The Role of Play Therapists in Children’s

Transitions: From Residential Care to

Foster Care
Amie C. Kolos
Johns Hopkins University

Permanency planning operates on the belief that all children have the right to stable
housing. This approach to child welfare has been implemented as a way to protect
children from the negative outcomes associated with long-term residential care and
multiple foster home placements. When a child is ready to leave residential care and
return to a family living environment, there are multiple steps involved in the selection
of a family and a child’s preparation for discharge. Play therapists perform many
roles in these cases, all of which are critically important to children’s success in their
new environments. This article’s aims are to (a) describe the various roles of play
therapists in the residential-to-foster care transition process, (b) highlight several
therapeutic techniques play therapists can use in their work with children preparing
to leave residential care and enter a new foster home, and (c) discuss some of
conflicting feelings that accompanies such sensitive work. A case study will further
illustrate the ways in which play therapists can advocate for children who are ready
to leave residential care.
Keywords: translations, foster care, residential care, advocacy

In the United States, one in 120 children will sleep in a residential placement
each night (Chipenda-Dansokho, Little, & Thomas, 2003), and between 20,000 and
40,000 children will be placed in settings that accommodate children with mental
health issues (Center for Mental Health Services, 2000). A child admitted into
residential care may be coming directly from the home of biological parents, or may
be placed after several attempts with different foster or adoptive families “fail.”
Placement failures are frequently undermined by children’s inability to develop
trust with their new families, families’ lack of knowledge about children’s histories
and family backgrounds, and/or insufficient post-placement support (Bruning,
2007). Children in the child welfare system commonly present with issues surround-
ing trauma, attachment, and both internalizing and externalizing behaviors, making
it difficult for many well-meaning foster parents to successfully provide a stable
living arrangement in which children can thrive. As a result, many of these children
experience multiple placement disruptions during their time in foster care (U.S.
Department of Health & Human Services, 2008). One study found that children
had experienced an average of nine foster home placements before entering
residential care, with over one third of these children having 11 or more placements

Correspondence concerning this article should be addressed to Amie C. Kolos, Johns Hopkins
Bayview Medical Center, 5510 Nathan Shock Drive, Baltimore, MD 21224. E-mail: akolos1@jhmi.edu

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International Journal of Play Therapy © 2009 Association for Play Therapy
2009, Vol. 18, No. 4, 229 –239 1555-6824/09/$12.00 DOI: 10.1037/a0016336
230 Kolos

(Budde et al., 2004). Some data suggests that the number of foster care placements
may be predictive of the level of posttraumatic stress symptomatology exhibited by
children who have experienced maltreatment (Benson, 2006).
The long-term effects of residential care at a young age have also been
documented. While symptom reduction and the development of a positive self-
concept and internal locus of control are commonly cited benefits of residential care
(see Little, Kohm, & Thompson, 2005 for a review), some studies have demon-
strated concerns that arise for children in residential care, such as their lack of
positive peer relationships as compared to children raised in two-parent families
(Vorria, Rutter, Pickles, Wolkind, & Holsbaum, 1998). Crucial components in the
residential care model, such as relationships between children and staff and struc-
tured routines within the facility, afford children the opportunity to experience the
stability and belonging that they may not have experienced before (Devine, 2004);
however, it is generally accepted that the placement in a residential facility is a
stressful experience for children (Little et al., 2005).
Permanency planning was implemented with the Adoption Assistance and
Child Welfare Act of 1980 to address the negative outcomes associated with
long-term residential care, as well multiple foster home placements. Permanency
planning asserts that every child has the right to a permanent, safe, and stable home
(Henry, 1999). Reunification with the child’s biological parents is the most desirable
permanency plan, followed by adoption, legal guardianship, and lastly, long-term
foster care. Permanency planning has had a positive effect on the child welfare
system, having resulted in earlier consideration of long-term plans for the child,
identification of options for moving the child out of foster or residential care
placements, provision of comprehensive services for the child’s biological family,
and collaboration with other service providers (Malucio, Fein, Hamilton, Klier, &
Ward, 1980).
A child’s transition from residential care to a stable home environment is
largely dependent on the cooperation of many different professionals invested in
the child’s success. While a play therapist may be the primary mental health
provider to the child, very little is available in the current play therapy literature
about the process of choosing a permanent placement, transitioning a child from
residential care to a new home, or the therapist’s additional roles as advocate and
multidisciplinary team member in this process.

