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The Role o Play The apy in S eng hening he Pa en -Child A achmen and I s Impac
on Childhood Anxie y
Haniyeh Gholami1*, Andisheh Golshan2
1Mas e 's s uden in Gene al Psychology, Bad ood Azad Uni e si y, I an
2Mas e 's s uden in Gene al Psychology, Bad ood Azad Uni e si y, I an
A icle in o
Recei ed: 18.09.2025
Accep ed: 21.10.2025
A ailable Online: 23.10.2025
Checked o Plagia ism: Yes
Keywo ds:
play he apy, pa en –child
a achmen , childhood anxie y,
ilial he apy, in e nal wo king
model
A B S T R A C T
Quali y o he pa en –child a achmen ela ionship is a ounda ional
de e minan o child en’s emo ional secu i y and esilience. Dis up ions in his
bond o insecu e a achmen pa e ns a e known isk ac o s o in e nalizing
p oblems, pa icula ly childhood anxie y. In ecen decades, play he apy has
eme ged as a po en , child- iendly in e en ion o os e emo ional exp ession,
egula ion, and ela ional epai . This pape explo es he heo e ical
unde pinnings linking a achmen , anxie y, and play, e iews empi ical
e idence on how play he apy can s eng hen a achmen , and examines i s
e icacy in alle ia ing childhood anxie y. Fi s , a achmen heo y (Bowlby,
Ainswo h) and i s de elopmen al psychopa hology ex ensions a e
summa ized, highligh ing how insecu e a achmen may p edispose o anxie y
symp oms. Nex , we delinea e mechanisms by which play he apy os e s
a achmen epai : o e ing a “sa e base” wi hin he apy, acili a ing co-
egula ion, enhancing pa en sensi i i y ia in ol emen (e.g., ilial play, child–
pa en play), and es uc u ing in e nal wo king models. Then, empi ical
s udies a e e iewed: (a) play he apy’s impac on a achmen secu i y and
ela ional quali y (e.g. Focal Play The apy wi h Child en and Pa en s), (b) g oup
play he apy educing insecu e a achmen in o phans, (c) child-cen e ed
g oup play he apy educing sepa a ion anxie y, and (d) non-di ec i e play
he apy lowe ing gene al anxie y in child en. Me a-analy ic and e iew da a
suppo ing play he apy in in e nalizing symp om educ ion a e also
conside ed. S eng hs, limi a ions, and gaps in cu en esea ch a e discussed,
such as small sample sizes, lack o long- e m ollow-ups, and he e ogenei y o
play modali ies. Finally, clinical implica ions and u u e di ec ions a e ou lined:
he impo ance o in eg a ing pa en al in ol emen , manualiza ion o play
in e en ions, combining play wi h cogni i e-beha io al app oaches, and
conduc ing igo ous longi udinal andomized con olled ials. In sum, play
he apy appea s o hold p omise no only as a symp om- educ ion ool bu also
as a ela ional in e en ion ha add esses he oo a achmen subs a es
unde lying anxie y.
In oduc ion
Childhood is a c i ical pe iod in which ounda ional
emo ional, social, and cogni i e capaci ies a e
es ablished. Among he my iad ac o s in luencing
heal hy de elopmen , he quali y o he pa en child
a achmen ela ionship s ands ou as a co ne s one
o emo ional secu i y and esilience. A achmen
heo y, ini ially o mula ed by John Bowlby (1982)
and expanded h ough empi ical esea ch by
Ainswo h e al. (1978), emphasizes ha child en
equi e a consis en and esponsi e ca egi e o eel
sa e explo ing hei en i onmen and managing
s ess. Secu e a achmen no only acili a es social
compe ence and adap i e coping bu also se es as a
p o ec i e ac o agains in e nalizing p oblems,
including anxie y diso de s. In con as , insecu e
a achmen pa e ns such as a oidan , ambi alen , o
diso ganized a achmen ha e been consis en ly
*Co esponding Au ho : Haniyeh Gholami (haniyehgh1375psychologis @gmail.com)
1 Email: Andisheh_gols[email p o ec ed]om)
Ad anced Jou nal o Managemen , Humani y and Social Science
Jou nal homepage: h ps://www.ajmhss.com/
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linked o ele a ed isks o anxie y symp oms,
emo ional dys egula ion, and di icul ies in o ming
heal hy in e pe sonal ela ionships. Childhood
anxie y, encompassing sepa a ion anxie y,
gene alized anxie y, and social ea s, ep esen s one
o he mos p e alen men al heal h conce ns in ea ly
de elopmen . Epidemiological s udies sugges ha
anxie y diso de s a ec app oxima ely 10-20% o
child en wo ldwide, o en esul ing in impai ed
academic pe o mance, social di icul ies, and
inc eased isk o psychia ic como bidi ies la e in
li e. T adi ional in e en ions, such as cogni i e-
beha io al he apy (CBT), ha e demons a ed
e icacy; howe e , many child en, pa icula ly
younge ones, s uggle o engage in e bal o
abs ac he apeu ic modali ies. This challenge
highligh s he impo ance o de elopmen ally
app op ia e, child-cen e ed in e en ions ha can
accommoda e limi ed e bal capaci ies and
encou age emo ional exp ession in a na u alis ic,
engaging o ma .
Play he apy has eme ged as a p ominen
in e en ion add essing hese needs. De ined as he
sys ema ic use o play o communica e wi h and help
child en esol e psychosocial challenges, play
he apy p o ides a medium o child en o exp ess
emo ions, p ocess expe iences, and de elop
p oblem-sol ing skills in a non- h ea ening
en i onmen . No ably, when combined wi h ac i e
pa en al in ol emen , play he apy holds po en ial
no only o alle ia e anxie y symp oms bu also o
s eng hen he pa en child a achmen bond, he eby
add essing he unde lying ela ional mechanisms
con ibu ing o emo ional dis ess.
