Navigating Resilience: Developing The MAP Framework for Supporting Children Through Familial Adversity in Hong Kong

抗逆力导航：开发 MAP 框架以支援香港儿童克服家庭逆境

Kit Ping Wong, Siu Yan Frances Leung, Lai Yin Galie Chow

Baptist Oi Kwan Social Service, Hong Kong

Abstract

Formulating interventions when working with children from a wide age range who have experienced familial adversity with diverse developmental needs present significant challenges that warrant investigation. The MAP framework, which was established by a support service in Hong Kong, encompasses guidelines for both therapeutic goals and strategies to facilitate focus and clarity in the therapeutic work based on literature review, critical reflection, and feedback from participants. As therapeutic goals, M stands for mindful awareness and management of emotions, A denotes attachment building, and P refers to positive self-worth. In working toward intervention strategies, M represents mindfulness practice, and A and P refer to art and play mediums, respectively. Case examples are included to illustrate the application of the model.

Keywords: family adversity, art therapy, play therapy, mindfulness, attachment

摘要

经历过家庭逆境之儿童，因應他们的年龄跨度很大，有着不同的发展需求，在为他们制定干预措施时面临着巨大的挑战，值得研究。MAP框架是由香港的一家支持服务机构建立的，我们根据文献回顾、批判性反思和参与者的反馈意见，建立了框架，其中包括治疗目标和策略指南，以促进治疗工作的重点和清晰度。作为治疗目标，“M”代表正念意识和情绪管理，“A”表示依恋关系的建立，“P”指积极的自我价值。在介入策略方面，"M"代表正念练习，"A"和 “P”指艺术和游戏媒介。本报告还列举了一些案例, 以说明模式的应用。

关键词： 家庭逆境, 艺术疗法, 游戏疗法, 正念练习, 依附關係

Introduction

In Hong Kong, adverse childhood experiences (ACEs) has gained great attention due to the alarming increase in mental health difficulties encountered by children and adolescents. A survey indicated that up to 39% of primary and secondary school students may show symptoms of mental health disorders, with family relationship being one of the significant sources of stress (Save the Children Hong Kong, 2020). Scully et al. (2020) research suggest a strong association between adverse childhood experiences and mental health problem in children and adolescents. In their well-known survey, Felitti et al. (1998) reported 10 types of ACEs, including physical/emotional/sexual abuse, physical/emotional neglect, divorce/battered spouse/mental illness/substance abuse/incarcerated relative of household dysfunction. A steady trend of increase of ACEs such as divorce and child abuse was noted in a Hong Kong government statistics report (HKSAR, 2022). In response to these familial adversities, a support service has been launched to provide early intervention for these family groups with children aged between 3 and 17 years. The large age range implies diverse developmental needs and unique characteristics of each client, which poses great challenges in formulating interventions. This article documents the team’s effort to establish the MAP framework that assists to formulate both treatment goals and intervention strategies. The rationale in the development process and the application of this framework in practice will be discussed.

Impacts of Familial Adversity

Familial adversity has significant impact on the personality and social development of children and adolescents in three main areas. The first impact is poor emotional regulation ability (Shahab & Taklavi, 2019). Neuroscience shows that the autonomic nervous system is responsible for emotion regulation. Specifically, the amygdala appraises stress and activates the “fight-flight-freeze” response to protect the individual against the perceived threat. For example, children may show explosive emotions or numbness/freeze when they encounter an abusive experience. Prolonged exposure to familial adversity may distort the nervous system in response to the stress by emotionally overreacting or underreacting. Therefore, the capacity to strengthen emotion regulation is helpful in promoting the frustration tolerance of children.

