Theraplay is an evidence-based, attachment-focused therapy that helps children overcome behavioral, emotional, and developmental challenges through structured, playful interactions between children and their caregivers. This therapeutic approach, typically used with children up to age 12, strengthens the parent-child relationship while addressing issues ranging from anxiety and behavioral problems to attachment difficulties and developmental delays.
Research demonstrates that Theraplay effectively improves attachment security, reduces behavioral symptoms, and enhances emotional regulation in children across diverse populations and settings. The approach has shown particular promise for children with trauma histories, autism spectrum disorders, and those in foster or adoptive care situations.
Table of Contents
- What Is Theraplay?
- History and Development
- Core Principles and Theory
- The Four Dimensions of Theraplay
- How Theraplay Sessions Work
- Conditions Treated with Theraplay
- Research and Effectiveness
- Theraplay Training and Certification
- Considerations and Limitations
- Frequently Asked Questions
- Find a Theraplay Therapist
What Is Theraplay?
Theraplay is a structured play therapy for children and their parents. Its goal is to enhance attachment, self-esteem, trust in others, and joyful engagement. The sessions are designed to be fun, physical, personal, and interactive and replicate the natural, healthy interactions between parents and young children.
Unlike traditional play therapy where children direct the play, Theraplay sessions are adult-led and focus on building connection through carefully structured activities. Instead, the therapist and parent(s) control and direct the play; they become the most enticing toys in the room. Theraplay® is sometimes confused with play therapy, whereby a child's experiences, feelings, and knowledge are communicated through self-directed play. Because Theraplay is directed by the adults, it works well for traumatized children, where play therapy does not.
The approach emphasizes physical touch, eye contact, and synchronized activities that mirror the natural interactions between securely attached infants and their caregivers. These elements help children develop trust, self-worth, and the ability to engage in healthy relationships.
History and Development
Origins in Chicago
Theraplay was developed in the late 1960s by clinical psychologist Ann Jernberg while serving as Director of Psychological Services at the Chicago Head Start Program. Recognizing the overwhelming number of children needing mental health services, Jernberg sought to create an intervention that could be implemented directly within Head Start facilities rather than referring children to outside clinics.
To meet this need, Jernberg developed an innovative approach employing paraprofessionals who worked under the supervision of licensed therapists. She specifically selected individuals who were "lively and playful" and could readily engage children in therapeutic interactions. Though initially met with resistance, Jernberg provided video evidence demonstrating the approach's effectiveness, leading to wider acceptance.
The Theraplay Institute
In 1971, Jernberg established The Theraplay Institute to formalize training and certification in this approach. Today, the Institute continues to train therapists worldwide, maintaining quality standards and advancing research in attachment-based interventions. The California Evidence-Based Clearinghouse has rated it a 3 on a scale of 1-5, indicating it has been well-supported by evidence.
Core Principles and Theory
Theraplay integrates concepts from multiple theoretical frameworks:
Attachment Theory Foundation
Theraplay® assumes that the primary motivating force in human behavior is a drive toward relatedness to others, not objects. Personality development is at its core interpersonal. The early interactions between parent and child are the crucible in which the self and personality develop.
The approach recognizes that children's behavioral and emotional difficulties often stem from disrupted early attachments. By recreating positive parent-child interactions, Theraplay helps repair these disruptions and build secure attachment patterns.
Key Theoretical Concepts
Positive Internal Representations: Children exposed to consistent, positive relationships develop:
- High self-regard ("I am lovable and special")
- Trust in others ("People are caring and reliable")
- Optimistic worldview ("I am safe to explore")
Negative Internal Representations: Children with disrupted attachments may develop:
- Low self-worth ("I am unlovable")
- Mistrust of others ("People are unreliable")
- Pessimistic outlook ("The world is unsafe")
The goal of treatment is to change the inner representation of the self and others from a negative to a more positive one.