This pape examines he heo e ical and empi ical
e idence linking play he apy, pa en –child
a achmen , and childhood anxie y. Fi s , i e iews
ounda ional a achmen heo y and he
de elopmen al pa hways h ough which insecu e
a achmen con ibu es o anxie y. Nex , i explo es
mechanisms by which play he apy can enhance
a achmen secu i y, including co- egula ion,
pa en al sensi i i y aining, and es uc u ing o
in e nal wo king models. The pape hen p esen s a
syn hesis o empi ical s udies in es iga ing he
e icacy o play he apy in e en ions in educing
childhood anxie y and imp o ing ela ional
ou comes. Finally, clinical implica ions, esea ch
gaps, and u u e di ec ions a e discussed,
emphasizing he impo ance o in eg a ing
a achmen - ocused s a egies wi hin play-based
he apeu ic in e en ions.
Theo e ical Founda ions
A achmen Theo y and In e nalizing
Symp oms:
A achmen heo y, pionee ed by John Bowlby
(1982) and empi ically expanded by Ma y
Ainswo h and colleagues (1978), p o ides a obus
amewo k o unde s anding how ea ly ela ional
expe iences shape emo ional and social
de elopmen . Acco ding o his heo y, he p ima y
ca egi e se es as a "secu e base," o e ing sa e y,
com o , and emo ional egula ion ha allows he
child o explo e he en i onmen and engage wi h
social and cogni i e challenges. Secu e a achmen
eme ges when ca egi e s consis en ly espond o a
child’s needs wi h sensi i i y and a ailabili y,
os e ing us , emo ional s abili y, and adap i e
coping s a egies.
In con as , insecu e a achmen a ises when
ca egi e esponsi eness is inconsis en , insensi i e,
o in usi e. The e a e h ee p ima y o ms o
insecu e a achmen :
A oidan a achmen , cha ac e ized by
emo ional dis ancing and supp ession o
a achmen needs, ypically de elops in
esponse o ca egi e s who a e emo ionally
una ailable o dismissi e.
Ambi alen (o anxious esis an )
a achmen , cha ac e ized by heigh ened
dis ess and p eoccupa ion wi h ca egi e
a ailabili y, o en eme ges when ca egi e
esponses a e unp edic able.
Diso ganized a achmen , e lec ing a lack
o cohe en s a egy o seeking com o , is
associa ed wi h ea -inducing o
igh ening ca egi e beha io and o en
co-occu s wi h auma (Main & Solomon,
1990).
Ex ensi e esea ch has demons a ed ha insecu e
a achmen pa e ns se e as isk ac o s o
in e nalizing p oblems, pa icula ly anxie y
diso de s (S ou e e al.,2005; an Ijzendoo n &
Sagi-Schwa z,2008). Insecu ely a ached child en
o en display heigh ened igilance o pe cei ed
h ea s, di icul ies wi h emo ion egula ion, and
maladap i e coping s a egies. Fo ins ance,
a oidan ly a ached child en may supp ess anxie y
ou wa dly bu expe ience ch onic physiological
a ousal, whe eas ambi alen ly a ached child en
may become excessi ely dependen on ca egi e s,
exhibi ing sepa a ion anxie y and heigh ened
dis ess. Diso ganized a achmen is equen ly
linked o se e e anxie y, beha io al dys egula ion,
and subsequen isk o dep ession and o he
psychopa hologies.
The mechanism unde lying his associa ion can be
concep ualized h ough in e nal wo king model.
These cogni i e-a ec i e schemas ep esen
expec a ions abou sel -wo h, ca egi e eliabili y,
and he p edic abili y o ela ionships. Child en wi h
insecu e a achmen in e nalize nega i e models,
such as “I am unwo hy o ca e” o “Adul s canno
be us ed,” which p edispose hem o an icipa o y
anxie y, hype igilance, and social wi hd awal.
Impo an ly, hese in e nalized models a e no ixed;
in e en ions a ge ing ela ional expe iences can
modi y hese ep esen a ions, highligh ing he
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ele ance o a achmen - ocused he apy o anxie y
educ ion.
De elopmen al Psychopa hology Pe spec i e
A achmen heo y aligns closely wi h a
de elopmen al psychopa hology amewo k, which
emphasizes he dynamic in e play be ween
indi idual ulne abili ies and en i onmen al ac o s
ac oss he li espan. F om his pe spec i e, insecu e
a achmen cons i u es a ulne abili y ac o ha
in e ac s wi h s esso s, empe amen , and ca egi e
psychopa hology o inc ease he likelihood o
anxie y symp oms. Fo example, a child wi h a
di icul empe amen may be mo e sensi i e o
inconsis en pa en ing, leading o heigh ened
anxie y, whe eas p o ec i e ac o s such as pa en al
in ol emen in he apy can mi iga e hese isks.
De elopmen al psychopa hology also unde sco es
ansac ional p ocesses, in which child and ca egi e
ecip ocally in luence each o he ’s emo ional
esponses, ein o cing pa e ns o a achmen
secu i y o insecu i y.
Play as a Medium o Emo ional Exp ession and
Regula ion
Play is a uni e sal and de elopmen ally essen ial
ac i i y ha suppo s cogni i e, emo ional, and
social g ow h. The Ame ican Academy o Pedia ics
highligh s ha play allows child en o explo e ideas,
mas e emo ions, sol e p oblems, and es ablish
social oles. F om a he apeu ic pe spec i e, play
se es as a na u al language h ough which child en
exp ess eelings, ea s, and expe iences hey may
no ye ha e wo ds o desc ibe. In pa icula ,
symbolic and p e end play p o ides a sa e con ex o
p ocess anxie y-p o oking expe iences, p ac ice
coping s a egies, and expe imen wi h ela ional
oles.