THE THERAPIST AS MULTIDISCIPLINARY TEAM MEMBER

Ideally, a therapist becomes a member of a multidisciplinary team from the

time a child enters a residential treatment center. Team members include those who
work at the center, such as therapists, direct care staff and program coordinators,
and external professionals, such as social workers, lawyers, school staff, doctors,
and referring therapists (Crenshaw & Foreacre, 2001). Collaboration among those
involved with the child allows for the sharing of observations, insights, and sugges-
tions for treatment and planning (Crenshaw & Foreacre, 2001; Maluccio, Fein,
Hamilton, Sutton, & Ward, 1982). Treatment goals may be reached more quickly if
children’s social, educational, and residential environments are consistent and
Transition From Residential Care 231

working toward the same goals. Little research has been conducted on the benefits
of such collaboration, although it has been suggested that through multidisciplinary
communication, professionals can identify new methods for reaching goals and
reach a clearer understanding of the context in which the child is operating
(O’Toole & Kirkpatrick, 2007). Further, research conducted in educational settings
states that collaboration among team members enhances positive outcomes (e.g.,
Barnes & Turner, 2001). Collaboration and communication among team members
is of primary importance when the decision is made to transition a child out of
residential care to a new home. When a child is demonstrating significant progress
in residential treatment, the treatment team determines the least-restrictive, most
appropriate setting to which the child can transition (Parsons, 1995). Settings
include group home placement, therapeutic foster care, kinship placement, and
reunification with biological parents. For the purposes of this article, the placement
setting discussed is foster care, as many children in residential care step down to
foster care before returning to a biological family member. Stepping down refers to
the process of decreasing the level of services for a child in out-of-home care
(Alabama Department of Human Resources, 2005). The social worker involved in
the case prepares information about the child to be sent to local foster care
agencies. These information packets are examined by various agencies, who deter-
mine if any foster families are available for the child.
A working relationship with the social worker often enables the therapist to
have a more involved role in the screening of potential families. The therapist can
utilize his or her in-depth knowledge and understanding of the child’s developmen-
tal level, interpersonal dynamics, defenses, and strengths to enhance the assessment
of potential foster families (Crenshaw & Foreacre, 2001). Further, foster parents
benefit from receiving as much information as possible about the child’s history, as
it allows them to have a clear understanding of expected behaviors and difficulties
prior to accepting the child into their home (VanFleet, 2006).
The mental health professional often assumes the role of psychoeducator on
the team. It is important that those working for the child understand typical child
development and behavior in order to conceptualize the child and his or her needs.
Once a child learns he or she will be going to a new home, there may be regressions
in behavior that can be effectively managed if teachers and direct care staff are able
to proactively anticipate the behaviors and strategize solutions. An appreciation of
the effects of early trauma on brain development, ability to form meaningful
attachments, and emotion regulation must be present in order to find an appropri-
ate family and facilitate a successful transition (Bruning, 2007).
There are also times when the play therapist is not situated within the residen-
tial setting and instead, is the referring clinician who is based in an outpatient or
school setting. Many times these therapists feel unsure about their role in the child’s
life once the referral has been made and the child has been admitted to residential
care. In these situations, the therapist can still work as an integral part of the
multidisciplinary team. Participating in meetings and discussions, disseminating
information about the child’s history and circumstances leading up to referral,
engaging in regular contact with the residential therapist, visiting the child to dispel
fears of abandonment, speaking with or even meeting with the child’s guardian(s),
making suggestions for discharge, and resuming therapy after discharge are just a
232 Kolos

