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

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.

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.