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Clinical Mental Health Counseling in Child-Centered Play Therapy


This research paper aims to conduct a theoretical review of literature on child-centered therapy. School-aged children are experiencing an increase in mental health issues that require the interventions of experts in mental health. Managing and treating mental health issues in children requires the role of clinical mental health counselors (CMHC/SC) who are based at school or community levels. School-based CMHCs are effective in providing mental health services to school-aged children. Among the most effective methods which should be used is child-centered play therapy (CCPT). Child-centered therapy is an important tool that CMHC/SCs must utilize to meet the individual needs of school-aged children with mental health issues. This tool is based on the view that children should live in an environment where they are appreciated, loved, accepted, and allowed to express themselves while also interacting with others.

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Keywords: Mental health issues, CMCH/SC, CCPT, school-aged children, counselors, school-based


In modern times, school-aged children are experiencing an increase in mental health issues that require the interventions of experts in mental health. Modern school-aged children are increasingly being exposed to various family, social, cultural, and economic issues that are likely to harm their mental health (Bitsko et al., 2019). The increased rate of divorce, parental conflict, children abuse, exposure to aggressive experiences, and other factors contribute to mental health issues among school-aged children and adolescents. In American today, parental divorce and conflicts, and child abuse are considered some of the major contributors of mental health issues among school-aged children. Children caught up in divorce, those exposed to parental conflict, and the child victims of abuse have a high risk of developing mental health issues that warrant the intervention of experts in clinical psychology and counseling (Bitsko et al., 2019). Other factors that contribute to mental health issues in school-aged children include physical bullying, cyberbullying, the stressful environment at home and neighborhoods such as exposure to violence, death of parents, siblings, and other family members, economic hardships, and others. Studies have shown that all these factors, whether alone or in combination, place school-aged children at high risks of developing mental health issues that warrant expert professionals to manage.

School-aged children experiencing mental health issues require the attention and services of school counselors. Nevertheless, the role of school counselors (SC) in addressing the children’s mental health issues is limited by certain factors (Bitsko et al., 2019). School counselors have to provide referrals to services provided by community-based counselors. Specifically, the community-based clinical mental and health counselors (CMHCs) bear the largest burden of providing services to children with mental health issues within their communities (Bitsko et al., 2019). However, there are still barriers that prevent students from receiving all the help they need from the CMHCs, even though these practitioners are equipped to give the necessary therapeutic interventions.

Therefore, to circumvent these barriers, many schools across the country are collaborating with MCHCs to provide mental health counseling services to the learners within their schools (Bitsko et al., 2019). These programs are run by CMHCs now known as school-based mental health counselors (SBMHC) who are trained and accredited professionals to address the mental health needs of school-aged children. School-based CMHCs apply evidence-based practices (EBP) approaches to ensure that the children receive care based on their conditions. At this point, it is imperative to note that care should be child-centered. Children suffer from mental health problems at different levels or scales based on individual differences and exposures (Bitsko et al., 2019). For this purpose, the concept of Child-Centered play therapy has become an important tool in practice for SBMHCs as they have to put the child at the center of care.

Consequently, this research paper aims to conduct a theoretical review of literature on child-centered therapy. Child-centered therapy is an important tool that CMHC/SCs must utilize to meet the individual needs of school-aged children with mental health issues (Bitsko et al., 2019). Furthermore, the paper provides recommendations for the roles and responsibilities of CMHC/SCs based on the current needs and historical developments in research and practice necessary to inform policy related to children’s mental health issues.

