumatized

children, as well as minimizing their symptoms. Additionally, children diagnosed with ADHD,

who were previously exposed to trauma, showed a reduction in symptoms after receiving CCPT

for treatment. The purpose of this thesis is to review the relevant literature for ADHD and

trauma-exposed/PTSD diagnosed in children and explore CCPT as an effective intervention to

better re-assess a diagnosis. Although limited research includes CCPT as a diagnostic procedure,

CCPT has shown to reduce behavioral symptoms that result from trauma and that are often

confused as ADHD. More research would be needed to test and review outcomes.
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Using Child-Centered Play Therapy as an Intervention to Reassess ADHD Diagnoses and

Trauma in Children: A Literature Review

Introduction

Attention Deficit Hyperactivity Disorder (ADHD) has grown to be a prevalent diagnosis

among children, affecting 8-12% of children worldwide (Biederman & Faraone, 2005) and is one

of the most frequent diagnoses of childhood (Ray, Schottelkorb, & Tsai, 2007). The process of

developing and defining criteria for ADHD has evolved over the decades, dating back to the

1930’s, and while such changes have been helpful in describing and assigning diagnosis, it has

also complicated clinicians’ understanding of the diagnosis (Weinsten, Staffelbach, & Biaggio,

2000). ADHD has shown to have overlapping symptoms with other psychiatric disorders within

the DSM-V, creating confusion when differentiating diagnoses.

In particular, childhood trauma and PTSD are recognized for having overlapping

symptoms with ADHD, despite the two not being listed as differential diagnoses for one another

in DSM-V. Because of such coinciding symptoms, questions have been raised regarding

whether children are being properly diagnosed. While there is possibility that ADHD and PTSD

can be comorbid, it is essential to determine and differentiate proper diagnosis to ensure children

are receiving appropriate intervention and treatment. A major consequence of misdiagnosing

ADHD in children who may have PTSD or underlying trauma is that the trauma is left untreated,

and without receiving proper attention or consideration, symptoms continue and can even

become exacerbated (Weinstein et al., 2000).

Childhood trauma can severely damage and impact the brain, altering healthy human

development and precipitating emotional and behavioral difficulties. In this respect, a traumatic

event or experience could ultimately lead to a psychological disorder. Trauma occurring during
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early childhood impacts neural developmental structure, connectivity, and function, leading to

maladaptive emotional, behavioral, and cognitive responses (Ryan, Lane, & Powers, 2017).

Prolonged or repetitive exposure to traumatic events can lead to widespread psychological and

biological consequences (Szymanski, Sapanski, & Conway, 2011). Another consideration is that

a traumatized child may experience new problems resulting from the trauma as they transition

into a new developmental stage; for example, transitioning into adolescence can reawaken old

conflicts regarding compromised autonomy (Terr, 1989).

When treating traumatized children, it is necessary to understand them from a

developmental perspective. Because children have difficulty putting words to their thoughts and

emotions, incorporating interactive methods like play therapy translates as a language that they

understand and use to communicate (Hall, 2019). Through play, a child feels more in control of

their world, whereas outside of play they are told what to do. Child-centered play therapy

(CCPT) functions off of that very principle, in which the child leads therapeutic sessions and has

full control of what they choose to do while the therapist follows. CCPT thrives off the belief in

a child’s ability to self-direct, and in cases of trauma, it allows the child to process their

experience, as well as obtain a sense of control over the event (Hall, 2019).

Treating traumatized children with CCPT allows them to transition from confronting

their pain to changing their perspective on their trauma to developing a sense of empowerment,

security, and well-being (Ogawa, 2014). Ultimately, this leads to an improved level of

functioning and a lessening of adverse emotional and behavioral symptoms. Considering the

effectiveness of CCPT to reduce unaddressed trauma or PTSD symptoms in traumatized

children, this could act as a potential intervention to re-assess misdiagnosis of ADHD in

children, or children who have been diagnosed comorbidly with PTSD.

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Before examining the possibility of CCPT as an effective intervention for re-assessing

childhood trauma and PTSD vs. ADHD, this thesis will begin by providing thorough information

and background of each diagnosis, including overlapping symptoms and the controversy and

challenges involved with assessing and diagnosing childhood trauma/PTSD and ADHD.

Further, examining the effects of childhood trauma will contain how children respond to

psychological stress and the resulting neurobiological effects and consequences. With enough

information to present an understanding of potential ADHD misdiagnosis in children with

underlying trauma, additional information will be provided on CCPT and its effectiveness in

treating trauma/PTSD, as well as differentiating ADHD. Collected research will highlight

CCPT’s therapeutic approach as an interventive resource to re-assess and differentiate between

trauma/PTSD and ADHD.

Literature Review

The core of ADHD’s characteristics is the result of neurological deficits connected to

executive functions, causing impairments in learning, emotion regulation, and behavior

management. Compared to ADHD, trauma and PTSD symptoms result from one or multiple

traumatic events that alter brain chemistry and lead to changes in how a child responds

cognitively, emotionally, and physically. Even though ADHD is a behavior disorder and

PTSD/childhood trauma is reactionary response to a traumatic event(s), both disorders present

with a number of overlapping symptoms. The first few sections will explore ADHD, childhood

trauma, and how their symptoms overlap and can potentially lead to mistaken diagnoses and

treatments.
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ADHD

Dating back to 1937, ADHD emerged as the first psychiatric disorder to be diagnosed

and treated in children and has evolved into one of the most common childhood diagnoses in the

21st century (Biederman & Faraone, 2005; Robinson, Simpson, & Hott, 2017). ADHD diagnosis

has found to be in approximately 5% of children and occurs in most cultures (Swank & Smith-

Adcock, 2018). Two of the leading reasons for children referrals to clinicians and psychologists

are due to attention and behavioral problems (Ray et al., 2007). Assessing and diagnosing

ADHD has proven to be difficult, partially attributing to the significant changes in diagnostic

criteria and terminology that have taken place over the past 60 years (Weinstein et al., 2000).

Such changes have been influenced by empirical studies of epidemiology, cause,

pathophysiology, and treatment (Biederman & Faraone, 2005).