The apeu ically, play enables child en o ex e nalize
in e nal con lic s, e-enac s ess ul scena ios, and
explo e al e na i e ou comes wi hou ea o
judgmen . Play in e en ions can be di ec i e
( he apis -guided), non-di ec i e (child-led), o a
hyb id app oach, depending on he child’s needs and
de elopmen al le el. Impo an ly, when pa en s a e
ac i ely in ol ed in play-based he apy such as in
ilial he apy o child pa en play he apy he
in e en ion add esses ela ional mechanisms in
addi ion o symp om elie . Th ough hese
in e ac ions, pa en s lea n o a une o he child’s
cues, egula e emo ional esponses, and os e a
secu e ela ional en i onmen .
In eg a ion o A achmen Theo y and Play
The apy
Play he apy and a achmen heo y in e sec h ough
se e al key mechanisms. Fi s , play p o ides a
secu e he apeu ic base, allowing he child o
explo e anxie ies and ela ional conce ns in a
s uc u ed ye lexible en i onmen . Second, he
in ol emen o he pa en in play acili a es co-
egula ion, eaching bo h child and ca egi e how o
manage s ess and emo ional a ousal
collabo a i ely. Thi d, epea ed, sensi i e play
in e ac ions help es uc u e in e nal wo king
models, p omo ing he de elopmen o mo e
posi i e expec a ions ega ding sel and ca egi e
a ailabili y. Finally, he play ul con ex encou ages
au onomy and mas e y, which a e p o ec i e ac o s
agains anxie y and con ibu e o long- e m
esilience.
Empi ical s udies suppo his concep ual
in eg a ion. Fo ins ance, Focal Play The apy (FPT)
has been shown o enhance pa en child in e ac ion
quali y, educe pa en al s ess, and inc ease
a achmen secu i y. Simila ly, child-cen e ed play
he apy demons a es e icacy in educing
in e nalizing symp oms, including anxie y,
pa icula ly when combined wi h pa en al
pa icipa ion.
O e all, he heo e ical ounda ions sugges ha
s eng hening he pa en –child a achmen
ela ionship h ough play-based in e en ions is a
p omising pa hway o educing childhood anxie y,
add essing bo h ela ional and symp om- ocused
dimensions o de elopmen .
Mechanisms: How Play The apy S eng hens
A achmen
Play he apy ope a es no only as a symp om-
ocused in e en ion bu also as a ela ional and
de elopmen al ool, a ge ing he unde lying pa en –
child a achmen sys em. Se e al in e ela ed
mechanisms explain how play he apy os e s
a achmen secu i y, he eby indi ec ly con ibu ing
o educ ions in childhood anxie y.
P o iding a Secu e Base wi hin The a :A cen al
concep de i ed om Bowlby’s a achmen heo y is
ha o he secu e base. In he con ex o he apy, he
he apis and/o pa icipa ing pa en unc ions as a
consis en , esponsi e igu e who p o ides sa e y
and p edic abili y (Bowlby,1982; Ainswo h e al.,
1978). Wi hin play sessions, child en a e
encou aged o explo e emo ionally challenging
hemes, expe imen wi h new beha io s, and exp ess
anxie ies in a non- h ea ening en i onmen . The
p edic abili y o he play se ing, combined wi h
empa he ic esponsi eness om he pa en o
he apis , helps he child in e nalize a sense o
secu i y, which can gene alize o he b oade pa en
child ela ionship. Fo example, in Focal Play
The apy, s uc u ed play ac i i ies c ea e
oppo uni ies o he child o exp ess emo ions while
he he apis models a uned esponses. O e ime,
child en epo eeling sa e o app oach ca egi e s
wi h dis essing emo ions, illus a ing he ans e o
secu i y om he he apeu ic o he amilial con ex .
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Co-Regula ion o Emo ion: Co- egula ion e e s o
he p ocess by which ca egi e s assis child en in
managing emo ional a ousal and s ess. In play
he apy, co- egula ion occu s when he pa en o
he apis models emo ional sel - egula ion, esponds
sensi i ely o he child’s cues, and sca olds adap i e
coping s a egies. Fo example, a pa en engaging in
a p e end scena io wi h he child can guide he child
h ough momen s o us a ion, ea , o sadness,
demons a ing s a egies o calm down, e balize
needs, and ole a e unce ain y. Resea ch shows ha
e ec i e co- egula ion s eng hens neu al and
beha io al sys ems suppo ing emo ion egula ion.
Child en who expe ience epea ed co- egula ion
wi hin a sa e ela ional con ex de elop con idence
in hei abili y o manage anxie y and unce ain y,
which is a p o ec i e ac o agains in e nalizing
diso de s.
Enhancing Pa en al Sensi i i y and
Responsi eness: Many play he apy modali ies
in ol e di ec pa en al pa icipa ion, such as Filial
The apy o Child–Pa en ela ionship he apy. These
in e en ions ain pa en s o ecognize and espond
app op ia ely o hei child’s emo ional cues,
os e ing a unemen and emo ional a ailabili y.
Enhanced pa en al sensi i i y has been s ongly
associa ed wi h inc eases in a achmen secu i y.
Pa en al in ol emen in play he apy also helps
pa en s e lec on hei own emo ional esponses and
in e pe sonal pa e ns. This e lec ion allows
ca egi e s o adjus maladap i e s a egies such as
o e con ol, inconsis ency, o emo ional
wi hd awal ha may pe pe ua e insecu e a achmen
and exace ba e child anxie y. Th ough consis en ,
empa hic engagemen , pa en s g adually es uc u e
ela ional pa e ns, suppo ing he child’s sense o
being unde s ood, accep ed, and p o ec ed.