few ways in which the referring clinician can remain a part of treatment while the
child is in residential care.
This author became a member of Mateo’s multidisciplinary team after Mateo
was admitted to a residential treatment facility. Mateo was a 5-year-old, Hispanic
male, who appeared smaller than his stated age. Mateo had been living in a
homeless shelter for 6 months, following his mother’s decision to leave her abusive
spouse, Mateo’s father. Mateo had witnessed the domestic violence and had been
exposed to pornography at an early age by an uncle who frequently babysat.
Mateo’s small height and weight suggested neglect, and exposure to cocaine and
nicotine in utero had resulted in developmental delays surrounding motor coordi-
nation and language development. At admission, Mateo’s mother reported that he
had become difficult to parent, frequently running away, hitting her, and acting out
sexually with peers at his school. Mateo was admitted to the residential center for
diagnostic testing, and the permanency plan was parental reunification.
Mateo adapted well to the consistency and structure he was afforded on the
unit, and after 6 months in treatment, Mateo’s treatment team determined he no
longer needed the intensity of residential care. Reports from his mother, teacher,
and social worker indicated significant behavioral issues at admittance; however,
Mateo was no longer displaying bolting, aggression, or sexualized behaviors. Ma-
teo’s mother had made progress in her own life as well, moving into a more stable
shelter and engaging in mental health and substance abuse treatment. However, she
was not ready to resume full-time care for Mateo, so the treatment team decided
upon therapeutic foster care as the next step toward reunification.

THE THERAPIST AS ADVOCATE

Once a placement is decided upon by the multidisciplinary team, the therapist

plays an important role as an advocate for the child. Later, when foster parents
have been identified, the play therapist’s advocacy will also extend to them as well,
and this role will continue until the child has been successfully transitioned to the
new home. The goal of advocacy counseling is to empower the client and increase
feelings of belongingness (Kiselica & Robinson, 2001; Lewis, Lewis, Daniels, &
D’Andrea, 2003). This role may feel overwhelming to some therapists, as the child
welfare system can be confusing and feel like unchartered territory to a professional
untrained in social work practice. Despite these reservations, however, it is impor-
tant that therapists remember it is often they who best know the child (Wanlass,
Moreno, & Thomson, 2006). Active participation in all aspects of the placement
process, not just therapy, is required of a play therapist if he or she is to advocate
for the child.
Because the therapist will have a significant amount of information about the
child, it is important to consider what information is most relevant to an appropri-
ate placement. This becomes especially important when the therapist is participat-
ing in the process of interviewing families. In the case of Mateo, the therapist chose
to disclose his presenting issues, family dynamics, exposure to domestic violence and
pornography, and his mother’s mental health issues. Doing so allowed the potential
foster parents to have a comprehensive view of the child they were considering
Transition From Residential Care 233

taking into their home. Research has shown that placements are less likely to fail
if the family is well-aware of the child’s history, strengths, and limitations (Bruning,
2007), and the therapist is often the multidisciplinary team member most capable of
providing such detailed information.
Further, it is important that the therapist advocate for the child to have
continued contact with his or her biological family, where appropriate. The litera-
ture suggests that children who are given the opportunity to have continued contact
with family members are more likely to successfully adapt to their new placement
(Kupsinel & Dubsky, 1999). Assuring Mateo’s biological mother that she would still
be involved in Mateo’s life allowed the team members to ally themselves with her
and provide an opportunity for the parent– child dyad to continue working toward
reunification. Finally, the mental health professional is responsible for ensuring
wraparound services will be provided for the child and family, including individual
therapy, family therapy, crisis intervention, and medication management.

THERAPIST AS MENTAL HEALTH PROVIDER

Regardless of the other roles therapists play in the transition process, their
primary role is that of mental health provider. Therapeutic goals in working with a
child transitioning from residential care to foster care will likely include issues such
as the child’s feelings about placement, separation and loss, and the child’s need for
permanency (Maluccio, Fein, & Olmstead, 1986). Children moving into a new
home may also need the therapist’s assistance to understand where they are going
and what they will tell new people about themselves. The therapist can facilitate the
child’s mastery of the new living situation using various tools in the play room, such
as books, puppets, and art projects. Additionally, the incorporation of the foster
parents in treatment can be helpful in preparing the child for transition.