The State of Mental Health in American School-Aged Children

Children in America continue to face a myriad of social, cultural, physical, academic, and economic issues that affect their mental health. Among children, mental disorders are described as serious changes they typically behave, learn, or handle their emotions, resulting in problems handling coping with life or distress (Bitsko et al., 2019). Among the most common mental issues that affect young people are anxiety, behavior disorders, and attention-deficit/hyperactivity disorder (ADHD). Various studies have shown that these and other mental health issues among children are increasing. The Centers for Disease Control and Prevention (CDC) provides annual statistics on the state of mental health issues in children. According to CDC’s 2019 report, ADHD, depression, anxiety, and behavior problems are the most commonly diagnosed mental health problems in children throughout the country (CDC, 2019). The report shows that about 9.4% of American children aged between 2 and 7 (about 6.1 million) are diagnosed with some form of ADHD. Furthermore, about 7.4% (4.5 million) of children aged between 3 and 7 have diagnosed behavior problems. Approximately 7.1% of those between 3 and 17 years, which is about 4.4 million, have been diagnosed with anxiety (CDC, 2019). For diagnosed depression, the burden of disease is about 3.25 of those aged between 3 and 17, which is approximately 1.9 million. Moreover, it is worth noting that the prevalence of depression and anxiety among school-aged children has increased over time.

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Similarly, the number of school-aged children that have at one point in time been diagnosed with anxiety or depression has increased rapidly. The statistics provided indicate this number increased from 5.4% in 2003 to over 8% in 2007 (CDC, 2019). Between 2011and 2012, the number increased again to about 8.5%, and then reached about 8.8% in 2019 (CDC, 2019). In the same way, the number of children aged between 6 and 17 who have been diagnosed with anxiety increased from about 5.5% in 2007 to more than 6.8% in 2018. For depression, those who have ever had a diagnosis are about 5.1% (2019) right from about 4.7% in 2007 (CDC, 2019). Statistics also provide evidence of the extent of these conditions based on the number of those seeking treatment. CDC reports that nearly 8 out of 10 children (over 78%) between the ages of 1 and 17 with depression are receiving treatment (CDC, 2019). Similarly, about 6 in every 10 children (approximately 59.4%) of those between 3 and 17 years receive treatment for anxiety disorder. For behavioral disorders, about 5 in every 10 (approximately 53.5%) of those aged between 3 and 17 receive treatment (CDC, 2019). Therefore, it is evident that there is a large burden of mental health issues among children in the country.

In terms of occurrences, there are differences in the rates of diagnoses among genders, social, economic, and racial backgrounds. Among the children between the ages of 2 and 8, boys have a high risk of developing behavioral, mental ma developmental disorders compared to girls (CDC, 2019). Among the children from families living below 100% of the federal poverty line, over one in every 5 children (22%) has a behavioral, mental, or developmental disorder (CDC, 2019). Both age and level of poverty affect the likelihood of children receiving treatment for behavioral problems, depression, or anxiety disorders.

Studies have shown that early identification of mental health issues among young people is important for success in school and elsewhere. ASCA states that unmet mental health needs among young people tend to interfere with their academic, personal, social, and career development. Those with mental health issues tend to have poor academic outcomes and more than 50% of those who drop out of school have at least one diagnosed mental issue (CDC, 2019). Even though not all mental issues warrant a mental diagnosis, almost every aspect of poor mental health problems affects academic outcomes.

The Role of School-Based Counseling

The CDC states that schools are a convenient setting for children and their families to access healthcare, especially in isolated areas and rural settings. Studies have shown that over 18% of the school-aged children receiving treatment for mental health issues exclusively access school-based services, only 11% exclusively received treatment out of school while about 17% received treatment both at home and school. Furthermore, evidence from research shows that even though school-based counselors are authorized to refer school-aged children to the appropriate services outside the school, most families do not follow the directions and only rely on the schools to provide these important services.

Research shows that providing mental health services at school is likely to improve academic performance as well as personal and social functioning among school-aged children. These studies provide evidence to support the establishment and enhancement of school-based treatment as an important avenue for addressing the mental health needs of school-aged children.

The Concept of Child-Centered Play Therapy

Developed by Axline in 1947, child-centered play therapy (CCPT) is an evidence-based and theoretically grounded intervention that focuses on the relationship between a therapist and a child as the primary factor for healing children with emotional and behavioral problems (Axline, 1964). This intervention is based on the concept of a person-centered counseling approach and has since undergone several refinements to achieve efficiency in treating children with mental health issues (Wilson & Ray, 2018). With more than 80 years of research by various scholars, CCPT is now widely accepted as an evidence-based approach in treating and managing mental health issues in young people (Blanco et al., 2019). A meta-analysis of various studies has shown that CCPT participation across various settings and parts of the world result in statistically significant improvements in behavioral and emotional problems, and child-parent relationships.