Res uc u ing In e nal Wo king Models: Play
he apy acili a es he modi ica ion o in e nal
wo king models, he cogni i e-a ec i e schemas
ha child en de elop ega ding sel -wo h and
ca egi e eliabili y. Du ing guided play, child en
a e p o ided oppo uni ies o expe ience p edic able,
nu u ing esponses om he pa en , which can
coun e ac maladap i e expec a ions such as “My
ca egi e will abandon me” o “Exp essing ea is
unsa e.” Symbolic play enables child en o e-enac
s ess ul scena ios, nego ia e ou comes, and
expe ience al e na i e ela ional sc ip s, g adually
al e ing in e nal ep esen a ions owa d mo e secu e
a achmen models. Empi ical s udies suppo his
mechanism. Fo example, Mousa i and Sa a zadeh
(2016) epo ed ha s uc u ed g oup play he apy
imp o ed a achmen secu i y in o phaned child en
by c ea ing expe iences o ela ional eliabili y and
ca egi e esponsi eness. Simila ly, Chi ico e al.
(2020) obse ed ha pa en s pa icipa ing in ocal
play he apy sessions epo ed mo e a uned
in e ac ions, e lec ing changes in bo h pa en al
beha io and child expec a ions.
P ac icing Au onomy and Mas e y: A key
p o ec i e ac o agains anxie y is he de elopmen
o au onomy and mas e y. Play he apy o e s a sa e
space o child en o ake ini ia i e, make decisions,
and sol e p oblems independen ly while s ill being
suppo ed by he pa en o he apis . This balance o
challenge and suppo encou ages esilience and
sel -e icacy, coun e ac ing anxie y-d i en
a oidance and helplessness. The epea ed
expe ience o success and compe ence wi hin play
con ibu es o a posi i e eedback loop: inc eased
sel -con idence os e s secu e explo a ion and
u he s eng hens a achmen bonds.
Gene aliza ion o E e yday In e ac ions: Finally,
he changes cul i a ed wi hin play he apy sessions
gene alize o daily pa en –child in e ac ions.
Child en who expe ience sensi i e co- egula ion and
secu e ela ional sc ip s in he apy a e mo e likely o
seek com o om ca egi e s in eal-li e s ess ul
si ua ions, while pa en s become mo e a uned and
esponsi e ou side he he apeu ic con ex . O e
ime, his gene aliza ion consolida es a achmen
secu i y and educes eliance on anxie y-d i en
beha io s as a coping s a egy. In sum, he
mechanisms h ough which play he apy s eng hens
pa en child a achmen and educes childhood
anxie y include:
P o iding a sa e and p edic able ela ional
base.
Facili a ing co- egula ion o emo ion
be ween child and ca egi e .
Enhancing pa en al sensi i i y, a unemen ,
and e lec i e capaci y.
Res uc u ing maladap i e in e nal
wo king models in he child.
P omo ing au onomy, mas e y, and sel -
e icacy.
Encou aging gene aliza ion o secu e
ela ional pa e ns o e e yday li e.
These mechanisms a e in e connec ed and mu ually
ein o cing. Fo ins ance, pa en al sensi i i y
suppo s co- egula ion, which in u n ein o ces
secu e in e nal wo king models, leading o educed
anxie y and mo e con iden engagemen wi h he
en i onmen . The he apeu ic p ocess is i e a i e,
wi h small gains in a achmen secu i y and
emo ional egula ion compounding o e ime o
p oduce meaning ul imp o emen s in bo h ela ional
quali y and men al heal h ou comes.
Empi ical E idence on Play The apy,
A achmen , and Anxie y
Empi ical esea ch o e he pas wo decades
p o ides subs an ial e idence suppo ing he
e icacy o play he apy in imp o ing pa en child
a achmen and educing childhood anxie y. S udies
span di e se popula ions, including child en wi h
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clinical anxie y, child en expe iencing amily
dis up ion, and hose in o phanages o ins i u ional
ca e. The ollowing sec ions summa ize key
indings, o ganized by ocus on a achmen
enhancemen , anxie y educ ion, and combined
ou comes.
Play The apy and A achmen Secu i y: One o
he p ima y aims o play he apy is o s eng hen he
pa en child ela ionship, which is e lec ed in
nume ous s udies examining changes in a achmen
quali y. Focal Play The apy (FPT), de eloped o
pa en child dyads, has demons a ed signi ican
imp o emen s in pa en child in e ac ion quali y and
a achmen secu i y. Chi ico e al. (2020) conduc ed
a clinical s udy in ol ing 30 child en and hei
pa en s, using s uc u ed play sessions o enhance
a unemen and communica ion. Resul s indica ed
inc eased pa en al sensi i i y, educed pa en al
s ess, and measu able imp o emen s in he child’s
a achmen - ela ed beha io s. Speci ically, child en
showed g ea e willingness o seek com o ,
communica e needs, and engage in coope a i e play
wi h ca egi e s, sugges ing a modi ica ion o
in e nal wo king models owa d mo e secu e
ep esen a ions. Simila ly, g oup play he apy
in e en ions a ge ing o phaned child en in
ins i u ional ca e ha e demons a ed inc eases in
a achmen secu i y. Mousa i and Sa a zadeh (2016)
implemen ed a s uc u ed g oup play he apy
p og am wi h 45 o phaned child en aged 6–12 yea s.
Pos -in e en ion assessmen s using a achmen
ques ionnai es and obse a ional coding e ealed
signi ican educ ions in insecu e a achmen
beha io s, including clinginess and emo ional
wi hd awal. Child en also displayed inc eased
explo a o y beha io , posi i e social in e ac ions,
and adap i e coping s a egies. These indings
highligh ha s uc u ed, de elopmen ally
app op ia e play can compensa e, a leas pa ially,
o de ici s in ca egi e a ailabili y o
esponsi eness, p o iding oppo uni ies o child en
o expe ience ela ional p edic abili y and emo ional
suppo .