The second influence of familial adversity is on the attachment between the caregiver and the children. Attachment is an emotional bonding developed between the caregiver and the child/children during their upbringing. A secure attachment is crucial in children’s building of an internal working model to cope with different challenges in their environment (Bowlby, 1962). Familial adversity upsets the emotional capacity of the caregiver, which, in turn, affects their attunement with the child/children, which may manifest as being overly protective or emotionally neglectful. These parents demonstrate inadequate emotional availability to attune to the child/children’s emotional outbursts, which leads to insecure attachment and, in turn, hampers the child’s capacity to regulate their emotions (Malchiodi, 2014). In contrast, a secure attachment is a strong contributor to the development of positive self-identity in children (Ata & Guder, 2020).

The third influence of familial adversity is the negative impact on the development of self-identity. Self-identity refers to how someone perceives, identifies, or defines one’s own self. In humanistic orientation, self-identity includes ideal self, self-image, and self-esteem. Ideal self means the expectation or future vision toward self, self-image refers to the current perceptions of self, and self-esteem indicates how one evaluates the worth or value of one’s own self. A low self-confidence in mood management together with inadequate emotional support and understanding from the parent-child relationship affects the child/children’s self-identity development.

Intervention Goals that Address the Impacts of Familial Adversity

To cope with the three impacts of familial adversity, the “attachment-regulation-competence” (ARC) framework proposed by Kinniburgh et al. (2005) establishes concrete intervention goals for children who have experienced complex trauma. Attachment building, improvement of emotional self-regulation, and enhancement of competence are the three core domains of treatment goals in the ARC framework. Within this frame, 10 building blocks for intervention are organized and developed into skill-building suggestions at individual, familial, and community levels. In the attachment domain, the focus is to build the caregivers’ capacity to establish a safe and attuning environment, through four building blocks (caregiver management of affect, attunement, consistent response, routines and rituals) for the children to strengthen their self-regulation. For the self-regulation domain, three intervention goals (affect identification, affect modulation, and affect expression) are targeted to enhance the children’s capability to cope with emotional arousal and communicate their internal experience. In the competence domain, promotion of children’s executive functions, such as problem-solving, and the development of positive self-identity are two building blocks. The last building block is the meaning-making of traumatic experience, which integrates learning from all three domains, which assist children to develop a coherent self-narrative and achieve a fruitful life.

We share similar observations of the importance of establishing the three core domains in our clinical practice. According to Struik (2014), attachment, emotion regulation, and the self-concept are closely related and must be addressed when working with traumatized children. A study of Chinese children who have experienced repeated familial physical and sexual abuse in Hong Kong also emphasizes the inclusion of attachment building and emotional regulation ability as intervention core components (Ma & Li, 2014). Hence, the ARC principles provide insight on setting the intervention goals. The considerations in planning concrete strategies to put these components into actual practice should be determined.

Consideration of Stages of Trauma Recovery and Developmental-Sensitive Strategies in Processing Adverse Childhood Experiences

Herman’s (2001) three stages of trauma recovery and neuroscience knowledge provide information on processing trauma and recovery. Herman highlights the first stage of safety, and in the second stage of remembrance and mourning, stabilization builds a foundation for the children to process their traumatic experiences without re-traumatization. Such processing of difficult experiences facilitates deeper understanding and helps make new meaning, which, in turn, establishes an integral self and reconnects with the society in the final stage. Similar with the intervention components of ARC, the enhancement of emotional regulation ability within a trustful therapeutic relationship and the strengthening of attachment bond are strong indicators of building a sense of safety and stabilization in children and adolescents (Malchiodi, 2014), which is an initial focus of intervention.

In the subsequent processing of traumatic experiences, the developmental characteristics and needs of the children and adolescents must be considered. The neuroscience knowledge advises that trauma is a mind–body-connected experience in which the input signal from our senses, including visual, auditory, olfactory, tactile and taste, are linked to the brain for processing. For example, traumatic experiences become implicit memories stored as “photographic forms” in the brain, and without working these through, these images can become intrusive flashbacks or nightmares (Pifalo, 2007). Hence, children need a nonverbal and metaphorical medium that matches with their developmental needs to facilitate their processing of emotions and experiences. The concept of expressive therapies continuum (ETC) (Hinz, 2020; Lusebrink et al., 2013) corresponds to the information processing development of the brain, matches with the developmental needs of children, and informs to consider creative modalities suitable for them.