Generally, ADHD diagnosis involves difficulties with fundamental academic and social

tasks that promote learning, which are presented as not staying attentive, not following

directions, and not working appropriately with others (Swank & Smith-Adcock, 2018). The

most recent edition of DSM-V categorizes ADHD diagnostic criteria into 3 subtypes: primarily

inattentive, primarily hyperactive/impulsive, and combined presentation (APA, 2013). These

classifications include children displaying developmentally inappropriate levels of inattention,

hyperactivity, and impulsivity that begin in childhood and cause impairment in school

performance, intellectual functioning, and social skills (Biederman & Faraone, 2005). To meet

diagnostic criteria for ADHD according to DSM-V, there must be a persistent pattern of

inattention and/or hyperactivity-impulsivity that interferes with functioning or development

present in two or more settings, and must meet at least six symptoms for at least 6 months prior

to 12 years of age (APA, 2013).

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Weinstein et al. (2000) and Biederman and Faraone (2005) identified children with

ADHD as having disruptive and inattentive behavioral problems that include school dysfunction

and academic underachievement, developmental reading and mathematical disorders,

aggressiveness towards peers, family conflict, uncooperative and antisocial behavior, and

injuries. Children with ADHD show an increased risk for being held back in class and

suspended from school (Pottinger, 2014). Contributing to the complexity of ADHD is that such

behaviors can affect other areas of functioning, can appear as overlapping symptoms of other

disorders, or exist comorbid to other mood disorders, anxiety disorders, learning disabilities and

PTSD (Weinstein et al., 2000). Clinical errors will arise if clinicians routinely disregard

symptoms of comorbid disorders as associated features of ADHD, such that symptoms of the

untreated disorder will get worse and cause further problems (Biederman & Faraone, 2005).

Biederman and Faraone (2005) explained that executive disfunctions commonly seen in

ADHD are controlled by frontal-subcortical circuits, which consists of inhibition, working

memory, set-shifting, interference control, planning, and sustained attention. Dysregulation of

frontal-subcortical circuits creates neuropsychological deficits, which in structural and functional

neuroimaging studies appear as small volume reductions in these regions (Biederman & Faraone,

2005). Other studies have also shown abnormalities in structures widespread or outside the

frontal-subcortical circuits, supplementing and supporting Biederman and Faraone’s (2005)

research. Although brain-imaging studies have documented both structural and functional

pathological changes in front-subcortical-cerebellar circuits, imaging methods are not valid

enough to consider a method for diagnosing (Biederman & Faraone, 2005).

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Childhood Trauma and PTSD

For the purpose of this paper, childhood trauma will be considered on a broader spectrum

rather than relying solely on PTSD diagnosis. Children exposed to trauma who do not meet

DSM-V criteria for PTSD diagnosis should not be overruled or excluded, as exposure to trauma

can still have harmful and damaging effects. According to Szymanski et al. (2011), children may

respond to trauma with a wider range of symptoms than those captured by PTSD. Ogawa (2004)

noted that DSM-V criteria is largely dependent on clients’ verbal descriptions and accounts of

their experiences, which is not sensitive enough to diagnose traumatized infants and preverbal

children. Therefore, PTSD doesn’t account for all children who have experienced trauma or

show symptoms of trauma as a result. Consequently, if children do not meet PTSD criteria, they

may not receive treatment for their underlying trauma, which ultimately dismisses the potential

prolonging negative impact trauma will have on their development and well-being.

Trauma is described as horrible external events that are experienced intimately and

forcefully through either a single incident occurring in one sudden moment or continuing

traumatic experiences that occur over a period of time (Hall, 2019; Myers, Bratton, Hagen, &

Findling, 2011). Instances of childhood trauma are known to include: sexual, physical and

emotional abuse, devastating emotional loss, life-threatening illness, life-threatening accidents,

war, disaster, neglect, domestic violence, and community violence (Ford, Racusin, Ellis, Daviss,

Reiser, Fleischer, & Thomas, 2000; Gregorowski & Seedat, 2013). Additionally, Gregorowski

and Seedat (2013) consider disruptive early attachment relationships in infancy and childhood as

traumatic due to the probability of lifelong developmental consequences; whether abuse, loss,

betrayal, or dysregulation in the caregiver, children are unable to develop the capacity to self-

regulate or to rely on safe, consistent caregiving relationships for support.

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The exposure of trauma during childhood causes internal changes that severely disrupt

healthy functioning and impact brain development, putting children at extreme risk for

behavioral disorders and developmental delays in social, emotional, cognitive, and physical

domains (Ryan et al., 2017). Symptoms can have a lasting effect for years, and some symptoms

may actually extend or expand with time (Terr, 1989). For some child trauma survivors,

symptoms persist more than a decade later in adolescence or young adulthood (Ford et al., 2000).

The age of the child during trauma exposure, the severity of the trauma, and the child’s

disposition mediate the impact these experiences will have on development and symptom

presentation (Ryan et al., 2017; Myers et. Al, 2011).

The overwhelming and debilitating effect that trauma has on children is that it interferes

with multiple domains including cognitive development, emotional functioning, behavioral

control, physical health, social skill development, attachment, identity formation, and the ability

to trust the self and others (Myers et al., 2011; Pottinger, 2014). Issues with these domains can

manifest into distractibility, disorganized affect, and disruptive behaviors (Szymanski et al.,

2011). Recurrent trauma may develop into more severe symptoms, which can lead to various

diagnoses such as personality disorders, conduct disorders, attention-deficit disorders,

depression, dissociative disorders, and anxiety disorders (Hall, 2019). Multiple experiences of

trauma have such an impact on a child’s sense of control in that they are abruptly deprived of the

sense of security that is crucial to healthy emotional growth, which limits cognition,

verbalization, and abstract thinking (Ogawa, 2004). Consequently, this increases vulnerability,

hopelessness, anxiety, instinctual arousal, and feelings of danger (Ogawa, 2004; Myers et al.,

2011). Preschool children who experience trauma exposure struggle with age-appropriate motor

and social skills or regression to more childish behaviors, whereas school-aged children and
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adolescents have heightened levels of psychopathology, including severe fears and anxiety when

faced with a wide range of situations (Weinstein et al., 2000).

