




































Journal Final Revised Margins.indd


Aarons 

   Journal of Student Social Work, Volume II   27

Over three million children in the United States are reported to state child 
protection services as alleged victims of sexual, physical, and emotional 
abuse and neglect each year. Of these cases, approximately 903,000 are 
substantiated. Twelve percent of the substantiated cases involve child 
sexual abuse. This author provides an overview of the prevalence, risk 
factors, and symptomology of sexually abused children and critically ex-
amines the use of play therapy as an assessment and intervention tool.

THE USE OF PLAY THERAPY WITH CHILD 
VICTIMS OF SEXUAL ABUSE

Jamie D. Aarons 

Introduction to Child Sexual Abuse

Over three million children in the United States were reported 
to state child protection services as alleged victims of sexual, 

physical, and emotional abuse and neglect in 2003 (US Department of 
Health and Human Services, 2003). Of these cases, approximately 903,000 
were substantiated. Twelve percent of the substantiated cases involved child 
sexual abuse (Kuehnle, 2003). Among males, the rate of sexual abuse is .4 
per 1000; among females it is 1.7 per 1000 (US Department of HHS, 2003). 
While these abuse and neglect figures encompass children under age 18, 
over 50% of those children are below the age of eight. Childhood sexual 
abuse is clearly a pressing social problem.

Research suggests that national incidence figures may represent less 
than one-third of all occurring cases of maltreated children in America 
(Briere & Elliott, 2003; Finkelhor, 1994). This may be especially true for 
boys who are sexually abused, perhaps due to a stigma attached to their 
accounts. Incidents of child abuse during the preschool years are also likely 
to be underreported (Kuehnle, 2003). Further variability in national rates 
may exist because of the diversity of definitions that are employed by 
individual states. For instance, some states exclude child-on-child sexual 
abuse from their data. For the purposes of this paper, the definition of child 
sexual abuse will be that published by Cohen and Mannarino (1984), which 
defines child sexual abuse as “sexual exploitation involving physical contact 
between a child and another person. Exploitation implies an inequality of 
power between the child and the abuser on the basis of age, physical size, 
and/or the nature of the emotional relationship. Physical contact includes 



anal, genital, oral, or breast contact” (p. 343).
Children are at an increased risk of sexual abuse when parents are unable 

to adequately supervise or nurture them, due to factors such as community 
or domestic violence, substance abuse, poverty, and single-parent status 
(Kuehnle, 2003). In a study by Straus, Gelles, and Steinmetz (as cited in 
Kuehnle), physical or sexual child abuse was found to occur simultaneously 
in 30 to 70% of two-parent families in which there was domestic violence. 
Other risk factors include early sexual maturation in girls and emotional and 
physical disabilities. Based on general population surveys, abuse by parents 
and step-parents constitutes between six and 16% of all cases, and abuse by 
any other relative comprises more than one-third of the cases. In clinical 
samples, parent figures comprise between one quarter and one third of the 
offenders, and all other relatives comprise approximately one half (Berliner 
& Elliott, 2002). 

Symptomology of Child Sexual Abuse Victims
Sexually abused children may exhibit a wide range of potential 

symptoms, including low self-esteem, anxiety, depression, anger and 
aggression, posttraumatic stress, or dissociation. Much of the externalized 
emotional distress comes as a result of the children’s level of hyperarousal, 
emotional pain, and restimulation of abuse memories; the abuse represents 
a constant challenge to their coping mechanisms (Berliner & Elliott, 2002). 
Thus, any external activity that successfully reduces internal tension (e.g., 
through distraction, self-soothing, or anesthesia) is reinforced and sought 
out by the child. According to Berliner and Elliott, negative manifestations 
of these behaviors include self-mutilatory activities; increased or precocious 
sexual activity; bingeing and purging; and alcohol or substance abuse. 
Some minors who have been sexually victimized exhibit school-related 
difficulties, including low time-on-task, acting-out behaviors, and low 
academic achievement. In a study of adults who had been sexually abused 
as children, Saunders, Villeponteaux, Lipovsky, Kilpatrick, and Veronen 
(1992) found that these adults suffered a wide range of psychiatric disorders 
and problems, including depression, phobias, obsessive-compulsive 
disorder, panic disorder, post-traumatic stress disorder, sexual disorders, 
and both suicidal ideation and suicide attempts. 