The ETC consists of three stepwise levels—kinesthetic/sensory, perceptual/affective, cognitive/symbolic, which are all connected with creative level. For younger children, the emphasis on the kinesthetic/sensory level can be a starting point to get acquainted with them instead of focusing on the cognitive/symbolic level. Meanwhile, the focus on cognitive/symbolic level may be suitable for some latency-aged children and adolescents due to the development of abstract cognitive functioning. The ETC model assists in developing a strategy focused on the treatment goals of regulation, attachment, and competence. For example, the building of attunement in the attachment domain can be promoted through the sensory mode by introducing body-touch activity between the caregiver and a young child or through an affective and cognitive mode by drawing their memorable moments and sharing their feelings for preadolescents with their parents. ETC also recommends the formulation of a strategy in a comprehensive manner, such as in the processing of grief emotions either in a sensory or an affective way and in making meaning of their experience in cognitive or symbolic ways when working with bereaved children.

The Integrated Use of Mindfulness, Art and Play

In addressing the intervention goals of emotional regulation, attachment, and competence building, with the consideration of stages of trauma recovery and developmentally sensitive strategies, the integrated use of mindfulness, art, and play is suggested.

Mindfulness emphasizes several elements, including self-awareness, a focus of here-and-now, and a non-judgmental and self-accepting attitude (Kabat-Zinn, 2015). A strength of cultivating an attitude of self-acceptance enables a self-healing capacity to emerge. Increased self-awareness facilitates the identification of the emotional state and the learning of self-regulation. A growing number of research reveal the benefits of mindfulness intervention in promoting emotional regulation capacity and self-awareness when working with children (D’Alessandro et al., 2022). One significant explanation is that mindfulness practice can improve the ability to pay attention, which facilitates executive functions such as cognitive flexibility and reasoning to promote insightful thinking (Ren et al., 2011). Such capacity is crucial for children and adolescents to process their adverse experiences and manage the associated strong emotions in a tolerable state.

In Hong Kong, encouraging results were found in reducing depressive symptoms and stress, improving well-being and enhancing executive functioning for children and adolescents by mindfulness practice (Lau & Hue, 2011). However, scholars also point out some adolescents showed low commitment in attending mindfulness activity due to the static and quiet nature of the activity (Lam et al., 2015). Incorporating elements that are relevant to the age, interests, and cultural characteristics of the children and adolescents are helpful to strengthen their motivation to participate (Burrows, 2022). An arts-based medium (Coholic et al., 2023) and play (Lee et al., 2020) have been integrated in mindfulness practice when working with children and adolescents, and they have shown positive results in their well-being. The benefit of integrating art and mindfulness is to facilitate the child’s access to practice the skill in a developmental sensitive way (Bokoch & Hass-Cohen, 2021). Both art and play therapy emphasize the process of expression, and the fun and entertaining characteristics facilitate learning and practice of mindfulness in children and adolescents (Turner-Bumberry, 2018). Particularly, using a creative medium promotes of a sense of acceptance within the creation process in the therapeutic relationship. According to Gambrel et al. (2020), “awareness alone is not necessarily growth enhancing; it is the combination of awareness and acceptance that promotes positive change” (p. 85). The integration of mindfulness with art and play promotes both awareness and acceptance in the therapeutic relationship, which is important in working with children to learn regulate emotion and process traumatic experiences.