Lee, Park, Jin, Lee, and Hahn (2017) discovered that children diagnosed with PTSD

showed an impairment in sustained attention and were easily distracted compared to controls

with no reports of trauma; in particular, a history of physical trauma worsened the effect on one’s

attention. It was further concluded that childhood trauma was significantly correlated with

attention and concentration in a negative way, and these findings support that childhood trauma

are likely to affect neurocognitive problems into adulthood (Lee et al., 2017). Children exposed

to chronic stress or trauma can result in a brain trained to exist in a state of hyperarousal, in

which they cannot concentrate, and they become easily frustrated, more impulsive, and moody

(Stewart, Field, & Echterling, 2016). This is substantially disorganizing for children as it results

in problems with motor restlessness, difficulty concentrating, explosive or aggressive outbursts,

and emotional constriction (Szymanski et al., 2011).

Identifying and communicating feelings for children is difficult because they lack the

ability to process their internal experiences and the world around them, but when trauma

exposure is involved, they may demonstrate excessive clinginess, anxiety, aggression, and

dissociation (Gregorowski & Seedat, 2013). Common symptoms exhibited by traumatized

children include flashbacks, repetitive behavior, trauma-specific fear, and futurelessness (Ogawa,

2014). Ways in which children process traumas may be displayed by persistent avoidance,

making up reasons why the trauma took place and how they could have prevented it, developing

sense of guilt, self-blame, omen-type thoughts, loss of sense of security, and increased separation

anxiety from parent (Ogawa, 2004). Children are unaware that their behavior is related to
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original thoughts and feelings about the trauma, but intrusive and repetitive thoughts are

presented in drawings, stories, and play (Ogawa, 2004).

To express their traumatic experiences through play is not uncommon, as this is largely a

way for them to cope (Gregorowski & Seedat, 2013). More often, repetition of traumatic events

is seen and played out in dreams, fantasy, aggressive play, self-destructive behavior, and

delinquency; usually aggressive and destructive types of responses are connected to behavioral

problems (Weinstein et al., 2000). Not being able to regulate or manage emotions can result in

impulsivity, and experiencing intense emotions such as rage and shame can lead to withdrawal or

behavioral enactments, either avoiding emotional states or attempting to protect themselves from

reoccurring feelings (Gregorowski & Seedat, 2013).

When behaviors display in the form of social withdrawal, over compliance, impulsivity,

aggression, and/or defiance, additional strain may be inflicted on attachment relationships, and

further may prevent potentially supportive relationships from transpiring in the future

(Gregorowski & Seedat, 2013). A negative sense of self may contribute to hypervigilance and

faulty information processing (Gregorowski & Seedat, 2013). Responses to both neutral and

traumatic stimuli often are confused and disorganized, leading to further self-perceptions of

helplessness (Gregorowski & Seedat, 2013). It is not uncommon for children to children develop

the ability to disassociate themselves, mentally and emotionally in order to avoid feeling the

emotions associated with the trauma, including denial and numbing (Hall, 2019). If children

present as withdrawn, it is an unconscious coping mechanism to which they can either become

easily enraged or abnormally passive, possibly fluctuating between the two (Hall, 2019).

Ongoing avoidance and hyper-vigilance that results from trauma can become automatic rather

than conscious, which may lead to dissociation and fragmented consciousness (Gregorowski &
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Seedat, 2013). Dissociation can have maladaptive consequences including a disconnect between

thoughts and feelings, an inability to be consciously aware of bodily sensations, and behavioral

reactions that are outside of awareness or control (Gregorowski & Seedat, 2013).

Although a number of children may be resilient to trauma exposure with initial symptoms

of distress reducing over time, some children develop sustained psychological difficulties

including anxiety, depression, behavioral symptoms, and clinical or subclinical levels of

posttraumatic stress (Schilpzand, Sciberras, Alisic, Efron, Hazell, Jongeling, Anderson, &

Nicholson, 2017). Behavior and emotional manifestations arise from major psychological

distress and can surface in the form of depression, guilt, anxiety, frequent nightmares, anger,

hostility, identity confusion, impaired trust, low self-esteem, symptoms of hypervigilance,

impaired impulse control, and social inappropriate behavior, dreams, and fantasy (Weinstein et

al., 2000). Furthermore, emotional symptoms and disturbances resulting from trauma are also

connected to the development of phobias and panic attacks, heightened irritability and alertness,

and problems with peers and schoolwork; if hostile behavior appears, it can be displayed as

active defiance, disorderly behavior in family, and quarreling or fighting with classmates

(Weinstein et al., 2000).

Stress elicited by trauma can influence physiological dysregulation, causing or

exacerbating medical conditions and illness, which has been connected to increased sympathetic

adrenergic activity, higher resting heart rates, digestive issues, sleeping irregularities, sensory

motor issues, hypervigilance, and physical hyperactivity (Gregorowski & Seedat, 2013; Ryan et

al., 2017). Often, traumatized children are diagnosed with comorbid psychiatric and medical

disorders in that the common etiological factor of trauma exposure can go unrecognized

(Gregorowski & Seedat, 2013). Knowing the etiological experience of trauma is essential in
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assessment to inform both diagnosis and treatment, otherwise, treatment plans may be

inefficient, or may even run the risk of re-traumatizing (Gregorowski & Seedat, 2013). Without

proper knowledge, assessment, or consideration of trauma history, it may be possible that

symptoms are mistaken for ADHD.

Overlapping Symptoms of Childhood Trauma/PTSD and ADHD

There is a growing body of research developed to examine and better understand the

relationship between exposure to childhood trauma/PTSD and ADHD (Szymanski et al., 2011).