Once sexual abuse has occurred, the child’s functioning is likely to be 
more positive if the following conditions occur: the child is not closely 
related to the perpetrator; the child’s mother believes the report and is 
supportive; the family is stable and without violence; the sexual acts were 
not violent in nature; and the child endured the abuse for a shorter period 
of time (Kuehnle, 2003). The child will also have an increased likelihood 
of long-term positive outcomes if he or she utilizes an active/social coping 
strategy – as opposed to avoidant, internalized, or angry strategies – and does 

The Use of Play Therapy with Child Victims of Sexual Abuse

28   Journal of Student Social Work, Volume II   



not blame him- or herself for the abuse (Kuehnle). Based on the significant 
impairment that sexual abuse poses to the psychological and behavioral 
outcomes of children and adults, it is obvious that effective intervention 
strategies are necessary at an early age. 

Reviews of the treatment outcome literature provide evidence that 
abuse-specific cognitive behavioral treatments (CBT) are effective for the 
posttraumatic stress reactions related to child sexual abuse (Berliner & 
Elliott, 2002). Commonly, this therapy includes psychoeducation, which 
involves the provision of information about the nature of the abuse and 
offenders, in addition to anxiety management. Children are taught how 
to identify their emotions and how to use various relaxation and coping 
strategies. Elements from exposure therapy are utilized, involving the 
gradual exposure to the abuse experience in order to de-condition automatic 
negative associations and to reduce maladaptive avoidance. This is sought 
through talking, drawing, or writing about the abuse. Finally, cognitive 
therapy is “used to challenge and replace cognitive distortions about the 
event or generalized negative attributions about self and others” (Berliner 
& Elliott, 2002, p. 67). Parents can be included in this treatment with some 
positive outcomes related to child behavior problems and improved parental 
support. Other potential approaches for this population, such as family 
therapy, behavioral interventions, and pharmacological treatments, have yet 
to be thoroughly empirically evaluated for effectiveness in treating sexually 
abused children. 

Another therapy that has not undergone empirical testing for use with 
sexually abused children but that may prove effective is play therapy. One 
reason that play therapy may be a particularly useful approach for sexually 
abused children is that they have not yet developed the abstract reasoning 
abilities and verbal skills needed to adequately articulate their feelings, 
thoughts, and behaviors. “For children, toys are their words, and play is their 
conversation” (Hall, Kaduson, & Schaefer, 2002, p. 515). Play provides a 
symbolic language that makes communication possible. This paper will 
provide an overview of play therapy and critically examine its role as an 
assessment and intervention tool with the population of child sexual abuse 
victims.

Defining Play Therapy
Play therapy is a general term used to describe a variety of interventions 

that incorporate the use of play into the assessment and treatment of children 
and families. There are two basic forms of play therapy: directive and non-
directive. Directive approaches are those in which the therapist selects the 
activity and moves the child’s play or discussion toward a specific topic or 
goal. This structured approach includes cognitive-behavioral play therapy, 
as described by Knell (1999). In nondirective, unstructured play therapy, 

Aarons 

   Journal of Student Social Work, Volume II   29



the therapist concentrates on establishing a relationship of unconditional 
acceptance of the child, within a safe environment, while the child is 
allowed to choose the play medium, set their own rules, and use the play 
objects and time as they wish (Guerney, 2001). Included in this category 
is the child-centered play therapy (CCPT) method developed by Axline 
(1969), based on the client-centered work of Carl Rogers, and non-directive 
puppet therapy (Carter, 1987). 