Play The apy and Anxie y Reduc ion: E idence
also suppo s he ole o play he apy in alle ia ing
childhood anxie y symp oms. Child-cen e ed play
he apy (CCPT), a non-di ec i e app oach allowing
child en o lead he play, has been associa ed wi h
educ ions in gene alized anxie y, sepa a ion
anxie y, and beha io al inhibi ion. B eine e al.
(2020) e alua ed 60 child en aged 5-10 wi h
clinically signi ican anxie y symp oms,
implemen ing 12 sessions o non-di ec i e play
he apy. Child en exhibi ed s a is ically signi ican
dec eases in anxie y sco es as measu ed by
s anda dized assessmen ools, such as he Re ised
Child en’s Mani es Anxie y Scale (RCMAS).
Imp o emen s we e main ained a 3-mon h ollow-
up, sugges ing du able bene i s.
Child–pa en and ilial play he apies u he
illus a e he alue o pa en al in ol emen in
anxie y educ ion. Xiang, Chen, and Wang (2023)
compa ed child-cen e ed g oup play he apy and
na a i e he apy o child en wi h sepa a ion
anxie y diso de . Resul s indica ed ha child en
pa icipa ing in play he apy no only educed
obse able anxie y beha io s bu also epo ed
highe subjec i e emo ional secu i y wi h hei
pa en s. Pa en al epo s co obo a ed imp o emen s
in emo ional egula ion and ela ional closeness,
ein o cing he idea ha he in e en ion
simul aneously add esses anxie y symp oms and
a achmen quali y.
Combined E ec s on A achmen and Anxie y
A g owing body o li e a u e emphasizes ha
a achmen enhancemen and anxie y educ ion a e
in e ela ed ou comes o play-based in e en ions.
Fo ins ance, Chi ico e al. (2020) ound ha
imp o emen s in pa en child in e ac ion quali y
media ed educ ions in child anxie y symp oms,
sugges ing ha s eng hening a achmen may se e
as a pa hway o alle ia ing anxie y. Simila ly,
me a-analy ic e iews indica e ha play he apy is
mos e ec i e when pa en al in ol emen is
included, as his app oach add esses bo h ela ional
and emo ional needs concu en ly.
Addi ional e idence om ins i u ional se ings
ein o ces his conclusion. Child en in o phanages
o os e ca e, o en a isk o insecu e a achmen
and heigh ened anxie y, show ma ked bene i s om
play he apy p og ams ha inco po a e adul
ca egi e s. Gains include educ ions in anxie y and
dep essi e symp oms, enhanced social compe ence,
and imp o ed ela ional beha io s, suppo ing he
no ion ha ela ionally ocused play is pa icula ly
impac ul in ulne able popula ions.
Limi a ions and Resea ch Gaps
While he empi ical e idence is p omising, se e al
limi a ions mus be no ed:
Sample sizes a e o en small, limi ing
gene alizabili y.
He e ogenei y o in e en ions (di ec i e,
non-di ec i e, ilial, g oup) makes di ec
compa ison ac oss s udies challenging.
Long- e m ollow-up da a a e limi ed; ew
s udies ack ou comes beyond six mon hs
o one yea .
Mechanis ic pa hways emain
unde explo ed; al hough imp o emen s in
a achmen a e co ela ed wi h anxie y
educ ion, causal mechanisms a e no ully
es ablished.
Cul u al conside a ions: Many
in e en ions a e de eloped in Wes e n
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Ad . J. Manag. Humani . Soc. Sci. (2025), Volume 1, Issue 10, 610-619
con ex s, wi h limi ed adap a ion o non-
Wes e n cul u al amewo ks.
Despi e hese limi a ions, he consis ency o indings
ac oss di e se popula ions suppo s he in eg a ion
o play he apy in o clinical p ac ice as bo h a
ela ional and symp om- ocused in e en ion.
O e all, empi ical esea ch unde sco es ha play
he apy:
Enhances pa en child a achmen secu i y
by p omo ing co- egula ion, pa en al
sensi i i y, and posi i e ela ional
expe iences.
Reduces childhood anxie y symp oms,
pa icula ly sepa a ion anxie y and
gene alized anxie y, h ough exp essi e
and explo a o y play.
P oduces in e ela ed bene i s, whe e
imp o ed a achmen may media e
educ ions in anxie y.
Demons a es s onge e ec s when
pa en al in ol emen is included,
highligh ing he impo ance o ela ionally
ocused in e en ions.
These indings p o ide a solid ounda ion o
heo e ical in eg a ion and clinical applica ion,
sugges ing ha play he apy is no only a ool o
symp om educ ion bu also a mechanism o
os e ing secu e ela ionships and long- e m
emo ional esilience.
Syn hesis and Theo e ical In eg a ion
The empi ical and heo e ical e idence p esen ed in
p e ious sec ions highligh s a cohe en pic u e: play
he apy s eng hens pa en child a achmen and
educes childhood anxie y h ough in e connec ed
mechanisms. Syn hesizing hese indings allows us
o a icula e a concep ual model and cla i y how
ela ional p ocesses media e emo ional ou comes.
In e connec ed Mechanisms: F om a heo e ical
s andpoin , a achmen heo y p o ides a amewo k
o unde s anding he ela ional ounda ion o
anxie y. Insecu e a achmen , cha ac e ized by
inconsis en ca egi e esponsi eness o lack o a
secu e base, con ibu es o heigh ened igilance,
emo ional dys egula ion, and in e nalizing
symp oms such as anxie y. Play he apy, pa icula ly
when in ol ing pa en s, add esses hese ela ional
ulne abili ies h ough mul iple, mu ually
ein o cing mechanisms:
P o ision o a secu e base in he apy:
The s uc u ed and esponsi e play se ing
o e s child en a sa e space o explo e
emo ions and p ac ice ela ional s a egies.