Researchers have investigated the comorbidity, as well as how the symptoms resemble, overlap,

and differentiate, and whether or not one diagnosis is mistaken for another. The overlapping

symptoms between both diagnoses displays parallel psychobiological and social learning

impairments, as well as disruptive behaviors in information processing and emotion regulation

(Ford et al., 2000). Children exposed to trauma often present with symptoms resembling core

characteristics of ADHD, and additionally, ADHD symptoms also overlap with PTSD,

characterized by difficulty concentrating, restlessness or irritability, and impulsivity (Pottinger,

2014; Weinstein et al., 2000). Because of the overlap in symptoms, distinguishing between

diagnosing PTSD and ADHD makes for a complicated process.

Research conducted by Lee et al. (2017) produced findings that proposed childhood

trauma may affect the onset of ADHD, while Ford et al. (2000) suggested that children with

preexisting ADHD may be at higher risk for accidental trauma due to difficulties with self-

regulation and impulsive behaviors. Ford et al. (2000) acknowledged that trauma and PTSD

symptoms can contribute to, or exacerbate ADHD’s attention, impulse regulation, and

physiological hyperreactivity symptoms, as well as that trauma can create symptoms parallel to

ADHD. According to a study conducted by Biederman, Petty, Spencer, Woodworth, Bhide,

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Zhu, and Faraone (2012), findings showed that ADHD probands had a significantly higher

prevalence of PTSD compared to non-ADHD probands. Correspondingly, Schilpzand et al.

(2017) studied the association between childhood trauma exposure and outcomes in children

with ADHD, and findings showed that ADHD children exposed to trauma had greater ADHD

severity compared to ADHD children non-exposed to trauma. The research of Schilpzand et al.

(2017) also determined that trauma exposure in childhood is a risk factor for developing mood

and anxiety disorders, and prolonged exposure to trauma has been associated with poorer

academic performance and deficits in executive functioning. Respectively, ADHD is a disorder

in which symptoms result from problems, weaknesses, or deficits with executive functioning. It

seems feasible that a traumatized child might manifest what appears to be ADHD symptoms of

inattention, hyperactivity/impulsivity, or overt externalizing behaviors, when possibly PTSD

symptoms are misinterpreted as ADHD symptoms (Weinstein et al., 2000). Through brain

diffuser tensor imaging, researchers were better able to examine the neurobiological

consequences of childhood trauma exposure and ADHD; it was determined that the etiology of

ADHD involves multiple biologic and psychosocial factors to which trauma and PTSD

symptoms may contribute (Park, Lee, Kim, Kwon, Cho, Han, Cheong, & Kim, 2016).

According to the research of Szymanski et al. (2011), traumatized children’s feelings of

emotional numbing, avoidance, and disengagement from others may facilitate ADHD’s

functional impairments at home, at school, and in social relationships such as intrafamilial

conflict, school suspension, and rejection by peers. Trauma exposure impacts a child’s ability to

regulate his/her affect, in that they are more prone to be easily overwhelmed, overreact to minor

stresses, have difficulties with self-soothing, react excessively in response to neutral stimuli, and

have trouble modulating their anger (Szymanski et al., 2011). Traumatized children have a
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compromised ability to regulate their emotions, which creates a particular vulnerability for

exhibiting behaviors typical of an ADHD diagnosis (Szymanski et al., 2011). Avoidance

symptoms of trauma and PTSD are understood to be a defense mechanism in response to the

cognitively and emotionally overwhelming experience of a traumatic event (Szymanski et al.,

2011), which involves intentional efforts to not think about the trauma, as well as general

experiences of inattention to stimuli, high distractibility, and forgetfulness (APA, 2013). These

symptoms mirror symptoms of inattention, distractibility, and avoidance of activities within the

inattentive cluster of ADHD (Ford et al., 2000).

In comparing PTSD’s Hyperarousal cluster to ADHD Hyperactivity cluster, there are also

mirroring symptoms. Within PTSD Hyperarousal cluster, the innate protective mechanism is to

defend the self from future traumas (Szymanski et al., 2011) which is displayed in the form of

hypervigilance, irritability, and an exaggerated startle response (APA, 2013). Compare that to

Hyperactivity cluster of ADHD, and it is displayed in the form of fidgeting, excessive moving

around, and restlessness (Szymanski et al., 2011). Additionally, PTSD’s symptoms of intrusive

recollection and the re-experiencing of traumatic memories can present as ADHD’s symptoms of

difficulty in organization and incapacity to listen, as well as disorganized, agitated behavior due

to painful memories that overwhelm a child’s ability to cope (Szymanski et al., 2011). Anxious

feelings that arise due to trauma/PTSD can mirror the Impulsivity cluster of ADHD (Szymanski

et al., 2011).

Neurobiology of Childhood Trauma

Understanding the neurobiology behind trauma helps in attaining essential information

that’s needed during assessment, as well as the direction of treatment (Ryan et al., 2017). Brain

growth is most active during the early years of life, and emotional and cognitive disruptions
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during those years leads to potential impairment in brain development (American Academy of

Pediatrics, 2000). Within the first 2 years of life, children develop important cognitive capacities

such as symbolism, language, and autobiographical self-awareness (Gregorowski & Seedat,

2013). During the third and fourth year, they develop schemas and a sense of self and others,

differentiating between emotions/intentions, impulses/actions, and anticipating future

occurrences based on past experiences (Gregorowski & Seedat, 2013). In the third and fourth

years specifically, the anatomic brain structures that govern personality traits, learning processes,

and coping with stress and emotions are established, strengthened, and made permanent;

however, if these structures are influenced by negative environmental conditions, the nerve

connections and neurotransmitter networks that are forming, atrophy (American Academy of

Pediatrics, 2000).

Trauma experienced during these stages affects how the brain interprets information and

stimuli, possibly confusing all stimuli and experiences to be potentially traumatic (Gregorowski

& Seedat, 2013). Thus, curiosity is restricted and learning is constrained, resulting in an over-

developed memory and response for traumatic events, which then leads to deficits in attention,

hypothesis testing, problem solving, linguistic organization and memory, and short-term memory

(Gregorowski & Seedat, 2013). The pre-frontal cortex, which overrules executive functions, is

in charge of directing behavior and helping modulate emotions, but it is not fully developed in

children (Stewart et al., 2016). Essentially, the pre-frontal cortex is one of the last brain regions

to fully develop and isn’t achieved until a person’s mid-20s, which means the ability for planned

behavior or organization is still “under construction” earlier in life (Stewart et al., 2016).