Through the tactile nature of art materials, which promotes the stimulation of the sensory nervous system, the art medium contributes to the externalization of feelings that are usually blocked by overwhelming emotions in the experience of trauma (Malchiodi, 2014). The art-making process promotes expression through metaphor, which helps children to access their traumatic memories, create a narrative to communicate, and process the difficult experiences in a non-threatening and symbolic way (Armstrong, 2013). The art-making process offers a transitional space (Winnicott, 1971) in which a symbolic expression of the inner world becomes a bridge to outer reality, so that children can gain an understanding of their own struggles. Moreover, the artwork can act as a symbolic containment for traumatic experience in the form of a tangible object that can be witnessed, mastered, or discarded to promote a sense of mastery (Malchiodi, 2014).

In the field of play therapy, Schaefer and Drewes (2014) emphasize that the therapeutic value of play lies in facilitating communication, fostering emotion wellness, enhancing social relationships, and increasing personal strengths. Play is the language of children (Landreth, 2012), and the process of playing provides a transitional space where children can express their experiences in a safe way. With selected toys, during play, the children can identify with an object and project their feelings or thoughts onto it. Such expression facilitates their access to the unconscious state, which encourages a release of emotions and lets them communicate their concern through metaphors such as pretend play, thus gaining new insight in the process.

An integrated approach of art therapy and play therapy is advocated in the recent decade by scholars (Gil, 2006; Green & Drewes, 2013), in terms of a combination of non-directive and structured approaches and modes of intervention. A non-directive approach with the base from humanistic orientation strongly recognizes the child’s capacity for self-healing and self-direction with the support of therapist’s unconditional positive regard and empathy. Although the choice of client is respected in the process, Gil (2006) indicates the need to give directives or to have an active approach in terms of structured activities, which can help promote self-awareness and transformation, for example, when a child becomes “stuck” in post-traumatic play (Gil, 2015). The introduction of therapist’s flexible response and guided activity can facilitate the children’s exploration of materials when they feel hesitation (Green & Drewes, 2013). According to Gil (2006), the decision on how to use which approach is “the ‘art’ of therapy” (p. 15). In the therapy process, children choose their own preferred materials, and they can focus on using one medium or combine the materials. What stands out as important is the therapist’s sensitivity to the underlying themes that the children communicate in the artmaking or play process as the therapeutic relationship progresses so that mutual understanding can be deepened. The enriched understanding informs the therapist’s decision on the approach of intervention that matches the children’s needs.

Development of the MAP Framework

For context, the support service targets family groups with children aged between 3 and 17 years who have experienced familial adversities. Families are referred by schools or family service centers who observed the children to demonstrate mood or behavioral problems, with some consulting or being on a waitlist for psychiatric services. Individual sessions and/or parent-child dyad work was offered between 6 and 9 months. The large age range of our target group meant tailor-made interventions are needed in the planning process, with basic intervention principles as reference in structuring therapeutic work, underpinning the development of the MAP framework.

We are a working team of three members who are all registered social workers in Hong Kong. We all have completed introductory training in child-centered play therapy, with each of us also completing training in mindfulness practice, art therapy, and play therapy. The challenges in working with the target group led the team to continuously seek mutual support in regular peer discussion of case development and gain feedback on the intervention goal and strategy. Such dialogue incubated the development of the MAP framework. The model was created based on literature review, observation, team discussion, critical reflection, and feedback from the participants.

The MAP framework covered both therapeutic goals and intervention strategies. As therapeutic goals, MAP represents mindful awareness and management of emotions (M), attachment building (A), and positive self-worth experiences (P). These three goals aim to directly address the potential impacts of familial adversity on the children and their families.

First, mindful awareness and management of emotions acknowledges that children are capable of being aware and can identify, accept, express, and regulate their emotions when encountering difficult experiences. The awareness of emotions implies their sensitivity to the bodily sensations of their emotions and to name the feelings, whereas the expression and modulation of emotions indicate their capability to communicate the feelings and adjust the aroused emotions to a comfortable state.