Co- egula ion o emo ions: Pa en s o
he apis s model emo ional egula ion,
guiding child en h ough dis ess and
ein o cing adap i e coping.
Enhancemen o pa en al sensi i i y:
Pa en pa icipa ion inc eases a unemen
and e lec i e unc ioning, imp o ing
ca egi e esponsi eness in e e yday
in e ac ions.
Res uc u ing in e nal wo king models:
Posi i e, consis en ela ional expe iences
challenge maladap i e belie s abou sel -
wo h and ca egi e eliabili y.
P omo ion o au onomy and mas e y:
Th ough play, child en gain con idence,
p oblem-sol ing skills, and esilience,
educing anxie y-d i en a oidance
beha io s.
Gene aliza ion o eal-wo ld
in e ac ions: Changes in pa en –child
dynamics wi hin he apy ex end o daily
li e, consolida ing a achmen secu i y and
emo ional s abili y.
These mechanisms a e no linea bu cyclical:
imp o emen s in a achmen secu i y enhance
emo ional egula ion and educe anxie y, which
u he s eng hens ela ional in e ac ions and
p omo es secu e a achmen in an ongoing eedback
loop.
Concep ual Model
A concep ual model eme ges om his syn hesis
(Figu e 1):
Play The apy In e en ion → Enhanced Pa en –
Child In e ac ion → S eng hened A achmen
Secu i y → Reduced Childhood Anxie y
Di ec e ec s: Play he apy di ec ly
educes anxie y by p o iding a medium o
emo ional exp ession, coping p ac ice, and
mas e y expe iences.
Indi ec e ec s: Imp o emen s in
a achmen ac as media o s; as child en
expe ience secu e, a uned ca egi ing in
he apy, hei in e nal wo king models shi
owa d us and emo ional con idence,
acili a ing anxie y educ ion.
Mode a ing ac o s: In e en ion
e ec i eness may a y by age, baseline
a achmen secu i y, pa en al in ol emen ,
and cul u al con ex .
This in eg a ed model aligns wi h de elopmen al
psychopa hology pe spec i es, which emphasize
ansac ional p ocesses in which child and ca egi e
ecip ocally in luence emo ional and ela ional
ou comes. By inco po a ing bo h ela ional and
symp om- ocused pa hways, play he apy add esses
no only he mani es a ions o anxie y bu also he
unde lying ela ional ulne abili ies ha con ibu e
o i s de elopmen and main enance.
Implica ions o In eg a ion
The syn hesis o heo y and e idence unde sco es
se e al key insigh s:
A achmen as a he apeu ic a ge : Play
he apy can modi y he ela ional subs a e
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Ad . J. Manag. Humani . Soc. Sci. (2025), Volume 1, Issue 10, 610-619
unde lying anxie y, a he han solely
alle ia ing su ace symp oms.
Pa en al in ol emen is c i ical:
In e en ions inco po a ing pa en s show
mo e obus imp o emen s in bo h
a achmen and anxie y, highligh ing he
ela ional dimension o ea men .
De elopmen ally app op ia e me hods:
The non- e bal, expe ien ial na u e o play
is pa icula ly sui ed o child en who may
s uggle wi h e bal o abs ac cogni i e
in e en ions, enhancing engagemen and
e icacy.
In e en ion e sa ili y: Play he apy can
be adap ed o di e se popula ions,
including child en wi h auma his o ies,
ins i u ionalized child en, and hose wi h
clinical anxie y diso de s.
Mechanis ic cla i y: Unde s anding he
pa hways secu e base, co- egula ion,
in e nal wo king model es uc u ing
acili a es e inemen o in e en ions and
guides u u e esea ch aimed a op imizing
ou comes.
In conclusion, he heo e ical in eg a ion o
a achmen p inciples and play he apy mechanisms
p o ides a compelling a ionale o using
ela ionally ocused play in e en ions o add ess
childhood anxie y. By simul aneously a ge ing
ela ional p ocesses and emo ional egula ion, play
he apy unc ions as a dual in e en ion: i enhances
a achmen secu i y and educes anxie y symp oms,
yielding du able de elopmen al bene i s.
Clinical Implica ions
The syn hesis o heo e ical and empi ical e idence
highligh s se e al p ac ical implica ions o
clinicians, ca egi e s, and policymake s aiming o
suppo child en wi h anxie y h ough ela ional
in e en ions such as play he apy.
In eg a ing Pa en al In ol emen : One o he
clea es indings om he li e a u e is he c i ical
ole o pa en al pa icipa ion in enhancing he
e ec i eness o play he apy. Pa en al in ol emen
acili a es co- egula ion, inc eases a unemen , and
s eng hens he pa en child bond, he eby media ing
educ ions in childhood anxie y. Clinicians should:
T ain pa en s in ilial he apy echniques,
including obse ing, e lec ing, and
pa icipa ing in play sessions.
Encou age egula home-based play
in e ac ions, ein o cing skills lea ned in
he apy sessions.
P o ide psychoeduca ion abou a achmen
and i s ole in emo ional egula ion o
enhance pa en s’ unde s anding and
engagemen .
S uc u ing De elopmen ally App op ia e
In e en ions: Play he apy should be ailo ed o
he child’s de elopmen al s age, cogni i e capaci y,
and emo ional needs. Younge child en may bene i
om non-di ec i e play, allowing o ee
exp ession and explo a ion, whe eas olde child en
may bene i om s uc u ed, goal-o ien ed play
in e en ions ha in eg a e p oblem-sol ing and
coping s a egies. Clinicians should:
Selec ma e ials, games, and ac i i ies
app op ia e o age and de elopmen al le el.