Exposure to traumatic events elicits and activates a stress response; when the stress

response is acute or chronic and occurs during a sensitive period of development, the brain then
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becomes organized in an atypical manner, leading to maladaptive emotional, behavioral, and

cognitive responses (Ryan et al., 2017). Chronic stress causes structural changes in higher

regions of the brain (amygdala, hippocampus, orbital frontal cortex, and medial prefrontal

cortex) attributing to issues with emotional control, problem solving, and learning; therefore,

influencing anxiety, memory, mood control, executive functions, and social emotional learning

(Ryan et al., 2017).

When children experience trauma, their stress response varies in that cortisol levels either

become hyper- or hypoactive due to a dysregulated feedback loop (Boparai, Au, Koita, Oh,

Briner, Harris, & Bucci, 2018). The body’s physiological response to stress is based on

involuntary actions of the brain, and exposure to early or chronic stress impacts the brains

structure and function at the cellular level (American Academy of Pediatrics, 2000; Ryan et al.,

2017). Research has demonstrated chemical and electrical evidence for this type of brain

response pattern which causes a child to react in a hypervigilant, fearful manner (American

Academy of Pediatrics, 2000). Additionally, altered stress responses are linked with

inflammatory responses, affecting long-term physical and emotional health, as well as the ability

to respond typically to lower levels of stress (Ryan et al., 2017).

Depending on the child’s developmental age, the “fight” response to stress can vary in

the form of temper tantrums, aggressive behaviors, or inattention and withdrawal (American

Academy of Pediatrics, 2000). The “flight” response may appear to become psychologically

disengaged, leading to detachment, apathy, inattention, excessive daydreaming, or a freeze in

motor activity (American Academy of Pediatrics, 2000). The same areas of the brain that are

involved in the acute stress response also mediate motor behavior and such functions as state

regulation and anxiety control (American Academy of Pediatrics, 2000). Repeated exposure of
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traumatic events can lead to dysregulation in these various functions resulting in behaviors such

as motor hyperactivity, anxiety, mood swings, impulsiveness, and sleep problems (American

Academy of Pediatrics, 2000). As a result of severe stress, changes in brain functioning

materialize and learned experiences of threat and/or deprivation can affect neural development,

which happen to produce alterations in brain structures consistent with ADHD (Thomson &

Lewis, 2015). Some theories propose that there is a direct neurobiological link between trauma

and ADHD, possibly involving dysfunctions of the stress response and/or neuron development

(Thomson & Lewis, 2015).

Distinct types of stressors, including traumatic ones, have particular effects on learning

(Thomson & Lewis, 2015). Childhood trauma stemming from a neglectful environment, where

support and communication are limited, makes it more difficult for a child to develop the brain

connections that facilitate language and vocabulary development, and therefore may impair

communication skills (American Academy of Pediatrics, 2000). Another way in which

childhood trauma can affect linguistic growth is that it alters the social interactional process by

which children acquire and use language to talk about their own and others’ emotions

(Szymanski et al., 2011). Psychological trauma that occurs before 2-3 years of age tends to leave

behavioral, rather than verbal memories (Terr, 1989). Neurological advances have found that

traumatic memories in children are stored and processed in a sensory manner (somatically,

visually, auditorily), which disrupts cognitive abilities to process the traumatic event (Hall,

2019). Children affected by trauma need additional professional support in processing

sensorimotor and affective memories (Hall, 2019). With altered brain functioning at a limited

cognitive developmental level, traumatic memories are unavailable to verbal recall, and instead

are displayed through habitual and erratic body movements (Sories, Maeir, Beer, & Thomas,
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2015). Repeated physiological expressions and affective states can activate somatic disorders

and traumatic traits (Sories et al., 2015).

Lee et al. (2017) conducted a study to determine the relationship between high frequency

electroencephalogram (EEG) bands, inattention, ADHD, and childhood trauma. It was

discovered that individuals exposed to childhood trauma portrayed an upward shift of high

frequency bands. These findings make it possible that the increased beta power of individuals

with childhood trauma may reflect attentional deficits in their brain, while increased beta power

of individuals without childhood trauma usually reflect healthy cognitive abilities. Such results

suggest that enhanced beta power may reflect alternative brain functioning in reducing attention,

which is rarely observed in healthy controls. Lee et al. (2017) also concluded that childhood

adversities could cause subjective inattention and ADHD symptoms.

Assessment Challenges

Research findings pertaining to trauma’s role in either the development or exacerbation

of ADHD are somewhat conflicted, and more review and attention are needed to better identify

trauma and differentiate diagnosis of PTSD and ADHD (Szymanski et al., 2011; Weinstein et al.,

2000). Given the possibility for diagnostic confusion, distinguishing between these disorders is

vital for accurate diagnostic decision making (Weinstein et al., 2000). Accounting that ADHD

prevalence is quite high in psychiatric populations, it is probable that many of the children may

have been exposed to trauma with undetected symptoms of trauma or PTSD (Szymanski et al.,

2011). Spitzer, Schrager, Imagawa, and Vanderbuilt (2017) discovered there was a lack of

trauma screenings performed during assessments, and Weinstein et al. (2000) noted that ADHD

assessments may not routinely assess for trauma if children appear to present with ADHD

symptoms, which could predispose a misdiagnosis of ADHD. Research showed that one in four
PLAY THERAPY AS DIAGNOSTIC REASSESSMENT 20

children aged 6-8 years with ADHD had been exposed to a traumatic event, which highlights the

need for clinicians to be evaluating potential trauma exposure in children presenting with ADHD

(Schilpzand et al., 2017).