The Four Dimensions of Theraplay
Each Theraplay session incorporates four essential dimensions that promote healthy parent-child relationships:
1. Structure
- Purpose: Promotes safety, organization, and self-regulation
- Activities: Adult-led games with clear rules and boundaries
- Benefits: Helps impulsive children develop focus and security
- Target Issues: Hyperactivity, poor impulse control, difficulty with limits
2. Engagement
- Purpose: Builds emotional connection and attunement
- Activities: Playful, interactive games promoting eye contact and synchrony
- Benefits: Develops deeper parent-child bonds
- Target Issues: Social withdrawal, autism spectrum disorders, attachment difficulties
3. Nurture
- Purpose: Provides comfort, soothing, and care
- Activities: Gentle touch, feeding activities, calming interactions
- Benefits: Reinforces child's sense of being valued and loved
- Target Issues: Anxiety, aggression, trauma, neglect
4. Challenge
- Purpose: Builds confidence and mastery
- Activities: Age-appropriate tasks with achievable goals
- Benefits: Develops competence and self-efficacy
- Target Issues: Low self-esteem, anxiety, developmental delays
How Theraplay Sessions Work
Initial Assessment Phase
Sessions 1-3: The treatment begins with a comprehensive assessment:
- Parent interview to understand family dynamics and concerns
- Observation of parent-child interactions
- Marschak Interaction Method (MIM), a structured procedure used to evaluate the bond between two individuals and reveal relationship strengths and weaknesses
- Video recording for detailed analysis
Session 4: Treatment planning meeting where therapists and parents:
- Review assessment findings
- Discuss specific goals
- Develop individualized treatment plan
- Address parent questions and concerns
Active Treatment Phase
Session 5: Introduction session where therapists:
- Demonstrate planned activities
- Explain therapeutic rationale
- Model appropriate responses
- Prepare parents for child's potential reactions
Sessions 6-25: Regular Theraplay sessions featuring:
- 30-60 minute sessions (shorter for younger children)
- Two-therapist model when possible
- Progressive parent involvement
- Activities tailored to address specific treatment goals
Treatment duration is usually 30-45 minutes, once a week for 18-20 sessions. Initially the therapist is the adult directing play and interacting with the child; over time the parent(s) are expected to take over the play, thus developing the bonds of attachment.
Follow-Up Phase
Treatment typically includes:
- Final assessment using original measures
- Recommendations for continued support
- Four follow-up visits over one year
- Booster sessions as needed
Conditions Treated with Theraplay
Primary Applications
Money et al. found promising results for Theraplay outcomes with children who exhibited externalizing, internalizing, dual diagnosis, and developmental disabilities. Of the eligible studies, Theraplay was found promising in its effectiveness when used with internalizing and externalizing difficulties, dual diagnoses, and developmental disabilities.
Behavioral Challenges:
- Oppositional defiant disorder (ODD)
- Aggressive behaviors
- Conduct problems
- Attention difficulties
- Hyperactivity
Emotional Difficulties:
- Anxiety disorders
- Depression
- Trauma-related symptoms
- Emotional dysregulation
- Social withdrawal
Attachment and Relationship Issues:
- Reactive attachment disorder
- Foster care and adoption challenges
- Parent-child relationship difficulties
- Separation anxiety
- Trust issues
Developmental Concerns:
- Autism spectrum disorders
- Theraplay has been found to have promise for neurodiverse populations including Autistic children (Chang et al., 2021; Coleman & Hong, 2023; Hiles Howard et al., 2018; Simeone-Russell, 2011), children with Attention Deficit Hyperactivity Disorder (Askari et al., 2014; Siu, 2017), and children with intellectual disabilities (Hofstra et al., 2023; Mohamed & Mkabile, 2015; Siu, 2014)
- Developmental delays
- Communication difficulties
- Sensory processing issues
Special Populations
Foster and Adoptive Families: Because of its focus on attachment and relationship development, Theraplay has been used for many years with foster and adoptive families. Research shows particular effectiveness in:
- Building new attachment relationships
- Addressing past trauma
- Improving placement stability
- Reducing behavioral problems
Children with Prenatal Substance Exposure: A 4-year retrospective service evaluation of outcomes between 2020 and 2024 is currently being completed evaluating the use of principles of Theraplay, the alert model, and parenting support sessions, with a much greater sample size and comparisons to a non-PAE control group.