The person-centered theory provides the basis for child-centered play therapy. According to this theory, states a child’s construction of the self develops through a tradeoff between his or her innate self-actualization and the personal perceptions of experiences as well as interactions with others in the environment (Wilson & Ray, 2018). The perceived expectations and acceptance by others help young children to come to evaluate their self-worth. A child’s view of the self and the continuous experiences in the environment form the basis from which emotions, thoughts, and behaviors emerge holistically (Blanco et al., 2019). Those children who perceive incongruence between the information they receive from others and personal perceptions are likely to develop fragile and rigid ways of being. In addition, such children are likely to have problematic thought patterns, emotions, and behaviors as they grow. According to Wilson and Ray (2018), there is a powerful force that exists within each child and which strives continuously for self-actualization. Theoretically, the striving force drives the child towards a state of maturity, independence, and self-direction.

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The concept of CCPT focuses on facilitating an environment that gives acceptance, safety, and empathic understanding as a way of unleashing the natural path towards achieving self-growth and other aspects of maturity. In this case, CCPT requires therapists to trust the inner direction of the child to move towards positive growth within their environment (Perryman & Bowers, 2018). It also requires the CMHC practitioner to recognize that the best method of understanding the behaviors and emotions of the child is to empathically understand how that particular child perceives his or her world (Wilson & Ray, 2018). In an environment where the therapist produces and the child perceives a relationship accepting the child’s internal world, CCPT becomes effective. In such a situation, the relationship between a therapist and the child bears personal functionality and integration.

Achieving effective therapy with CCPT requires therapists to consider the children as their clients (Perryman et al., 2020). In this case, CCPT treats the child as the primary focus for a therapist. In most cases, school-aged children are referred to therapists because of their challenging behaviors. However, CCPT therapists must always strive to build a relationship with these children rather than focusing on the problem or reason for the referral (Wilson & Ray, 2018). Studies in the CCPT concept have shown that in most cases, maladjustments tend to result from incongruence that the child experiences between the environmental encounters with others and the concept of the self. Furthermore, studies show that problematic behaviors among school-aged children develop from an inability of the child to reconcile self-perceptions in environmental demands or relationships with others (Wilson & Ray, 2018). This theory suggests that a child’s exhibition of problematic behaviors is a manifestation of his or her view of the self as well as the surrounding environment. Therefore, CCPT therapists should not view problematic behaviors as a representation of a deficit in the child client. Rather, therapists are required to view the problematic behaviors as the child’s attempt to achieve acceptance, attention, or positive perception from others. Nevertheless, studies demonstrate that even CCPT therapists trained in diagnosis tend to conceptualize children through medicalized and deficit-based perspectives (Wilson & Ray, 2018). Indeed, this is a major problem in practice because it violates or negates the tenets of child-centered play therapy and its goals and objectives.

Having reviewed the theoretical tenets of CCPT, it is important to review the literature that describes the appropriate environment for implementing treatment. CCPT should occur in a playroom where carefully selected toys and other play materials are provided to complete the environment (Parker et al., 2021). The purpose of these materials and toys is to facilitate therapeutic use, encourage the expression of different feelings, and promote the building of relationships. Playroom materials should be placed throughout the space within specific categories such as real-life, creative/expression, and acting-out/aggressive release to allow good visibility of each material (Wilson & Ray, 2018). It is imperative to consider the fact that CCPT is concerned with the provision of an environment of safety as a way of facilitating the child’s exploration of the self and release rigid behaviors. Therefore, an important feature in the setting should be the child-directed nature of the entire session. The role of a therapist in the CCPT setting is to facilitate the child’s exploration and also emphatically respond to his or her worldview without the use of guiding goals or therapeutic content.

The specific responses consistent with the CCPT approach include reflective contents, feelings, tracing behaviors, limit setting, encouraging, facilitating relationships, and others. These kinds of responses are the basic skills in therapy that should demonstrate the CMHC’s acceptance, understanding, and belief in the child client.