Second, attachment building denotes the importance of nurturing experiences between caregivers and children to strengthen the attunement in their relationship. The caregiver is aware of his/her own emotions and contains and responds to the emotional arousal of the child to communicate and acknowledge the child’s competence. Such attunement can be enhanced by offering a safe environment with experiential activities for both the caregiver and the child. The experiential activity is appropriate to the developmental characteristics of the child/children and the emotional readiness of the parent-child dyad. Sensory, affective, or symbolic activities are all possible ways to promote attachment.

The final goal of equipping the children with positive self-worth experiences facilitates establishing competence in the children. As described by Kinniburgh et al. (2005), trauma upsets the development of four domains of competencies, including interpersonal, intrapersonal, emotional and cognitive, in children. Interpersonal competence relates to secure attachment building; emotional competence refers to the healthy regulation of emotions; intrapersonal competence implies a positive self-identity development; and cognitive competence is capabilities in problem-solving, concentration, reasoning, and learning. These competencies are interconnected, as reflected in the first two goals of MAP, which help in building interpersonal and emotional competencies. Cognitively, providing the opportunity to process and integrate adverse experiences can facilitate new insights and be helpful to build a positive self-concept. The accumulation of positive experiences in these four domains contributes to the building of positive self-worth and resilience in the children.

Strategically, MAP guidelines denote the use of M (mindfulness practice), A (art), and P (play) medium in working with the target group. Incorporating all three media in a flexible manner enables practitioners to customize interventions according to the developmental needs and pace of each child. The following are general directions for intervention, but there is still a need to consider them on a case-by-case basis.

In practice, other than toys and art materials, storybooks and boardgames have also been provided in our playroom to suit the needs and interests of children and adolescents from different age groups and facilitate the building of therapeutic relationship. Generally, in the initial stage, the building of a sense of safety and emotional regulation would be the focus. A non-directive approach is first used to offer a sense of freedom and choice so that the children get acquainted with the setting and the therapist. The therapist can observe and gain a better understanding of the children during the process. Some mindfulness practices, such as breathing and mindful walking, are applied if the children are found to have disturbances in emotional regulation to enhance their self-awareness and self-acceptance. Art and play mediums are incorporated to enhance the fun element such as inviting the children to imagine a flower they like and make use of the five senses to portray the flower by art materials; afterwards, they can practice mindful breathing by blowing the flower. The children can also express their feelings and experiences using soft-clay or drawing after doing mindfulness activity.

In the subsequent stage up to termination, themes that emerged in the art-making and play process are identified. Such assessment informs further intervention goals and strategies to facilitate the exploration of experiences and find new meaning. For example, a storybook, which provides a safe medium for children to touch and express inner experiences through metaphors (Pernicano, 2015), is often used. The children can reveal their struggles and memories and consider new solutions by talking about the story and the characters and constructing a new plot, within an empathetic therapeutic relationship. Storybooks are classified around the three goals of self-regulation, attachment, and competence, with themes such as expressing emotions, the relationship with parents and siblings, and exploration of self-identity. Some specific topics around divorce and bereavement are also used. The books are preselected according to the developmental needs of the children before the session. Art-making is often incorporated as a follow-up activity to consolidate the children’s understanding of inner experiences and learning.

In addition, the parent-child dyad work may also need a structured play design to promote their mutual interaction and facilitate the connection between the caregiver and the children. Theraplay (Booth & Jernberg, 2010) provides useful elements to formulate our structured intervention. This model aims to build attachment between caregiver and children by promoting shared and attuned experiences through structurally designed activities. The activities focus on offering engaging, nurturing, structuring, and challenging experiences by promoting sensory touch, and the level of difficulty can be gradually increased to enhance competence. The following two case examples can shed light on the application of MAP framework in our practice.

Ethical Procedures

The case information was collected following the ethical procedures set by the agency and with informed consent obtained from the clients.

