Play Therapy

Child analysis and the use of play

A 2023 case series in Cureus summarizes the early history in a table and in text. It places the first documented use of play in a psychological case with Sigmund Freud's 1909 report on a five-year-old boy known as Little Hans, whom Freud did not meet in person, and with Melanie Klein's use of play as a counterpart to free association in adult analysis. It also credits Anna Freud with using play to build rapport with children in 1946.

The same paper is internally inconsistent on dates: Klein is given as 1935 in the text but 1933 in a table and the reference list, and David Levy's structured Release Therapy is dated 1938 in the text but 1983 in the reference list. The article is a clinical case series and not a history, so these dates should be treated as provisional until checked against primary sources.

Person-centered and structured lineages

The same source describes a second line of development. It dates Hambidge's structured approach to 1955, Carl Rogers's introduction of nondirective play therapy to 1951 and Virginia Axline's expansion of that work to 1947, and says Gary Landreth later extended Axline's model. The order of the 1947 and 1951 dates is as printed in the paper and has not been reconciled here.

The paper states that the Association for Play Therapy was launched in 1982, leading to professional standards in the United States. A systematic review of child-centered play therapy for trauma cites Axline's 1969 book as its foundational source and gives no further history of its own.

What the sources reviewed do not cover

A narrative review of play therapy in autism says play therapy has been used in psychiatry for nearly a century and has been practiced for hundreds or even thousands of years, without citing evidence for the longer claim. That statement is a general assertion and is not used here to date the practice. The sources opened for this page do not cover the history of play therapy outside the United States and Europe, or the later development of UK professional bodies beyond the registers described below.

Play therapy as a clinical term

Play Therapy UK, a professional register, describes play therapy as a structured psychological intervention in which trained therapists use play and art materials as the main way for the client to express themselves. Its referrers' guide calls it a clinical discipline and not simply playing with children, and says it is primarily for children but can be adapted for adolescents, young people and adults.

The same organization acknowledges that research on play therapy is complicated by inconsistent definitions of the term. In a meta-analysis of 100 studies, the authors noted that few outcome measures were used in more than one or two studies, which also limits comparison between studies.

Child-centered, directive and related models

The Cureus case series describes nondirective child-centered play, based on Rogers's principles of empathy, unconditional positive regard and congruence, and structured approaches associated with Levy and Hambidge. It also lists filial therapy, in which parents are taught to play with their child, and cognitive-behavioral play therapy, which embeds cognitive-behavioral strategies in play.

A review of child-centered play therapy describes a playroom with selected toys in which the therapist may reflect feelings, track behavior, encourage the child and set limits, and says the play is not directed. The autism review notes that no play therapy approach is standardized and that outcomes can depend on the individual therapist.

Therapeutic play in hospitals

Reviews of hospital care use the term play therapy for planned, purposeful play activity adapted to a child's condition, age and development, such as doll-based simulation of procedures, storytelling and games. These activities are often delivered by nurses and play staff, and the evidence from them should not be assumed to apply to psychotherapy delivered by a registered play therapist.

Setting and structure

According to Play Therapy UK, sessions are held in a consistent space, at a consistent time, with the same therapist. The guide does not state session length or number of sessions. A therapist assesses each child and can advise on alternatives, and the guide says play therapy should not run at the same time as another psychotherapeutic intervention.

In its own analysis of routine practice data, the organization reports an average of 16 sessions, or 18 for children with higher needs. This figure comes from the register itself and is not a clinical standard.

The role of parents and other adults

Meta-analytic work has examined parent involvement as a feature of treatment. The 2005 review of 93 controlled studies reported the largest effects where parents were used in the play therapy, and a 2015 review of 52 studies of child-centered play therapy reported that caregiver involvement was one of several study characteristics related to effect size, without stating the direction in its abstract.

Examples of study protocols

Protocols in research differ from routine practice. In a small Taiwanese study of children with attention-deficit/hyperactivity disorder, the treated group received child-centered play therapy weekly for 12 sessions, while a waitlist group continued its usual treatment. In hospital studies, interventions ranged from a single one-hour doll-based session before surgery to 30-minute sessions repeated daily.

Presentations named by the profession

Play Therapy UK lists presentations for which referral may be considered, including trauma and abuse, anxiety, attachment difficulties, grief and loss, attention-deficit/hyperactivity disorder, autism, emotional and behavioral difficulties, family transitions, and illness or medical challenges. It says referral may be worth considering when difficulties affect daily functioning and seem to have an emotional or relational side, or when a child struggles with talk-based approaches.