Ensu e he he apeu ic en i onmen is sa e,
p edic able, and lexible, os e ing a sense
o secu i y.
Use bo h symbolic and ole-play
echniques o add ess emo ional and
ela ional hemes.
Ta ge ing A achmen as a The apeu ic Focus:
S eng hening pa en child a achmen should be
conside ed a p ima y goal o in e en ions o
childhood anxie y. Clinicians a e encou aged o:
Assess baseline a achmen pa e ns using
obse a ional me hods o alida ed
ques ionnai es (e.g., S ange Si ua ion
P ocedu e, A achmen Q-So ).
Design play in e en ions o enhance
secu e a achmen beha io s, such as
seeking com o , coope a i e play, and
emo ional sha ing.
Moni o changes in a achmen - ela ed
beha io s as an indica o o in e en ion
e ec i eness, in addi ion o anxie y
symp om educ ion.
Combining Play The apy wi h O he E idence-
Based App oaches: Play he apy can be e ec i ely
in eg a ed wi h cogni i e-beha io al echniques o
auma- ocused in e en ions. Such hyb id
app oaches allow o he simul aneous a ge ing o
cogni i e dis o ions, maladap i e beha io s, and
ela ional dynamics. Fo example:
Inco po a e elaxa ion, coping skills, and
p oblem-sol ing asks in o play-based
ac i i ies.
Use na a i e and s o y- elling app oaches
o add ess anxie y-p o oking hough s
while main aining a play ul and engaging
o ma .
Adap in e en ions o child en wi h
auma his o ies by emphasizing sa e y,
p edic abili y, and empowe men wi hin
play con ex s.
Moni o ing and E alua ion: To op imize clinical
ou comes, ongoing moni o ing and e alua ion a e
essen ial:
Use s anda dized measu es o anxie y (e.g.,
RCMAS, SCARED) and a achmen (e.g.,
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Pa en –Child Rela ionship In en o y) p e-
and pos -in e en ion.
Collec quali a i e eedback om bo h
child en and pa en s ega ding ela ional
quali y, emo ional egula ion, and
engagemen in he apy.
Adjus he apeu ic s a egies based on
obse ed p og ess, ensu ing ha
in e en ions emain child-cen e ed and
de elopmen ally app op ia e.
Cul u al Sensi i i y and Accessibili y: Play
he apy in e en ions mus be cul u ally adap ed o
espec di e se amily s uc u es, pa en ing no ms,
and communi y con ex s. Clinicians should:
Inco po a e cul u ally ele an ma e ials
and na a i es in o play sessions.
Engage ca egi e s in discussions abou
cul u al belie s and p ac ices a ec ing
pa en ing and a achmen .
Ensu e accessibili y o unde se ed
popula ions, including ins i u ionalized
child en, low-income amilies, and hose in
emo e o esou ce-limi ed se ings.
Clinical applica ion o play he apy highligh s i s
dual ole: alle ia ing anxie y symp oms while
enhancing pa en –child a achmen . By ac i ely
in ol ing pa en s, ailo ing in e en ions o
de elopmen al needs, and in eg a ing e idence-
based s a egies, he apis s can maximize he
bene i s o play he apy. The emphasis on ela ional
epai and emo ional co- egula ion unde sco es he
unique ad an age o play-based in e en ions o e
pu ely symp om- ocused app oaches.
Fu u e Di ec ions and Resea ch Gaps
Despi e he g owing e idence suppo ing he
e icacy o play he apy in enhancing pa en –child
a achmen and educing childhood anxie y, se e al
esea ch gaps and u u e di ec ions emain c i ical
o ad ancing he ield.
Need o La ge-Scale Randomized Con olled
T ials (RCTs): Many exis ing s udies ely on small
sample sizes o quasi-expe imen al designs, limi ing
he gene alizabili y o indings. Fu u e esea ch
should:
Conduc la ge-scale RCTs ac oss di e se
popula ions o es ablish obus e idence o
e ec i eness.
Include con ol g oups ha allow o
di e en ia ion be ween in e en ion e ec s
and na u al de elopmen al changes.
Examine long- e m ou comes beyond 6-12
mon hs o assess du abili y o a achmen
imp o emen s and anxie y educ ion.
Elucida ing Mechanis ic Pa hways: While
a achmen imp o emen is heo ized o media e
anxie y educ ion, causal mechanisms emain
unde explo ed. Fu u e s udies should:
Use media ional analyses o examine
whe he changes in a achmen beha io s
di ec ly p edic dec eases in anxie y
symp oms.
In es iga e neu obiological co ela es o
a achmen and anxie y changes, such as
s ess eac i i y, co isol le els, and b ain
connec i i y pa e ns.
Examine he ole o co- egula ion and
pa en al sensi i i y as p oximal
mechanisms linking he apy o child
ou comes.
Compa a i e S udies o In e en ion Modali ies:
The di e si y o play he apy modali ies—including
non-di ec i e, di ec i e, child-cen e ed, and ilial
he apy c ea es he e ogenei y in ou comes. Fu u e
esea ch should:
Conduc head- o-head compa isons o
di e en app oaches o iden i y which
me hods a e mos e ec i e o speci ic
popula ions o anxie y p o iles.
Explo e hyb id in e en ions ha combine
play he apy wi h cogni i e-beha io al o
auma- ocused echniques.
Assess whe he g oup-based e sus
indi idual in e en ions di e in hei
impac on a achmen and anxie y.
Cul u al and Con ex ual Adap a ion: Mos play
he apy esea ch o igina es om Wes e n cul u al
con ex s. To ensu e global applicabili y, u u e
esea ch should:
Adap in e en ions o non-Wes e n
cul u al no ms ega ding pa en ing, play,
and emo ional exp ession.