Bibliotherapy

Bibliotherapy can be a powerful tool in working with children who are strug-
gling with the idea of transition into a new home. Unlike the spoken word which
can be forgotten, distorted, or misinterpreted, books provide children with written
words that remain the same over time (Stepakoff, 2003). Furthermore, books often
act as transitional objects and can be used by foster parents to continue the
development of a relationship between them and their foster child after the
transition has occurred.
Various authors recommend books for working with children transitioning to
foster care (Pardeck, 1990; Stepakoff, 2003), and a list of selected books is provided
in Table 1. The use of bibliotherapy in Mateo’s transition from residential care to
his foster family was helpful when explaining the process to him. The Star: A Story
to Help Young Children Understand Foster Care and its accompanying activity book
(Lovell, 2005) proved useful in describing foster care to a small child in an
interactive way. Throughout therapy, Mateo enjoyed sitting on the floor with his
therapist and leaning against her while they read books, and reading The Star
234 Kolos

Table 1. Selected Books for Bibliotherapy With Transitioning Children

Title of book
A Mother for Choco (Kasza, 1996)
Murphy’s Three Homes: A Story
for Children in Foster Care
(Gilman, 2008)
My Foster Family: A Story for
Children Entering Foster Care
(Levine, 1993)
Our Gracie Aunt (Woodson, 2002)
Zachary’s New Home (Bloomquist
& Bloomquist, 1990)
Age group Brief synopsis
3–8 Choco, a bird, believes that animals must look the
same to be a part of the same family. He learns
that families are all different when he is taken
in by Mrs. Bear and meets the other animals in
her family.
4–8 Murphy the puppy is confused when he is taken
away from his family and placed in a new
home, but he begins to find ways to cope with
his emotions and new surroundings.
4–8 A boy waiting to visit his mother tells two
children (recently removed from their home)
what it means to be in foster care.
5–9 A boy and girl begin to stay with their Aunt
Gracie after being seemingly abandoned by
their mother.
3–8 Zachary is a small kitten who has many different
feelings surrounding moving from his biological
family to foster and adoptive families.

enabled Mateo to equate a nurturing experience with the explanation of foster care.
After placement, Mateo’s foster parents chose to purchase this book to read it to
him at night to continue the nurturing experience and continue to answer any
questions that remained about foster care.
While there are books written specifically for children in foster care, other
books can be used to target concerns voiced by children in transition. Clinicians
working with children are encouraged to become familiar with a range of popular
books and poems, as some can be appropriate for working with children’s issues
and concerns. One therapist used both The Three Little Pigs (Marshall, 1989) and
The Velveteen Rabbit (Williams, 1986) to work with a client who worried about the
security of his new home and struggled with feeling wanted and loved (Stepakoff,
2003).
Books can also be useful resources for new or veteran foster parents as a way
to prepare them for the transition that will occur in their own lives. Equipping
parents with information about both the child and the process are critical in
securing a successful placement for a foster child (Bruning, 2007). Mental health
professionals may recommend books such as A Child’s Journey Through Placement
(Fahlberg, 1994), and Attaching in Adoption: Practical Tools for Today’s Parents
(Gray, 2003) to foster parents in an effort to help them better understand the
children coming into their lives. Mateo’s foster parents reported that A Child’s
Journey through Placement was helpful in elucidating some of the problem behav-
iors children with abuse and neglect histories may display. By reading and prepar-
ing themselves for some of the issues Mateo might be struggling with, they felt more
equipped to support him and effectively respond to him.

Puppet Stories

Puppet stories are useful with children who are nervous about their new homes
and surrounding environments. Studies have long employed the use of puppets in
Transition From Residential Care 235

