RePost from NOFASD Australia, written by Suzanne Hall 

While limited empirical research has been done on the effectiveness of therapies for FASD, practice-based evidence tells us that Play Therapy is beneficial for many children and teens with FASD. Therapist Suzanne Hall shared this case study with NOFASD, with permission from the family involved. Read it below. 

Over the past two years, I’ve had an opportunity to work with a delightful family. My interaction with this family has been just as enriching for me as, I hope, it has been for them. The mother came to me as a last resort. After trying many therapeutic approaches for her son with FASD, she came across Filial Therapy on our website.

I am a psychologist, who works primarily with children through play therapy, but I also teach a hybrid of Filial Therapy and Child Parent Relationship Therapy – an approach that teaches parents and carers the basic skills to conduct play therapy sessions at home with their child. This approach appealed to the mother, as her son often shut down with other professionals and the parents then experienced an escalation in aggressive behaviours from him afterwards.

When the mother first came to see me, I was practicing Child Centered Play Therapy exclusively. More recently I have incorporated Synergetic Play Therapy into my practice, which has made all the difference to this family. But more on that later. Child Centered Play Therapy (CCPT) was founded by Virginia Axline over 60 years ago and is based on Carl Roger’s Person Centered Therapy. Essentially, the tenets of this approach are to accept the child exactly as they are and to form a relationship of complete acceptance and non-judgment. Synergetic Play Therapy is much more recent in origin; founded by Lisa Dion in 2008. It incorporates the latest findings from Neuroscience and Interpersonal Neurobiology (Dr Dan Siegel). One of the most important aspects in Synergetic Play Therapy is that it helps clinicians act as the external regulator for children’s dysregulated states. The result is much faster therapeutic progress.

Both approaches use play as the primary means of healing, and are non-directive. This means that, rather than the clinician choosing what therapeutic activities will help the child heal, the clinician trusts the child to lead the clinician to the exact source of their concerns, through play. In practice, this means that the child chooses what, and how, they play. When this safe and trusting relationship is established, children naturally begin to play through their issues. The clinician’s job is to stay present and attuned to the child and to facilitate a deepening of their play, and therefore, their emotional issues. Whilst doing this, the clinician brings the child’s awareness to what and how they are playing and facilitates their awareness of the emotion that arises (or lack of). Because most children play, play therapy is a very gentle and effective means of helping children. They are not cognitively advanced enough to talk through their concerns. Instead, they can unconsciously project their issues onto toys. For example, the dinosaur can chase the frightened mouse, or the doll can be sad.

 For children with FASD, play therapy can be particularly appropriate:

• Play does not require verbal skills, so children do not have to rely on the complex task of turning thoughts into words.
• Children with FASD often struggle to emotionally regulate. Play therapy helps them to gently become aware of their difficulties in this area, and creates a space for experimenting with different ways of being and acting.
• Play therapy provides a consistent and predictable environment that can allow the child’s nervous system to take a deep relaxing breath. For 45 minutes, once per week, the child can experience an environment free of the myriad threats and challenges that constantly bombard their nervous system.
• Often, children with FASD have many therapies to help them ‘be as normal as possible’. The tenets of CCPT are to accept the child as they are, and through this acceptance comes growth and healing. For a child who is inundated with (well-meaning) indirect messages of ‘you are not ok the way you are, you need to change’; play therapy can be a much-needed sanctuary and respite.
• Likewise, CCPT provides a space free from behavioural restrictions. While there are of course limits which keep child, therapist and toys safe, the therapist strives to place as few limits on the child’s behaviour as possible. For children who are so used to being told “no!” (with good reasons no doubt!), this freeing space can be just what they need to emotionally express frustrations, anger, sadness or any other pent up emotion.

When the mother of this child approached me, I expressed my concerns regarding my lack of FASD knowledge and the fact that there was no research known to me that supported this therapeutic approach with children who have FASD. My other concern was that the child’s already aggressive behaviours may escalate, as this is a common initial side effect of play therapy (as the child’s concerns come to the surface, they can temporarily exacerbate). We both agreed to proceed with caution and to carefully monitor the impact on her son.

I would be lying if I said that this child’s therapeutic course was straight forward! While initially showing promise, he later became quite resistant to therapeutic sessions with his mother. He didn’t like that she didn’t seem to be herself (the style of speaking in CCPT can be quite different for children). I also suspect that the therapeutic issues being brought to the surface by his play were at times too overwhelming for his sensitive neurology. The mother and I worked hard to modify the therapy in ways that would not cause too much opposition in him. In the end, we arrived at an approach that worked. But we both agreed that it was important to have a starting point in traditional CCPT. The mother and I still believe that CCPT would be an appropriate intervention for many children with FASD, however, like in this child’s case, it may need some modifying.

This child’s therapeutic journey has come a long way. Now, in addition to the therapeutic sessions, a powerful intervention has been integrating Synergetic Play Therapy skills into the mother’s everyday interactions with her child. Through reflecting how she feels during her interactions with him, she is able to use this skill as a tool for being the external regulator for him, which has in turn decreased his volatility and increased his emotional awareness. Additionally, a most important and overlooked aspect of parenting a child with FASD is parent/carer burn out. One of the most exciting gifts I have been able to offer the mother is a way to begin to regulate her own self during interactions with her son, which helps preserve her emotional well-being and guard against burn out.

I have learned many things while working with this family. The obstacles that children with FASD face are unique and therefore their responses to therapy are highly individual. Rather than soldiering on with one approach, I have learned the importance of modifying the approach for success, based on each child’s presentation. Professionally, I value and place great importance on my relationship with parents/carers. However, in cases of children with FASD, this takes on a much greater significance. I have grown to learn that the world of psychology is largely ignorant of FASD, and that included myself. I had to step back as the ‘expert’ and honour the mother’s profound knowledge of her child and of FASD. We became collaborators rather than professional and client, where the mother guided me and I followed along with ideas and suggestions. A lovely outcome of my work with the mother, is a relationship I have begun to develop with her son. Although I have heard what he is like at his worst, I have also been able to come to know him at his best. I cherish my relationship with him just as much as I do my relationship with his mother and I hope that I am another resource he can use for support.

For parents and carers looking for a play therapist, they may be hard pressed finding one who is also sufficiently knowledgeable in FASD. Although ideal, I think there are other important traits to look for in a therapist. I also do not want to suggest that CCPT and/or Synergetic Play Therapy are the only successful paths. There are many wonderful play therapies out there each with their own merits. I’ve listed below, some of the most important qualities I think are needed in a therapist. Please feel free to comment below with your own thoughts on the qualities needed – you are the experts!

• Do they listen to you? Do you feel heard and understood?
• Do you feel accepted and honoured as a parent or carer, rather than judged?
• Are they willing to learn about FASD?
• Are they willing to treat you as an expert?
• Are they willing to work with you as a collaborator, or as a co-therapist?
• Are they able to be creative, and modify their approach to suit the child?
• Perhaps most importantly, does the therapist take an approach of viewing behaviours from a neurological and brain-based perspective? Can they support you in reframing your reactions to your child’s behaviour, to one of compassion and understanding?
• Will the therapeutic approach accept your child for who they are? Or will it just be another intervention that tries to change who they are?

Through my work with this family, I have been able to get a sense of what living with FASD and parenting a child with FASD is like. The challenges can be monumental and the courage and effort are heroic, for both parent and child. I think the most important gift that a therapist can give a child and parent alike, is the message which is embedded in the play therapy approach: “I hear you. I see you”.

Suzanne Hall

Read more NOFASD Australia blogs