Examine he in luence o socioeconomic
s a us, amily s uc u e, and ins i u ional
en i onmen s on in e en ion e icacy.
De elop cul u ally sensi i e measu es o
bo h a achmen and anxie y o accu a ely
cap u e ou comes.
De elopmen al Conside a ions: Cu en s udies
o en ocus on a na ow age ange. Fu u e esea ch
should:
In es iga e e ec i eness ac oss di e en
de elopmen al s ages, om p eschoole s o
adolescen s.
Examine age-speci ic mechanisms, such as
symbolic play o younge child en e sus
na a i e o ole-play o olde child en.
Explo e ea ly p e en i e in e en ions in
a - isk popula ions be o e clinical anxie y
de elops.
In eg a ion wi h Technology: The use o digi al
and in e ac i e echnologies p esen s new
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oppo uni ies o play-based in e en ions. Fu u e
s udies could:
De elop digi al play he apy pla o ms o
emo e o unde se ed popula ions.
E alua e he e ec i eness o in e ac i e
games and i ual eali y scena ios in
os e ing a achmen and educing anxie y.
In es iga e blended in e en ions
combining in-pe son and digi al play o
enhance engagemen and accessibili y.
Add essing hese esea ch gaps will ad ance bo h
he scien i ic unde s anding and p ac ical
applica ion o play he apy. By cla i ying
mechanisms, compa ing modali ies, in eg a ing
cul u al conside a ions, and le e aging echnology,
u u e s udies can e ine in e en ions ha
simul aneously a ge pa en –child a achmen and
childhood anxie y. A s a egic esea ch agenda
ocused on igo ous me hodology, longi udinal
ollow-up, and mechanis ic cla i y is essen ial o
solidi y play he apy as a co e in e en ion in child
men al heal h.
Conclusion
The p esen syn hesis o heo e ical and empi ical
e idence unde sco es he cen al ole o play he apy
in s eng hening pa en child a achmen and
educing childhood anxie y. Childhood anxie y, a
p e alen and po en ially debili a ing condi ion, is
closely linked o insecu e a achmen pa e ns,
maladap i e in e nal wo king models, and
di icul ies in emo ional egula ion. Play he apy
o e s a de elopmen ally app op ia e, engaging, and
ela ionally ocused in e en ion ha add esses bo h
he emo ional and ela ional dimensions o child
de elopmen .
Th ough mechanisms such as p o ision o a secu e
base, co- egula ion o emo ions, enhancemen o
pa en al sensi i i y, es uc u ing o in e nal
wo king models, and p omo ion o au onomy, play
he apy os e s a achmen secu i y while
concu en ly educing anxie y symp oms. Empi ical
s udies, including Focal Play The apy, child-
cen e ed play he apy, and ilial he apy,
consis en ly demons a e imp o emen s in pa en
child in e ac ions, ela ional a unemen , and
child en’s emo ional well-being. Impo an ly,
pa en al in ol emen eme ges as a c i ical ac o ha
ampli ies he e ec i eness o play-based
in e en ions, highligh ing he necessi y o
ela ionally o ien ed app oaches.
Theo e ical in eg a ion and empi ical indings
suppo a concep ual model in which play he apy
s eng hens a achmen , which in u n media es
educ ions in anxie y, c ea ing a posi i e eedback
loop ha enhances bo h ela ional and emo ional
ou comes. Clinical implica ions emphasize he
impo ance o ailo ing in e en ions o
de elopmen al le els, inco po a ing pa en s, and
combining play he apy wi h o he e idence-based
app oaches when app op ia e. Cul u al adap a ion,
de elopmen al conside a ions, and echnological
inno a ions o e addi ional a enues o b oaden he
each and e ec i eness o play-based in e en ions.
Fu u e esea ch should ocus on la ge-scale,
longi udinal andomized con olled ials,
elucida ion o mechanis ic pa hways, compa a i e
analyses o in e en ion modali ies, and cul u ally
sensi i e adap a ion. Add essing hese gaps will
p o ide mo e obus e idence base and in o m bes
p ac ices o in eg a ing play he apy in o child
men al heal h se ices.
In conclusion, play he apy ep esen s a dual-
pu pose in e en ion ha no only alle ia es anxie y
symp oms bu also s eng hens he ounda ional
ela ional bonds c i ical o heal hy socio-emo ional
de elopmen . By a ending simul aneously o
a achmen and emo ional egula ion, play he apy
o e s a p omising pa hway o p omo ing esilience,
secu i y, and well-being in child en ac oss di e se
con ex s.
Disclosu e S a emen
No po en ial con lic o in e es epo ed by he
au ho s.
Funding
This esea ch did no ecei e any speci ic g an om
unding agencies in he public, comme cial, o no -
o -p o i sec o s.
Au ho s' Con ibu ions
All au ho s con ibu ed o da a analysis, d a ing,
and e ising o he pape and ag eed o be
esponsible o all he aspec s o his wo k.
Re e ences
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(2020). The e ec o non-di ec i e play he apy
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and Psycho he apy Resea ch.
[2] Chi ico, I., And ei, F., Sal a o i, P., Malagu i,
I., & T ombini, E. (2020). The Focal Play
The apy: An Empi ical S udy on he Pa en
The apis Alliance, Pa en Child In e ac ions
and Pa en ing S ess in a Clinical Sample o
Child en and Thei Pa en s. F on ie s in
Psychology.
[3] Chi ico, I., And ei, F., Sal a o i, P., Malagu i,
I., & T ombini, E. (2020). The Focal Play
The apy: An Empi ical S udy on he Pa en
The apis Alliance, Pa en Child In e ac ions
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Child en and Thei Pa en s. In e na ional
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