hypothetical vignettes for the assessment and intervention of children’s peer inter-
actions (e.g., Du Rocher Schudlich, Shamir, & Cummings, 2004; Murphy & Eisen-
berg, 1997). Because children may use puppets to enact fantasies or past traumas,
conquer worries or fears, or replicate actual behaviors in real life situations, it is
possible that the theme of a new placement may appear during their play. Play
therapists may also choose to initiate puppet play as a way to practice and develop
responses to potential situations in a nonthreatening way.
For children preparing to transition to a new home, puppets can be useful tools.
Shortly after moving, children are asked questions about themselves and where
they came from by a host of inquirers. Children left to fend for themselves in these
circumstances often feel forced to give answers, and may elaborate the truth or
share private details that ostracize them from their peers. With the therapist’s help,
such children can learn to respond to questions confidently and truthfully such as,
“Where did you come from?” or “Why don’t you live with your parents?” without
betraying private information. Mateo expressed concern over what he might say to
the peers at his current school on his last day.
Using puppets, the therapist can help a child role play the questions and
answers in a nonthreatening way. Each puppet can take turns practicing answers to
the questions the child may encounter. These can range from simple questions, such
as “What is your name?” to more challenging questions, such as “Where are you
from?” to the most difficult questions, such as “Why don’t you live with your
parents?” Mateo’s puppet, a turtle, liked to pull his head into his shell when the
therapist’s puppet, a snake, asked questions about his family. The therapist used
these puppet sessions to familiarize Mateo with the questions he might be asked,
while also teaching appropriate social skills surrounding conversation starting and
ending. Mateo benefited from learning how to say, “That’s my family’s business and
I’d rather not talk about it,” when encountering a forceful “snake” asking probing
questions. Once a child’s puppet appears more comfortable, the therapist and child
can begin practicing directly with the child acting as him/herself. The therapist can
also include foster parents in the activity to develop a sense of unity between them
and the child, and prepare them for the probing questions their child may encounter
as well.

Life Story Book

A life story book is a book that the child creates with the therapist. The goal of
the book is to facilitate a sense of history and identity in the child with the use of
artwork, pictures, and writing about major events in a child’s life. The book also
acts as a transitional object, as children are told that they will be able to keep the
book and take it with them to their new home. The book is an objective account of
the child’s life, beginning with the child’s name, date of birth, names of parents, and
place of birth, and continuing through to the child’s current age. For children in
residential care who may have had several homes prior to admission, each one is
identified and included as a part of the child’s story.
While the completed life story book will contain a complete account of the
child’s life, it can be constructed in a way that is sensitive to the child’s level of
236 Kolos

comfort. For example, the child may feel more comfortable starting with the
present, or a less threatening time in his or her life. Mateo, for example, began his
life story book with his time at the residential unit, as he struggled to remember
living with his biological parents. The therapist’s unconditional acceptance of the
child throughout this process is paramount in facilitating the child’s acceptance of
the many aspects of his or her life. Further, the completion of sections of the book
conveys the message that the end of residential care is the end of one chapter in the
child’s life, and that a brand-new chapter is beginning with the foster family
(Bruning, 2007). Blank pages left at the end of the book symbolizes that many new,
exciting chapters are in the child’s future (Maluccio et al., 1986).

Filial Therapy

Even if the match between the child and the family is appropriate, the degree
and extent to which the foster parents have been trained to cope with behavioral
issues can play a critical role in placement success (Albers, Reilly, & Rittner, 1993;
VanFleet, 2006). Filial therapy, based on (a) building healthy attachments, (b)
allowing children to work through their problems, and (c) providing families with
the tools necessary to have the positive family environment they envision, is one
particularly useful treatment modality for this population (VanFleet, 2006).
Filial therapy is an empirically validated process by which mental health
professionals utilizing play therapy in their work with children train parents to
conduct child-centered play sessions with their own children (Bratton, Landreth,
Kellam, & Blackard, 2006). The mental health professional typically begins filial
therapy training by emphasizing the importance of play in understanding a child’s
world, often describing toys as children’s words and play as their language (Lan-
dreth, 2002). Parents are taught the basic skills of the child-centered, nondirective
approach of interaction with their children, such as allowing the child to lead the
play and giving words to the child’s nonverbal communication, also known as verbal
tracking. An example of verbal tracking might include saying, “You put that in
there,” as the child puts a block in a bucket. It is important that the parent refrain
from naming items, thus allowing the child full creative range in the playroom. As
they practice these skills in weekly play sessions with their children, parents are
introduced to more advanced concepts such as choice giving, limit-setting, and
esteem building (Bratton et al., 2006). After 10 weeks, parents complete their
training and continue to engage in play sessions with their children.
While filial therapy has demonstrated effectiveness with a range of populations
(VanFleet, Ryan, & Smith, 2005), its flexibility has particular usefulness with
adoptive and foster families. Filial therapy can be used as a preventative, stand-
alone approach, allowing parents to connect with their children and to feel confi-
dent in their parenting abilities. Or, filial therapy can be combined with a range of
individual and family interventions for parents and children who are experiencing
problems with their new living situation. VanFleet (2006) advocates its use in these
ways, but also suggests the implementation of filial therapy in the transition process.
This approach bolsters the relatively abrupt transition process typically employed
by helping families establish meaningful connections during the visitation process
and decrease anxiety.
Transition From Residential Care 237