Research and Effectiveness
Evidence Base Overview
Based on the results from 20 years of research, ABFT is listed on several national and international registries for evidence-based practices (Diamond, Levey, Russon, 2016). Registries include the California Evidence-Based Clearinghouse for Child Welfare (promising research evidence for adolescent depression), SAMHSA's evidence-based practice guidelines (2020; evidence-based practices for suicidal ideation, self-harm, and suicide attempts).
Recent Meta-Analysis Findings
A 2021 systematic review by Money and colleagues examined Theraplay effectiveness for children under 12. Key findings included:
Only six eligible articles were identified, meaning there was a lack of rigorous evidence eligible to offer conclusions into Theraplay's effectiveness. The review highlighted the small evidence base, mixed-quality research methodology, and high levels of heterogeneity in how Theraplay is practiced and evaluated. Of the eligible studies, Theraplay was found promising in its effectiveness when used with internalizing and externalizing difficulties, dual diagnoses, and developmental disabilities.
Specific Research Outcomes
Behavioral Improvements:
- Theraplay has been found to improve behavioral functioning (Francis et al., 2017; Purrington et al., 2022; Weir et al., 2013) and reduce aggression (Rezaeianzadeh & Yazdanfar, 2024)
- Significant reductions in conduct problems
- Improved compliance and cooperation
- Decreased aggressive behaviors
Emotional and Social Benefits:
- Enhanced emotional regulation
- Theraplay impact on parents and children with autism spectrum disorder: Improvements in affect, joint attention, and social cooperation
- Reduced anxiety and depression symptoms
- Improved peer relationships
Attachment Outcomes:
- Intervening in such a way has been found to improve affect regulation (Lindaman & Lender, 2009), trust (Wettig et al., 2011), and behavioral functioning in children (Francis et al., 2017; Weir et al., 2013), alongside promoting sociality and communication (Francis et al., 2017), and reducing trauma symptomology and externalizing difficulties (Purrington et al., 2022)
- Stronger parent-child bonds
- Increased secure attachment behaviors
- Improved caregiver sensitivity
Implementation Settings
Theraplay has been successfully implemented in:
- Outpatient mental health clinics
- School counseling programs
- Foster care agencies
- Adoption support services
- Residential treatment facilities
- Hospital settings
- Community mental health centers
- Private practice
Theraplay Training and Certification
Training Levels
The Theraplay Institute offers comprehensive training programs:
Level One (4 days):
- Introduction to fundamental techniques
- Theoretical foundations
- Basic intervention strategies
- Practice opportunities
Level Two (3 days):
- Advanced concepts and techniques
- Complex case conceptualization
- Specialized populations
- Prerequisite: Level One completion
Master Class (2 days):
- Expert-level skills development
- Advanced clinical applications
- Consultation on challenging cases
- Prerequisite: Level One completion
Group Therapy Training (1-2 days):
- Adapting Theraplay for groups
- Classroom applications (Sunshine Circles)
- Multi-family group formats
- Prerequisite: Level One
Certification Requirements
Certified Theraplay Therapist:
- Master's degree in mental health field
- Professional licensure
- Completion of required training levels
- Supervised practice hours
- Case consultation requirements
- Demonstration of competency
Theraplay Practitioner:
- Bachelor's degree minimum
- Completion of training requirements
- Work under certified therapist supervision
- Ongoing consultation
Professional Standards
The peer review research that has been done on Theraplay is what helped our modality attain Evidence-Based status from SAMHSA. Training emphasizes:
- Fidelity to the model
- Ethical considerations
- Cultural sensitivity
- Safety protocols
- Documentation standards
Considerations and Limitations
When Theraplay May Not Be Appropriate
Severe Cognitive Impairments: Children or parents with significant intellectual disabilities may require modified approaches or alternative interventions.
Active Substance Use: Theraplay is not recommended for abusive caregivers or caregivers who are experiencing substance dependency.
Abusive Caregivers: Safety concerns preclude use with actively abusive parents without concurrent protective interventions.
Severe Dissociation: Children with severe dissociative symptoms may require stabilization before beginning Theraplay.
Important Considerations
Scope of Treatment: Theraplay focuses on strengthening the child-caregiver relationship; therefore, issues existing between the child and individuals other than the caregiver, especially individuals who exist outside of the family setting, may not be thoroughly explored or addressed. Techniques learned in Theraplay may help children become better able to manage maladaptive issues, but the issues themselves are not directly treated.