Similar to most therapeutic approaches for dealing with people with mental health issues, CCPT has a set of goals that therapists seek to achieve in their intervention. According to Wilson and Ray (2018), traditional reference to a goal or objective of treatment is consistent with CCPT. In this case, goals help in evaluating the intervention and tracking specific and externally established achievements expected from the child client (Kottman & Meany-Walen, 2018). Rather than checking off goals, children are related to persons that the therapist must understand deeply during the sessions (Mullen & Rickli, 2014). Therapists must have an unwavering belief in the capacity of the client to grow and achieve self-direction. Therefore, establishing the goals of the treatment proves somewhat difficult.

Nevertheless, therapists applying CCPT should always seek to facilitate an environment for the child client to experience growth and move towards healthy mental and physical functioning. The environment allows the child client to be the leader of the relationship where he or she prefers. When the CMHC practitioner reaches the goal of providing the child with safe and accepting environmental conditions, the child engages in the innate process of moving towards independence and positive behaviors (Wilson & Ray, 2018). Research evidence supports the occurrence of behavioral change as one of the achievable outcomes of CCPT. However, it is worth noting that CCPT does not set out specific behavioral goals in theory and practice. Positive and substantial changes in behavior resulting from CCPT are measurable using instruments that assess the externalization and internalizing behaviors (Wilson & Ray, 2018). In addition, parent-child relationships, self-concept, teacher-child relationships, and academic outcomes are useful instruments for measuring CCPT success.


The large and ever-increasing number of children suffering from mental health issues in the US is attributable to the stressful factors in the environment in which they live. Mental health problems in children remain a social and health issue as they affect the behaviors, relationships, academic achievement, and career development in young people. Consequently, it is necessary to establish effective intervention methods for providing counseling services to the affected children. Nevertheless, the best and most effective intervention is the use of school-based CMHCs who can interact and work with children to help them cope with mental health problems. CCPT is one of the most effective tools and approaches that CMHC practitioners should utilize to effect changes in children’s behavior, relationships, and academic performance. It is based on the view that children should live in an environment where they are appreciated, loved, accepted, and allowed to express themselves while also interacting with others.


Axline, V. (1964). Dibs: In search of self. Houghton Mifflin.

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Bitsko, R. H., Holbrook, J. R., Ghandour, R. M., Blumberg, S. J., Visser, S. N., Perou, R., & Walkup, J. T. (2018). Epidemiology and impact of health care provider–diagnosed anxiety and depression among US children. Journal of Developmental and Behavioral Pediatrics: JDBP, 39(5), 395.

Blanco, P. J., Holliman, R. P., Ceballos, P. L., & Farnam, J. L. (2019). Exploring the impact of child-centered play therapy on academic achievement of at-risk kindergarten students. International Journal of Play Therapy, 28(3), 133–143. Web.

CDC. (2019). Data and statistics on children’s mental health. CDC. Web.

Kottman, T., & Meany-Walen, K. K. (2018). Doing play therapy: From building the relationship to facilitating change. Guilford Press.

Mullen, J.A., & Rickli, J.M. (2014). Child-centered play therapy workbook. Research Press

Parker, M. M., Hergenrather, K., Smelser, Q., & Kelly, C. T. (2021). Exploring child-centered play therapy and trauma: A systematic review of literature. International Journal of Play Therapy, 30(1), 2–13. Web.

Perryman, K. L., & Bowers, L. (2018). Turning the focus to behavioral, emotional, and social well-being: The impact of child-centered play therapy. International Journal of Play Therapy, 27(4), 227–241. Web.

Perryman, K. L., Robinson, S., Bowers, L., & Massengale, B. (2020). Child-centered play therapy and academic achievement: A prevention-based model. International Journal of Play Therapy, 29(2), 104–117. Web.

Ray, D. C., Purswell, K., Haas, S., & Aldrete, C. (2017). Child-Centered Play Therapy-Research Integrity Checklist: Development, reliability, and use. International Journal of Play Therapy, 26(4), 207–217. Web.

Wilson, B. J., & Ray, D. (2018). Child‐centered play therapy: Aggression, empathy, and self‐regulation. Journal of Counseling & Development, 96(4), 399-409. Web.

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