An ADHD assessment that does not obtain information about trauma history prevents

clinicians from having essential information that is needed to make accurate differential

diagnosis (Weinstein et al., 2000). The high rate of comorbidity and symptom overlap between

ADHD and trauma/PTSD alongside the high risk for inappropriate treatment interventions and

mismedication necessitates critical attention for the inclusion of trauma history in ADHD

assessment (Weinstein et al., 2000). Clinicians often approach questioning in a way that is not

specific to underlying the source of behavior or if it could be more applied to a trauma response

(Weinstein et al., 2000). This is unfortunate for children whose behavior issues are trauma

induced and who require specific interventions to reduce the psychological impact (Weinstein et

al., 2000).

Assessment is not always advantageous for properly screening for trauma prior to

diagnosis. A trauma history can be difficult to obtain and may only emerge over time as trust is

built between the child, parents, and therapist (Schilpzand et al., 2017). Schilpzand et al. (2017)

noted that their study was based on parent-reports of their child’s trauma exposure, which leaves

the possibility that some parents were unaware of or under-reported the child’s trauma history.

This consideration further prompted the notion that parents may be unreliable reports due to the

inability to accurately assess the child’s internalizing symptoms, the status of the parents’ mental

health, and the parents’ responses to traumatic events which can influence their assessment of

their child’s symptoms. Managing circumstances of this nature could include interactive
PLAY THERAPY AS DIAGNOSTIC REASSESSMENT 21

interventions such as CCPT, which allows children to speak independently of their experience

through play and metaphor, as opposed to relying on verbal communication or parental report.

Critics of ADHD have questioned the subjectivity and credibility of the diagnostic

process along with assessment (Biederman & Faraone, 2005). Generally, ADHD assessment

focuses on behavioral problems, whereas PTSD assessment focuses on identifying a traumatic

event that triggered symptoms, thus, misdiagnosis may occur as a result of inadequate history

taking (Weinstein et al., 2000). In the case of misdiagnosis, treatment interventions may be

overlooking or inadvertently avoiding the underlying issue and concern. Treatment interventions

for ADHD predominantly consist of behavior management, social skills training, and stimulant

or other medication, whereas treatment interventions for trauma and PTSD consist of emotional

distress management and alleviation through play, psychodynamic, and cognitive behavioral

therapy modalities (Weinstein et al., 2000).

Play Therapy

Play therapy has become a recognizable method for treating children with a range of

presenting issues based on its interventional characteristics. It is developmentally appropriate

and underlines how essential the act of play is to a child’s social, cognitive, emotional, and

physical development (Stewart et al., 2016). Unlike adults, children have not developed a

cognitive ability to understand, process, and communicate tragic events and information (Myers

et al., 2011). The lack of cognition attributes to them being less verbal, less insightful, and less

able to identify and express their emotions (Hall, 2019). However, playing is a natural way for

children to communicate (Hall, 2019); it is their language and channel for expression. The

messages children communicate through their play is fundamental; what free association is to
PLAY THERAPY AS DIAGNOSTIC REASSESSMENT 22

adults, free play is to children, and behind every playful action there is symbolic meaning (Sories

et al., 2015).

Incorporating play into therapy provides a unique framework for children to explore life

circumstances on a level that is familiar and relatable (Stewart et al., 2016). Children typically

struggle to bridge the gap between concrete experience and abstract thought, but through play,

children can better process abstract experiences through concrete means (Hall, 2019). This is

demonstrated when children use inanimate objects rather than words to project their feelings,

beliefs, and perceptions about themselves and the world (Hall, 2019). Play is a natural and

healthy tendency for children to cope with external difficulties and internal feelings, and it

provides an opportunity to work through a problem without labeling it as their own, such as, it

belongs to the “princess” or the “dinosaur,” not to them (Terr, 1989).

In response to trauma, children tend to reenact significant parts of their experiences

through play (Ogawa, 2004). When trauma occurs during preverbal and nonverbal

developmental stages, it is stored at a subconscious level, impacting emotions and behaviors that

may be evident in play (Hall, 2019). Play is a cathartic way for children to express their whole

experience of the trauma, work through emotions and distance the self as needed, while also

empowering them to gain a sense of security and a sense of control to change their story (Hall,

2019; Ogawa, 2004). Additionally, for preverbal and nonverbal traumas, play therapy enables

those components to be visited, manipulated, controlled, and integrated into a tolerable and

manageable experience (Hall, 2019).

PLAY THERAPY AS DIAGNOSTIC REASSESSMENT 23

Neuroscience behind play therapy. Play is not only the language of children, play is a

primary task of childhood in which children explore and experiment (Ryan et al., 2017). Playing

is a healthy way for children to develop physically, emotionally, and mentally. Child-directed

and adult-supportive play therapy interventions offer children opportunities to absorb cognitive

material and build growing neural pathways while creating more adaptive attachments and

successful social interactions (Ryan et al., 2017). Repetition of play experiences that support

relationally safe attachments and practice healthy self-regulation promote new neural

connections, reducing and overriding old dysfunctional pathways and reducing dysregulated

behaviors (Ryan et al., 2017).

Using play therapy when treating children elicits more of an engaged response and

positive outcome than traditional talk therapy alone (Hall, 2019). To understand why play

therapy is more appropriate than talk therapy during developmental periods, Stewart et al. (2016)

researched brain functions and development, discovering that child-centered principles evoke a

healing capability (Stewart et al., 2016). Further research in neuroscience has shown that play

therapy creates new neural pathways, enhancing neuroplasticity (Stewart et al., 2016).

Additional research indicates that oxytocin plays a key role in social behavior and social

understanding and that oxytocin secretion is typically correlated with increased trust, reduced

fear, and improved emotional recognition (Stewart et al., 2016). When a therapist tracks a

child’s nonverbal behavior, verbal behavior and feeling state, they demonstrate resonance which

increases oxytocin and supports social bonding (Stewart et al., 2016). The amygdala lessens

fearful effects so that children will be able to address previously threatening aspects of their

trauma; former automatic defensive responses become more relaxed so that dysfunctional

somatic characteristics can be unlearned and new patterns of engagement, responding and
PLAY THERAPY AS DIAGNOSTIC REASSESSMENT 24

problem-solving can be tried (Stewart et al., 2016). Interactive play shapes and reshapes brain

circuits which lay the foundation for later developmental outcomes such as academic

performance, mental health, and interpersonal skills (Stewart et al., 2016). Beneficial effects of

play have been documented in math, geometric knowledge, general academic achievement,

emotional competence and social competence (Schultz, 2016).