The four-step process for incorporating filial therapy into the transition process
includes (1) meeting with the foster parents and providing them with an overview
of what to expect, (2) educating the parents about trauma and attachment, (3)
providing suggestions for interacting with the child, including positive parenting
and behavior management skills, and (4) training the parents in filial therapy. A
more complete description of this process is available (VanFleet, 2006). The
training and practicing of skills is gradually intensified alongside the increasing
visits with the child. Mateo’s foster parents initially met with the therapist weekly
to practice filial therapy skills. When they began visiting with Mateo on site, filial
sessions began in the therapy room in the unit. As Mateo and his foster parents
became ready for day visits and overnight visits, their filial sessions moved into
Mateo’s new foster home. This allowed both Mateo and his foster parents to
become accustomed to participating in filial therapy before he was discharged.

TERMINATION ANXIETY:
A SPECIAL CONSIDERATION FOR THE PLAY THERAPIST

Termination is a healthy, integral part of the play therapy process (Osofsky,

2004). Therapists must keep in mind that the termination of therapy celebrates a
child’s ability to assume a more independent role. Despite the positive aspects of
termination, a play therapist must be aware of the possible mixed emotions that can
occur as the therapeutic relationship develops over time. One study found that
therapists frequently reported feelings of caring, respect, and protectiveness for the
child (Kranz & Lund, 1979). Such feelings may be even more prevalent in therapists
working with children in residential care. The formation of a therapeutic alliance
can take many months, as many of the children have lacked opportunities to
develop a positive closeness with an adult and/or believe that closeness with others
is hurtful (Crenshaw & Foreacre, 2001). Thus, it can be difficult for the therapist to
view the successful relationship as one that must end.
As therapists prepare a child for a new placement, they are likely to experience
fears and concerns similar to those of the child, such as the permanency of the
placement (VanFleet, 2006). Other worries, including safety, revictimization, place-
ment failure, and behavioral regression may intensify a therapist’s termination
anxiety, as many play therapists can describe children for whom “the system” has
failed. Play therapists are encouraged to engage in regular supervision during the
transition and termination period to process these concerns so that they are not
transmitted to the child and can be appropriately conveyed in sessions (Kranz &
Lund, 1979).

CONCLUSION

On Mateo’s last day at his residential treatment center, he was given a flower
ceremony, as are all the children who leave the center to go to a new home. At this
ceremony, each of the child’s peers tells a story or sends good wishes to the
discharging child and family. The members of Mateo’s multidisciplinary team were
238 Kolos

all in attendance, as were Mateo’s biological mother and foster parents. Mateo
made friends easily on the unit, and many of the children expressed sadness over his
leaving. One 6-year-old girl summed up the thoughts and feelings of the group best
when she said, “I’m sad you won’t be here anymore, but I know it’s time for you to
move on.”
In this case, and in many others like it, the therapist played a number of roles
including team member, advocate, and mental health provider, all of which were
critically important to the success of Mateo’s transition to a new foster family. Play
therapists must be aware of the various responsibilities they hold when working
with children who are transitioning from their current living environments to novel
ones. Education about the complexities of transition and collaboration with pro-
fessionals who regularly work within the child welfare system can prepare thera-
pists to competently participate in the decision-making process and effectively
support and prepare the child for life in a new home.

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