Populations studied in research

Published reviews have examined play therapy or play-based interventions in children exposed to trauma, children with autism, children with visual impairment, and hospitalized children. Each of these is a distinct population and setting, and the results of one cannot be carried over to another.

A narrative review in autism concludes that play therapy is an effective tool for managing children with autism, while also stating that research is minimal, many studies are small, designs are weak, and play therapy is usually part of a broader intervention, which makes it hard to attribute gains to play therapy alone.

Early meta-analyses

A 2005 meta-analysis by Bratton and colleagues reviewed 93 controlled outcome studies published from 1953 to 2000 and reported an overall treatment effect of 0.80 standard deviations. Humanistic treatments showed more positive effects than nonhumanistic ones, and effects were similar across age, gender and presenting issue. This page read the abstract record only.

A 2015 meta-analysis of child-centered play therapy by Lin and Bratton reviewed 52 controlled studies from 1995 to 2010 and estimated a moderate treatment effect of 0.47. The abstract reports that effect size was related to child age, ethnicity, caregiver involvement, treatment integrity, publication status and presenting issue.

A review of outcome quality

A 2017 meta-analysis by Jensen and colleagues pooled 100 studies and found a significant moderate effect across all outcomes (d = 0.44), falling to d = 0.36 after four studies with unusually large effects were removed. The authors judged overall study quality to be poor, found that no study met criteria as a randomized controlled trial, and noted that studies did not use diagnostic criteria for inclusion.

On that basis the authors argued that play therapy cannot yet be considered an empirically supported treatment. Measures of family functioning produced larger effects than other types of measure, and teachers tended to rate treatment effects lower than other reporters. Both findings are reasons to read pooled figures with caution.

Trauma, autism and attention difficulties

A systematic review of child-centered play therapy for trauma-exposed youth included seven articles published between 1988 and 2012. All used pre-post designs, three had control groups, and many outcomes were not significant. The authors found little rigorous research supporting the approach despite its popularity, and noted attrition often of 40 to 50 percent and few reported effect sizes.

A 2026 meta-analysis of play-based interventions for social and play skills in children with autism included seven studies and reported improvements, with subgroup analyses suggesting larger effects for child-centered, image-sand and sensory-integration-based play therapy. Heterogeneity was very high and the authors advised caution. A small 2022 study of 17 children with attention-deficit/hyperactivity disorder reported improved cognitive flexibility after 12 sessions of child-centered play therapy compared with a waitlist. Both were read as abstracts only.

Hospital play

A systematic review of play in hospitalized children included 14 studies, of which six were randomized trials, one quasi-experimental and seven non-randomized descriptive studies. The review reported lower anxiety, pain or depressive symptoms in several trials, with a preoperative anxiety measure unchanged in one. Search methods were limited and no formal risk-of-bias tool was named, so this evidence concerns hospital play activities and should not be applied to psychotherapy.

Study design and reporting

Reviews identify recurring limits: pre-post designs, small samples, high attrition, a wide variety of outcome measures, few treatment manuals or fidelity checks, and little reporting of effect sizes. A review in children with visual impairment included nine quasi-experimental studies, none randomized, and noted that adverse events were often not reported.

Source independence

Play Therapy UK, which promotes its registered members, reports routine-practice data on over 61,000 clients in which most were rated as improved, and notes that some showed no change or deterioration. These data come from routine practice without a control group. The register acknowledges difficulties with control conditions, definitions and long-term follow-up in the research.

What the sources report about harms

None of the sources opened for this page reports a systematic analysis of harms from play therapy. A review of hospital play states no harms, and the visual impairment review notes that adverse events were often not reported. An absence of reports is not evidence that none occurred. Play Therapy UK notes that routine-practice outcome data included some children who deteriorated.

Suitability and care boundaries

Play Therapy UK states that play therapy is not suitable for all children in all circumstances and is not a medical treatment, and that it does not replace clinical, educational or social care interventions. Concerns about development, mood, behavior or safety are reasons to seek assessment from a qualified health or social care professional, and play therapy should not delay that assessment.

Training, registration and regulation

In the United Kingdom, Play Therapy UK runs a Register of Play and Creative Arts Therapists, which it says was first accredited by the Professional Standards Authority in April 2013. It states that certified therapists have 200 hours of clinically supervised practice and accredited therapists 450, after an accredited training programme. Members renew each year with evidence of clinical governance and continuing professional development.

The referrers' guide adds that registered practitioners hold an Enhanced DBS disclosure and professional indemnity insurance and receive ongoing clinical supervision. These are the register's own statements and were not independently audited. The Association for Play Therapy's own pages could not be opened for this page, so United States credential requirements are not described, and no statutory regulation was reviewed.