Application of MAP Framework: Case Vignettes

Case 1

Dora (a pseudonym), a 12-year-old girl with a brain tumor, for which she needed continuous medical treatment and hospitalization. Dora’s school attendance and social life had been significantly impacted, which in turn affected her self-confidence in social relationships. The medication caused a puffy physical appearance, which affected her self-image. Dora had shown emotional outbursts, locking herself in the washroom and self-slapping. She presented as depressed, sometimes being hyper-aroused manifesting as screaming or yelling or occasionally being hypo-aroused and numb.

In the initial stage of therapeutic work, the focus was to assist Dora to be aware of her emotions and be able to comfort herself through mindfulness practice. For instance, in one session, Dora was highly worried that she would not complete the huge amount of homework on time. Grounding techniques were introduced by counting one to five with the five senses, such as searching for five red-colored toys, four touchable hard materials, three types of sounds, two traces of smells, and one type of taste in the therapy room. The activity helped Dora focus on the here-and-now and calm herself when agitated. However, Dora sometimes rejected mindfulness practice such as body-scan because she felt it was boring, as she had learned before in school. Therefore, art medium was used to enhance Dora’s motivation to participate and raise her sense of self-awareness and self-acceptance. The “mindful self-portrait” was introduced; this required Dora to draw her self-portrait with a non-judgmental attitude through her four senses, to watch and touch her face, smell her body, and listen to her heartbeat. She felt the calmness inside herself and drew herself smiling under a mask.

The initial stage of mindfulness practice and art-making established Dora’s confidence in stabilizing herself and regulating her mood. Attachment building and positive self-worth were the subsequent focus. Dora shared her self-perception as being a burden to her family due to her long-term illness, which made her feel a heavy sense of guilt. Parent-child dyad work was introduced at this period to strengthen the attachment and establish a positive self-concept. A “lifeline” activity was given to Dora and her mother; in it they had to draw and share their past experiences and memories of happiness and difficulties together. Dora’s mother shared her experiences of miscarriage and her loss of hope of having a baby in the family. Therefore, when she found she was pregnant with Dora, she felt so excited and happy. Dora was treated as a treasure in the family after she was born. Although Dora had brain disease, Dora’s mother never regarded her as a burden, and the whole family was positive toward attending different treatments. This mutual sharing experience strongly released Dora’s heavy sense of guilt and significantly strengthened the attachment bond between Dora and her mother and enhanced Dora’s positive self-worth. Alongside this attachment work, which promoted Dora’s self-worth, storybooks and art and play activities were used to facilitate her individual reflection on her personal strengths and resources. For example, Dora readily engaged in the activity of decorating a movable wooden figure and showed different postures of a “self-cheerleader,” which reflected her self-affirmation in the later stage of our therapeutic work.

The first case showed the application of MAP framework, which reflected in Dora’s progress from better awareness and management of emotions to a rebuilding of parent-child attachment and accumulation of self-recognition experiences, through the integrated use of mindfulness practice, art, and play. Meanwhile, the application of MAP framework is not a linear process. The intervention goals and strategies were dynamically implemented according to the needs of the client as demonstrated in the second case.

Case 2

Jack (a pseudonym), an 11-year-old boy, showed anxiety features, often experiencing body trembling. When Jack was around 9 years old, he was separated from his mother and elder brothers due to their imprisonment or mental illness. He was then cared for by his father, and they had a close relationship. However, his father passed away suddenly due to an accident. As no other relatives could take care of Jack long term, he was moved to a children’s home. Jack received a total of 18 sessions, all in individual therapy format, within 11 months.

Jack’s life was full of fragility and a heavy sense of loss, separation, and abandonment. In the beginning stage, he needed to re-establish a sense of safety and capacity in stabilization. A non-directive approach was used to build a safe and trustful therapeutic relationship. Jack picked up the toys and chose the activity he liked such as playing ball with the therapist. Within the therapeutic relationship, the non-directive approach offered an important chance for Jack to gain a sense of choice, freedom, and mastery, which promoted his inner-self stabilization and self-affirmation. However, as he showed obvious body trembling in the session and he felt embarrassed before the therapist, the therapist’s active intervention was needed to enhance his bodily sense awareness, capacity in self-soothing, and a sense of safety through the integrated use of mindfulness practice, art, and play.