Past Research on Play Therapy
In a comprehensive play therapy literature review by Phillips in 1985 

(as cited in White & Allers, 1994), it was concluded that among 200 case 
studies, anecdotal articles, and empirical research reports that existed at 
the time, there were inconsistent definitions of play therapy, inadequate 
definitions of the qualifications and role of the play therapist, and inadequate 
or flawed statistical design. Based on the findings of this author’s research 
and current literature review, 18 years after Phillips’ analyses, the evidence 
related to play therapy appears nearly identical to that reviewed by Phillips, 
lacking well controlled-studies that could offer meaningful and informative 
statistics with which to empirically support the use of play therapy. 

Rationale for Play Therapy with Child Sexual Abuse Victims
For the past 17 years play therapy has been regarded by numerous 

clinicians and researchers as a potentially effective intervention tool for use 
with child victims of sexual abuse. Regardless of the specific approach, most 
of the authors emphasize providing these children with a secure therapeutic 
setting in which the therapist shows support, acceptance, and perseverance. 
The authors also emphasize a setting in which the therapist acknowledges 
the thoughts and feelings expressed within the sessions (Carter, 1987; Kelly, 
1995; Knell, 1999; McMahon, 1992; Singer, 1990). 

Psychoanalytic play therapy, which incorporates both directive and non-
directive approaches (Singer, 1990), aims to alter inner or outer functioning 
of the child by helping the sexually abused child understand his experiences 
and feelings. This occurs through the use of verbalization, interpretation, 
and clarification. A review of studies by Casey and Berman (as cited in 
Singer) “found good evidence that psychotherapy with children (compared 
to untreated controls) is at least as effective as with adults . . .” (p. 225). 
This supports the psychotherapeutic foundation on which child-centered 
play therapy is based. Consistent with the findings of Phillips, however, 
there is no indication that these studies had adequate sample sizes or that 
they utilized uniformed measurements. In a comparison study of parent 
therapy, play therapy, group therapy, and behavior modification for a cohort 
of children with a broad range of behavior problems, psychotherapeutic 
play therapy proved most effective for those children with internalizing 

The Use of Play Therapy with Child Victims of Sexual Abuse

30   Journal of Student Social Work, Volume II   



behaviors, such as depression, withdrawal, self-doubt, and fears (Singer). 
This could be promising evidence considering that these behaviors are 
consistent with those of many sexual abuse victims, as described earlier. 
Again, the term “psychotherapeutic play therapy” is used loosely, however, 
and it is impossible to surmise which aspects of the treatment were effective. 
The majority of support offered comes, instead, from individual case studies 
and anecdotes (Kelly, 1995; Singer).

Research related to both directive cognitive-behavioral play therapy 
and child-centered nondirective play therapy provides evidence to support 
the tenets on which they are based, but does not provide specific empirical 
evidence proving their effectiveness with sexually abused children. For 
example, Axline’s nondirective approach is based on the empirical and 
clinical evidence demonstrating support for Rogers’ client-centered 
methods. Likewise, in a study by Parpel and Maccoby (as cited in Guerney, 
2001), a group of children whose mothers were taught to make supportive 
statements and to use nondirective approaches during play demonstrated 
more compliance than children whose mothers followed their own course 
(p. 14). This data offers support for the potential of child-centered play 
therapy but certainly does not qualify as empirical evidence to back this 
clinical approach. 

Literature that devotes specific attention to the use of child-centered 
play therapy with sexually abused children is limited to case studies and 
anecdotal clinician and parent reports (Carter, 1987; Guerney, 2001; 
McMahon, 1992). By relaying examples from her own clinical practice, 
McMahon suggests a combination of nondirective and focused play 
techniques to be most effective with this population. She posits that the use 
of anatomically correct dolls is helpful both as an assessment and treatment 
tool, but provides no empirical evidence to back this claim. Suggested 
child-centered play therapy goals for the sexually abused child include 
the restoration of trust, the normalization of feelings, increasing feelings 
of control, expressing and coping with feelings of anger, fear, disgust and 
sadness, and enabling the eventual development of normal relationships of 
mutual sharing and care (McMahon). 