Child-centered play therapy. Child-centered play therapy was based on Carl Rogers’

person-centered approach, regarding the worth and significance of children as individuals so that

counselors can better understand them and how they relate to the world, their experiences, and

their development (Swank & Smith-Adcock, 2018; Hall, 2019). CCPT allows children the

freedom to be fully who they are, no matter what thoughts and feelings they bear, therefore

promoting independence and authenticity of self (Ogawa, 2004). Play within a child-centered

approach is an intrinsically motivated activity that is inherently complete, in which children

initiate play for their own purposes and for their own sake (Schultz, 2016).

The environment is intended to be safe and nurturing to promote growth, while

simultaneously setting limits when needed to maintain that safety (Swank & Smith-Adcock,

2018). The therapist attends to the whole child, including cognitions, behaviors, and emotions,

through an accepting, genuine, and empathetic relationship (Hall, 2019). Interactions between

counselor and child are based off of a set of skills that consist of tracking (reflecting play

behavior), reflecting content-meaning, reflecting feeling, returning responsibility (assisting

decision-making), and encouraging (esteem-building) (Hall, 2019). These types of interactions

offer a supportive presence to let children feel recognized and understood, while also validating

their internal state when they’re feeling stressed (Stewart et al., 2016). Because children’s body

language, tone of voice, and facial expressions are often outside of their awareness, tracking
PLAY THERAPY AS DIAGNOSTIC REASSESSMENT 25

behavior and reflecting feelings makes both actions and affect evident, allowing the child to have

introspective pauses to explore their inner experience (Stewart et al., 2016).

In the context of a caring relationship, play provides safe opportunities for the child to

practice creative exploration, reenactment, and rehearsal for dealing with challenging emotions,

people, and events (Stewart et al., 2016). Children begin to establish security in a safe

environment while the therapist holds space for the child to access unconscious processes,

encouraging them to approach rather than avoid difficult emotional states, revisit hurtful

experiences, and develop more adaptive coping responses (Stewart et al., 2016). Additionally,

play can reduce stress and allow the child to be in control, which supports the child’s

engagement in increasingly complex activities (Stewart et al., 2016). Child-centered approaches

may help with regulating behavioral impulses, increasing attention skills, and improving self-

confidence, all of which can be tied to better academic and social outcomes for students (Swank

& Smith-Adcock, 2018).

When playing-out traumas, children are able to regulate their distance from the traumatic

event because they control and decide how and when to confront their trauma, if they choose to

do so (Hall, 2019). Terr (1989) noted a case study in which Anna Freud and Dorothy

Burlingham allowed a traumatized boy to play out his trauma during multiple sessions until he

no longer felt the urge to do so; rather than interrupt his process or interpreting his play to him,

they responded with acceptance and support. Symbolic play allows children to experience

mastery over traumatic events and work toward a more integrated self by naturally desensitizing

the traumatic experience (Hall, 2019). Having the opportunity to independently make choices

without being told what to do by an adult reinforces self-regulation of emotion and behavior.
PLAY THERAPY AS DIAGNOSTIC REASSESSMENT 26

Effectiveness of child-centered play therapy in practice. Several studies have shown

positive outcomes in children who present with emotional and behavioral issues. Sories et al.

(2015) noted a case study of a child with reported extreme nightmares and separation who

showed a decrease in traumatic symptoms after multiple sessions of child-centered play therapy.

Similarly, Hall’s (2019) research revealed that more than half the children receiving CCPT

services demonstrated better behavioral and emotional outcomes compared to those who did not

participate in play therapy, and additionally, CCPT produced higher treatment outcomes than

other modalities of play therapy. Sories et al. (2015) noted that not only did children engaged in

CCPT show a noticeable reduction in negative behaviors, but the improvements achieved in

therapy even showed to last and maintain post treatment.

To determine if CCPT is effective in children diagnosed with ADHD, a few studies have

been executed. Ray et al. (2007) investigated if using CCPT with ADHD children would reveal

a reduction in problem behaviors, and findings showed that children receiving play therapy for

treatment showed a significant decrease in emotional issues compared to children to strictly

participated in reading mentoring. Another study by Swank and Smith-Adcock (2018) found

that ADHD children receiving CCPT exhibited a decrease in behaviors, and compared to the

non-CCPT intervention group, there was a significant decline in areas of emotional distress,

withdrawal, and anxiety. These findings support previous research on the effectiveness of CCPT

in reducing symptoms of ADHD (Swank & Smith-Adcock, 2018). A study administered by

Robinson et al. (2017) implemented CCPT as treatment for children with ADHD which

produced positive outcomes in reducing problematic behaviors; the improvements of participants

were additionally observed and noted by teachers during class. Collectively, teachers favored

CCPT’s approach and agreed that it had multiple purposes including being suitable for
PLAY THERAPY AS DIAGNOSTIC REASSESSMENT 27

behavioral problems, not having any negative side effects, and showing use for a variety of

presenting problems (Robinson et al., 2017).

Research continues to grow in discovering how effective CCPT is in treating emotional

and behavioral issues presented in children, including those exposed to childhood-trauma and

those diagnosed with ADHD. Although the studies in this literature review support CCPT as

effective in treating children with and without ADHD, there was no specification whether

ADHD probands had underlying or previous exposure to childhood trauma. This continually

raises the question as to what the etiology or source of the behavioral symptoms were and

whether trauma was ever present.

Discussion: Play Therapy as an Assessment Tool

Because there is no standardized procedure that exists for assessing ADHD, clinicians

generally use a clinical interview, behavior checklist, or formal diagnostic procedures; this poses

as problematic if clinicians miss symptoms or significant information, which can increase the

risk for misdiagnosis (Weinstein et al., 2000). Sometimes diagnoses are given based on behavior

alone without considering if there’s any underlying trauma or if the trauma was preverbal (Ferro,

personal communication, April 2, 2020). To better avoid misdiagnosis, Terr (1989) noted that

early child analysts used play largely for diagnosis, not necessarily for treatment. Although

modern day clinical interviews and assessments rarely incorporate play, Ogawa’s (2004)

research revealed the limitations of applying adult assessment and treatment methods to children

and reestablished the importance of play and play therapy.