Jack’s response was accepted and normalized by practicing mindfulness activities together such as breathing exercises. Different art materials such as feathers, foam cube, pipe cleaner and crepe paper were provided for touching to enhance his own awareness of different senses and emotions in the here and now. Later, in a body-scan exercise, he found a furry toy dog, which he put on the part of his body where he felt a sense of tightness. He found comfort, and the dog was treated as a protection guard for him. Jack was encouraged to be empathetic toward himself, and his awareness of the body sensation and his capacity to cope with the trembling gradually improved through continuous practice.

The challenges to Jack were coping with his grievance of his father and the feelings of abandonment without the support and participation from the other caregiver. However, the building of a sense of attachment was crucial to Jack to strengthen his inner self-integrity and self-worth. Therefore, the intervention for the goal of attachment was formulated in two ways: through nurturing the idea of “being a good friend of yourself” and establishing an internal connection with father in the process. Art medium was used to facilitate this process in a visual way. For example, a mirror was used to assist Jack to observe himself in detail so he could decorate a wooden movable human figure to represent himself and to move it into different postures to show his different feelings and how to care for this figure. Such an activity was also a mindfulness practice to cultivate awareness and self-compassion. In another episode, a storybook was incorporated with art medium to enable Jack’s exploration of his feelings and thoughts when facing problems. Jack made an artwork by gluing different foam cubes in a twisting manner to represent his trouble after reading. Jack was asked how to overcome his trouble, and he replied with a smile “these can be torn away.” He started showing a sense of mastery and self-awareness through his creation and expression.

To facilitate Jack’s reflection on the internal connection with his father, the storybook My Father is a Tree was used. An artwork of a tree was made to represent his memories of his father. Jack remembered his father’s qualities of kindness, sociability, and skill in playing basketball. An internal connection was maintained so Jack could keep an inner secure attachment. This process allowed Jack to mourn the loss of his father and to recognize in himself the positive qualities that his father had passed to him. This meaning reconstruction (Neimeyer & Thompson, 2014) process was important for Jack to find new insights and solutions to cope with his life challenges. Jack’s shivering responses reduced gradually in the whole therapeutic process. The goals and strategies of building a sense of safety, emotional regulation, attachment, and positive self-worth building were interwoven in the whole process to help Jack to cope with his trembling. The mindfulness practice and art and play mediums mutually enriched in the therapeutic process.

Discussion of the Application of MAP Framework

The presented case vignettes offer glimpses into the transformative impact of the MAP framework, reaffirming the efficacy in fostering resilience in children navigating challenging life circumstances. The framework links up both intervention goals and strategies in the formulation of treatment plan, which provides a map in the therapist’s mind to evaluate the progress.

Provide Direction/Structure with Flexibility

Instead of a stepwise manual, the framework offers general direction and structure, together with specificity and flexibility in practice. As treatment goals, mindful awareness and management of emotions tend to be the priority in the beginning stages of therapy because a stable mood facilitates reflections on attachment and self-identity. However, some children may benefit from strengthening the attachment or their self-identity first to build a sense of security to process their mood. As intervention strategies, both non-directive and directive/structured approach have been used in the process. Whether letting the children take the initiative to work on the materials they chose or taking active intervention to introduce relevant activities depends on the therapist’s assessment of the whole process. These two approaches look like two poles of a spectrum, where the intervention slides on this spectrum based on the understanding from the developmental needs, the pacing of the children, and the therapeutic relationship. Such flexibility in intervention shows in the preparation before the session starts and within the process in the session to cater to the needs of the children.