Like child-centered play therapy, cognitive-behavioral play therapy is 
grounded in a body of research based on intervention strategies that have 
been proven effective with adults. Modeling, which is useful with adults 
(Bandura, as cited in Knell, 1999), is used to improve coping and as a means 
of psychoeducation with children; role-plays are used to practice problem 
solving skills and adaptive behaviors. According to Knell, “the fact that 
cognitive behavior therapies for adults have been empirically validated does 
not mean the same holds true for children” (p. 402). Her own evidence in 
support of cognitive-behavioral play therapy with sexually abused children 
is in the form of case examples.

Aarons 

   Journal of Student Social Work, Volume II   31



Play Therapy as an Assessment Tool
Aside from the lack of empirical evidence to support the use of play 

therapy as an intervention tool, multiple authors recognize play as a vital 
means of assessing the sexually abused child (McMahon, 1992; Norton 
& Norton, 1997; White & Allers, 1994). Corresponding to the symptoms 
described previously, children who have been sexually abused may display 
developmental immaturity, opposition and aggression, withdrawal and 
passivity, self-destruction or self-deprecation, hypervigilance, sexuality, or 
dissociation during their play (Howard; Martin & Beezley; Terr, as cited in 
White & Allers, 1994). In comparison to a healthy child, the abused child 
may display a high level of intensity, atypical rigidity in play, or be overly 
dependent on the therapist for guidance in play. These play behaviors and 
themes have been shown to be valid and reliable means of identifying 
and assessing the sexual abuse victim. However, much of the research is 
based on small sample sizes and there is also a need for variables, such 
as hypervigilant and aggressive behaviors, to be defined thoroughly and 
consistently in future research.

Conclusion
Child sexual abuse is a disturbing problem within our nation – one that 

has serious behavioral and psychological ramifications for all involved. 
Play therapy, which may be directive, nondirective, or a combination of 
the two, is increasingly used for the clinical treatment of sexually abused 
children. Play therapy is the primary intervention model utilized by many 
social workers with children. Supporters of play therapy stand firm in their 
belief that this is an important clinical technique. Most of the research on 
play therapy and childhood abuse, however, has relied on non-statistical 
observations using single case or small-group samples. Just as Phillips (as 
cited in White & Allers, 1994) recommended 18 years ago, research deficits 
in the field must be addressed if therapists are to provide these children with 
effective care. 

Now, and in the future, social workers will play a significant role in 
providing empirical research for the use of play therapy in the treatment 
of child sexual abuse victims. Statistical evidence is needed to show the 
effectiveness, or lack thereof, of play therapy with this population. Evidence 
is also clearly needed that compares the effectiveness of play therapy to 
other treatment modalities, including cognitive behavior therapy, family 
therapy, or nonspecific supportive therapy. 

The Use of Play Therapy with Child Victims of Sexual Abuse

32   Journal of Student Social Work, Volume II   

References
American Academy of Child and Adolescent Psychiatry. (1998). Practice 

parameters for the assessment and treatment of children and 
adolescents with posttraumatic stress disorder. Journal of the American 



Academy of Child and Adolescent Psychiatry, 37(10, Suppl.), 4S-26S.
Axline, V. (1969). Play Therapy. New York: Ballantine Books.
Berliner, L., & Elliott, D. M. (2002). Sexual abuse of children. In J. E. 

B. Myers, L. Berliner, J. Briere, C. T. Hendrix, C. Jenny, & T. A. Reid 
(Eds.), The APSAC Handbook on Child Maltreatment (2nd ed.) (pp. 
55-78). Thousand Oaks, CA: Sage Publications, Inc.

Briere, J., & Elliott, D. M. (in press). Prevalence and psychological 
sequelae of self-reported childhood physical and sexual abuse in 
a general population sample of men and women. Child Abuse and 
Neglect.