Historically, play therapy was designed to treat more generic problems without

addressing specific diagnoses, but more importantly, the generic treatment approach could be

maintained while still assessing for specific disorders (Jensen, Biesen, & Graham, 2017).
PLAY THERAPY AS DIAGNOSTIC REASSESSMENT 28

Despite that CCPT would be an extensive assessment process with weekly treatments, it shows

potential to help identify any unreported underlying traumas that may be mistaken for ADHD.

Play therapist, Ferro (personal communication, April 2, 2020), mentioned witnessing how CCPT

surfaced unreported and hidden traumas in some of her children-clients diagnosed with ADHD,

and after a number of sessions their symptoms reduced. In a particular case, Ferro (personal

communication, April 2, 2020) worked with a diagnosed ADHD boy who, without prompt,

played out an abandonment issue that was not previously reported or acknowledged. Although

she was surprised to learn of his emotional conflict, she firmly believes CCPT was effective in

treatment because “what he needed to do was work through his abandonment” (Ferro, personal

communication, April 2, 2020). Over time, his symptoms lessened and Ferro (personal

communication, April 2, 2020) questioned if CCPT was never used, would she have ever given

him a place to work through that trauma.

Stewart et al. (2016) discussed a clinical case about a 6-year old boy who reportedly had

difficulty following directions, sitting still, maintaining appropriate boundaries with peers, and

managing emotional episodes. The teacher expressed concern of hyperactive behavior, and

notably, his behaviors were more difficult on transitional days between his divorced parents’

households (Stewart et al., 2016). After roughly 10 sessions of CCPT, both parents and teacher

reported observing a drastic improvement in the boy’s focus, attention, and emotion regulation

(Stewart et al., 2016). Child-directed play provided the boy with an environment to work

through his distress, resulting in more ease with transitions at both school and home, but also, the

disposition of play provided an opportunity for him to communicate his needs and underlying

issues in a way that seemed most natural (Stewart et al., 2016). While there were initial
PLAY THERAPY AS DIAGNOSTIC REASSESSMENT 29

suspicions of hyperactive behavior, CCPT was able to identify and address the boy’s emotional

distress, and further re-assess that ADHD was not the etiologic source of his diagnosis.

Looking at children’s behaviors alone are not enough to accurately assess and form a

diagnosis without considering if there is anything underlying. Not all children present with a

trauma background during assessment, but their traumas emerge through play so they can

address their inner emotional distress and communicate it to the therapist. Using CCPT as a

form of assessment may be inconvenient of timeliness, however, it may be an optional tool to

more accurately assess for underlying trauma and stressors that may be unknown to parents and

guardians, and even more so to the child’s comprehension and subconscious.

Conclusion

Some limitations occurred within this literature review. One limitation was that most of

the research included either used DSM-III OR DSM-VI as sources of diagnostic reference,

whereas this paper implemented the most recent version, DSM-V, as a reference source.

Additionally, little to no research included outcomes, opinions, or experiences from children who

were misdiagnosed or received CCPT as method of treatment. Although it is not an easy task,

asking children about their feelings and reflections can help bring awareness and understanding

to their experience of the therapeutic process (Carroll, 2000). Parents and guardians often

answer and report on behalf of a child during assessments, so it’s possible they don’t fully know

about a traumatic event, they don’t comprehend the impact on the child, or they may minimize

the child’s experience for fear of judgment or to protect themselves (Schilpzand et al., 2017).

Early interventions are key to minimizing long-term and permanent effects of trauma in

children (American Academy of Pediatrics, 2000). However, being able to identify and

recognize trauma or PTSD symptoms is essential to offering effective treatment. Misdiagnosis

PLAY THERAPY AS DIAGNOSTIC REASSESSMENT 30

of ADHD may lead clinicians to use inappropriate or irrelevant interventions and failing to

address and treat symptoms of trauma/PTSD by targeting disruptive behaviors instead could

cause the child to suffer (Weinstein et al., 2000).

According to Stewart et al. (2016), research shows that CCPT in treatment is empirically

validated for children with externalizing problems, internalizing problems, and academic

problems. Research has shown that CCPT has provided effective treatment with successful

results in improving children’s presenting problems and needs. Although CCPT is generally

utilized as a form of treatment, it has yet to be evaluated as a diagnostic method. Due to the need

to build a relationship with the therapist, CCPT may be a lengthier diagnostic process, but it

shouldn’t be ruled out as an option.

To prevent misdiagnosis and mistreatment, evaluating the child is necessary, especially

from their perspective and experience. It is also important to familiarize the developmental

aspects of play and how children confront problems (Myers et al., 2011). Clinical questionnaires

and interviewing alone is not enough for a child to fully comprehend or to relay traumatic

information. Welcoming a child into a safe space to develop a connection with the therapist and

to use symbolic expression may initiate comfort and trust within the child to reveal internal

emotional conflict, stress, and trauma (Ogawa, 2004). Observing children’s presenting behaviors

alone is not enough to answer why the behaviors are present or what the source of the behaviors

are. Because CCPT can explore deeper into the “why” questions, it has the potential to

differentiate if children organically have ADHD or if they have underlying, unresolved trauma.
PLAY THERAPY AS DIAGNOSTIC REASSESSMENT 31

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x
 THESIS APPROVAL FORM
Lesley University
Graduate School of Arts & Social Sciences
Expressive Therapies Division
Master of Arts in Clinical Mental Health Counseling: Expressive Arts Therapy

Student’s Name: Bethany Gibbons

Type of Project: Thesis

Title: Using Child-Centered Play Therapy as an Intervention to Reassess ADHD Diagnoses and

Trauma in Children: A Literature Review

Date of Graduation: May 16, 2020

In the judgment of the following signatory this thesis meets the academic standards that have
been established for the above degree.

Thesis Advisor: Elizabeth Kellogg, PhD