Compound Factors of Mindfulness, Art, and Play

Strategy-wise, the use of mindfulness, art, and play are interconnected; mindfulness allows children to ground in the here and now, and art and play mediums offer children a metaphorical language to express their feelings and thoughts and connect with their inner self. In combination, these three mediums enrich practice and facilitate children’s engagement and responsiveness. Mindfulness is a way of being/attitude and a skill that should be practiced, not just by the children but also by the therapist in the therapeutic relationship, so as to create a moment of sensitivity that helps the building of presence and resonance with the children (Kestly, 2016).

Reflective Practice for Clinicians

Therapist’s continuous observation and reflexive understanding is important in constructing the MAP framework in mind to formulate interventions responsive to the needs of those children. Regular discussion of the progress or difficulties encountered in the practice within the working team leads to the formulation of a framework that can guide the intervention and accumulate practice wisdom.

Conclusion

The MAP framework, developed to address the complex needs of children and families facing familial adversity, stands as a versatile and effective approach. The evolution of this framework was rooted in recognizing the diverse developmental needs within the target population and clinician’s critical reflection. Grounded in trauma-informed principles and neuroscience insights, focused on flexibility and tailored interventions, the MAP framework integrates mindfulness, art, and play to address emotional regulation, attachment building, and positive self-worth experiences. The framework offers a comprehensive approach to support children and families navigating adversity and opens avenues for scholarly inquiry.

About the Authors

Kit Ping Wong is a registered art therapist (ANZACATA) and a registered social worker (Hong Kong). She has completed her PhD and Master of art therapy in Western Sydney University. Her research thesis investigates the therapeutic relationship between an art therapist and a traumatized child through heuristic inquiry and autoethnography. With more than 25 years of practice experience in social welfare service, she commits in working with different clients, particularly children who have experienced trauma. While having direct practice in Hong Kong, she is also an Adjunct Fellow of Western Sydney University.

Author to whom correspondence should be addressed; E-Mail: Kit.Wong@westernsydney.edu.au. ORCID ID: https://orcid.org/0009-0006-5505-8287.

Siu Yan Frances Leung dedicated to the use of play therapy. She is the Registered Play Therapist in the Association for Play Therapy, United State (APT). She is also a certified Aut-Play therapy provider to provide play therapy for children with autism. Frances worked as a registered social worker in Baptist Oi Kwan Social Service for 7 years before and is passionate about children and parent work. Frances graduated from the University of Hong Kong with the Master of Social Work degree, specializing in “Family and marital counselling”. She completed her bachelor’s degree in counselling and psychology from the Hong Kong Shue Yan University. In working with children from diverse family structures, she is passionate to promote the parent education and enrich the parent-child relationship by assisting the parents to understand their children inner world and needs through talks, workshops, parent groups and individual consultations which enrich parents’ satisfaction, effectiveness, confidence and skills in parenting.

Lai Yin Galie Chow received Bachelor of Social Sciences (Hons) in Psychology from the Hong Kong Shue Yan University, and has completed professional counselling certificate of child-centred play therapy. Being a registered social worker, with more than 15 years of experience in social services for children and youth, she leads various activities in primary and secondary schools, including “MYmind: Mindfulness training for ADHD children and their parents”, “Emotional Management Group”, “Understanding the Adolescent Project”, “Positive Parenting Groups”, and “Parent Workshops”. Currently, Galie works in another new project, whom she provides individual or family counselling services, parent education programs, school-based support services, targeting children, youth, adults and parent-child, who have traumatic experiences.

Acknowledgements

The authors would like to thank for the valuable feedback from Susan Mowbray, Tristan Chan and Ricky Kwan in preparation for this paper. We also want to acknowledge the opportunity being the team members in the counselling service of Baptist Oi Kwan Social Service. Particularly, huge thanks to those children and their families who share their journey of recovery with us.

Conflicts of interest

The authors declare no conflict of interest.