Bromberg, D. S., & Johnson, B. T. (2001). Sexual interest in children, 
child sexual abuse, and psychological sequelae for children. 
Psychology in the Schools, 38(4), 343-355.

Carter, S. R. (1987). Use of puppets to treat traumatic grief: A case study. 
Elementary School Guidance and Counseling, 21(4), 210-215.

Cohen, J. A., & Mannarino, A. P. (2000). Predictors of treatment outcome 
in sexually abused children. Child Abuse and Neglect, 24(7), 983-994.

Finkelhor, D. (1994). Current information on the scope and nature of child 
sexual abuse. Future of Children, 4, 31-53.

Guerney, L. (2001). Child-centered play therapy. International Journal of 
Play Therapy, 10(2), 13-31.

Hall, T. M., Kaduson, H. G., & Schaefer, C. E. (2002). Fifteen effective 
play therapy techniques. Professional Psychology: Research and 
Practice, 33(6), 515-522.

Johnson, L., Bruhn, R., Winek, J., Krepps, J., & Wiley, K. (1999). The use 
of child-centered play therapy and filial therapy with Head Start 
families: A brief report. Journal of Marital and Family Therapy, 25(2), 
169-177.

Kelly, M. M. (1995). Play therapy with sexually traumatized children:
Factors that promote healing. Journal of Child Sexual Abuse, 4(3), 
1-12.

Knell, S. M. (1999). Cognitive-behavioral play therapy. In S. W. Russ & 
T. H. Ollendick (Eds.), Handbook of Psychotherapies with Children 
and Families (pp. 385-404). New York: Kluwer Academic/Plenum 
Publishers.

Kuehnle, K. (2003). Child sexual abuse evaluations. In A. M. Goldstein & 
I.B. Weiner (Eds.), Handbook of psychology: Vol. 11. Forensic 
psychology (pp. 437-460). Hoboken, NJ: John Wiley & Sons, Inc.

McMahon, L. (1992). The use of play in helping sexually abuse children. 
In The Handbook of Play Therapy (pp. 154-179). London: Routledge.

Norton, C., & Norton, B. (1997). Assessing children in the play therapy 
intake. In Reaching Children Through Play Therapy (pp. 138-141). 
Denver, CO: The Publishing Cooperative.

Saunders, B. E., Villeponteaux, L. A., Lipovsky, J. A., Kilpatrick, D. G., & 

Aarons 

   Journal of Student Social Work, Volume II   33



Veronen, L. J. (1992). Child sexual assault as a risk factor for mental 
disorders among women: A community survey. Journal of 
Interpersonal Violence, 7(2), 189-204).

Singer, D. G. (1990). Play as healing. In The House of Make-Believe (pp. 
201-229). Boston: Harvard University Press.

United States Department of Health and Human Services. (2003). Child 
welfare outcomes 2000: Annual report. Retrieved October 13, 2003, 
from http://nccanch.acf.hhs.gov/frames/frameset_c.cfm?url=http%3A
%2F%2Fwww%2Eacf%2Ehhs%2Egov%2Fprograms%2Fcb%2Fpubli
cations%2Fcwo00%2Findex%2Ehtm

White, J., & Allers, C. T. (1994). Play therapy with abused children: A 
review of the literature. Journal of Counseling and Development, 
72(4), 390-405.

Jamie D. Aarons is a second-year Master’s student at the Columbia Uni-
versity School of Social Work and is enrolled in the dual-degree program 

at Bank Street College pursuing a Master’s degree in Early Childhood 
Special Education. She is currently an intern at the Northside Center for 

Child Development in the Early Therapeutic Center in New York City. 
She holds a Bachelor’s degree in Human Development and Psychological 

Services from Northwestern University. 

34   Journal of Student Social Work, Volume II   

The Use of Play Therapy with Child Victims of Sexual Abuse