Cultural Adaptations: Therapists must consider cultural values around:
- Physical touch and proximity
- Eye contact expectations
- Parent-child interaction norms
- Family hierarchy and roles
Treatment Duration: While typical treatment lasts 18-26 weeks, some children require:
- Extended treatment periods (9-18 months)
- Modified pacing for complex trauma
- Additional supportive services
- Booster sessions for maintenance
Frequently Asked Questions
How is Theraplay different from regular play therapy?
Theraplay differs significantly from traditional play therapy in several ways. While play therapy typically allows children to direct the play and work through issues symbolically, Theraplay is adult-directed and focuses on building attachment through structured interactions. The therapist and parent lead activities designed to promote connection, rather than observing child-led play. Additionally, Theraplay emphasizes physical touch, eye contact, and playful engagement rather than toys or symbolic play materials.
What age range is appropriate for Theraplay?
Theraplay is primarily designed for children from infancy through age 12, though adaptations exist for older children and adolescents. The effect of interactive game therapy with the Theraplay model on students' sleep quality: A randomized control trial shows applications beyond traditional age ranges. The approach is most effective during developmental periods when attachment relationships are forming or can be repaired through relationship-based interventions.
How long does Theraplay treatment typically last?
Short — typical protocol runs for 26 sessions, which roughly equates to six months of weekly sessions. However, this can be adapted to families with greater needs to be used for longer periods of time. Some families see improvements within 8-12 sessions, while others with complex trauma histories or multiple challenges may benefit from extended treatment lasting 9-18 months.
Can Theraplay help children with autism?
Yes, research demonstrates Theraplay's effectiveness for children on the autism spectrum. Theraplay impact on parents and children with autism spectrum disorder: Improvements in affect, joint attention, and social cooperation. The structured, predictable nature of sessions combined with gradual introduction of sensory experiences helps children with autism develop social engagement skills and emotional regulation.
Is parent participation required?
Parent participation is essential to Theraplay's effectiveness. The approach aims to strengthen the parent-child relationship, so caregivers must be willing to actively engage in sessions. Initially, parents observe while therapists model interactions, but they progressively take the lead role. This ensures therapeutic gains transfer to daily life and continue after formal treatment ends.
What if my child resists physical touch or eye contact?
Theraplay therapists are trained to work sensitively with children who have difficulty with touch or eye contact. They start with the child's comfort level and gradually introduce therapeutic elements. For children with trauma histories or sensory sensitivities, therapists modify activities to ensure safety and avoid re-traumatization while still promoting connection and healing.
Find a Theraplay Therapist
If you're interested in exploring Theraplay for your child or family, qualified therapists can help assess whether this approach matches your needs. Certified Theraplay therapists have specialized training in attachment-based interventions and work collaboratively with families to address behavioral, emotional, and relationship challenges.
Search our directory to find Theraplay-trained mental health professionals in your area. Many therapists offer initial consultations to discuss how Theraplay might benefit your specific situation.
Remember that investing in your child's emotional well-being and strengthening family relationships creates lasting positive changes that extend far beyond the therapy room. With its evidence-based approach and focus on joyful connection, Theraplay offers hope for families facing various challenges.
References:
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- Booth, P., Lindaman, S., & Peacock, F. (2025). Theraplay®: An attachment theory-based treatment for relational and developmental healing. In D. A. Crenshaw, A. L. Stewart, & D. C. Ray (Eds.), Play therapy: Theory, research, and practice (Chapter 2). The Guilford Press.
- Bundy-Myrow, S., & Lender, D. (2026). Why Theraplay? Core concepts for attachment and regulation in various settings. New York Association for Play Therapy Newsletter, February 2026.
- California Evidence-Based Clearinghouse for Child Welfare. (2026). Theraplay. Retrieved from https://www.cebc4cw.org/program/theraplay/
- Centers for Disease Control and Prevention. (2023). Play therapy as effective options for school-age children with emotional and behavioral problems. Cureus, 15(6), e40093. https://doi.org/10.7759/cureus.40093
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