International Journal of Nursing and

Health Services (IJNHS)

http://ijnhs.net/index.php/ijnhs/home
Volume 3 Issue 1, February 20th 2020, pp 133-140
e-ISSN: 2654-6310

Play Therapy to Reduce Traumatic Stress in

Earthquake-affected Children in North Lombok,
West Nusa Tenggara, Indonesia
Lis Triasari1*, Ah. Yusuf2, Sestu Retno D. A3 , Triyana P.D 4, Zaenal Abidin5
1,4,5
Master Student in Nursing, Faculty of Nursing, Universitas Airlangga Surabaya,
Indonesia
2
Department of Nursing, Faculty of Nursing, Universitas Airlangga Surabaya, Indonesia
3
STIKES Pemerintah Kabupaten Jombang, East Java, Indonesia

Article info
Abstract. Play therapy is a therapy that is appropriate to the level of
Article history: child development as a period of play after exposure to a disaster.
Received; 27 June 2019 Children are the group most vulnerable to traumatic stress due to
Revised: 24 July 2019 exposure to disasters. Children are the group most vulnerable to
Accepted: 15 August 2019 traumatic stress due to exposure to disasters. The research design
used a quasi-Experimental with a non-randomized control group
pre-post-test design design. The population in this
Correspondence author: study was elementary school children who attended school in the
Lis Triasari North Lombok Regency. The sample used was 90 students in
E-mail:
accordance with the inclusion criteria and divided into two groups,
[email protected]
namely the treatment group with 45 students and the control group
with 45 students by using multistage random sampling. Play therapy
DOI:
can reduce traumatic stress in children after exposure to traumatic
10.35654/ijnhs.v3i1.209
events in the intervention group (p=0,000). Play therapy was
effective to redute the traumatic stress among children. They may
express their feeling by sharing stories and experience with peers

Keywords: Health coaching, health promotion model, adolescent,

behavior

This is an Open Access article distributed under the terms of the Creative
Commons Attribution 4.0 International License CC BY -4.0

INTRODUCTION

Disaster is a defined as a potentially traumatic event, which may be collectively

experienced and may be attributed to natural, technological or human causes (1). Natural
disasters such as earthquakes can threaten and disrupt the lives and livelihoods of people
caused by natural and or non-natural factors and human factors resulting in human casualties,
environmental damage, property losses, and psychological impacts (2). These psychological
impacts can cause many mental health problems (3).

International Journal of Nursing and Health Services (IJNHS), Volume 3, Issue 1, February 20th 2020 133
 Trauma to individuals associated with an event can be a dangerous physical or
emotional threat that can be life threatening and cause loss of effects on individual functions
and mental, physical, social, emotional, or spiritual well-being (4). The most common
reactions such as sadness, anxiety, anger, and stress experienced by victims after a disaster are
normal responses to very abnormal situations (4).
Even though everyone will be affected by some traumatic events, the various
reactions and feelings for each person can vary. Many people may feel very scared or anxious,
or numb, and feel separated. Some people can have a mild reaction, but not a few will
experience a severe reaction. Many factors can determine a person's reaction such as the
nature and severity of the trauma experienced, previous traumatic experiences, the support
they have from others, physical health, personal and family history of mental health problems,
cultural and traditional backgrounds, and age (children from different age groups will react
differently) (5).
Previous research examining the prevalence of traumatic stress in children aged 7-13
years in the form of earthquakes and tsunamis that occurred in Nanggroe Aceh Darussalam in
2004 showed that the prevalence of PTSD was 48% (6). Other studies also conducted on 10-
year-old elementary school children in the Yogyakarta Special Region in the earthquake that
occurred in 2006 showed that the prevalence of traumatic stress in children was 87% (7).
Everyone has the strength and ability to overcome life's challenges, but some people
who are very vulnerable in crisis situations will need additional assistance such as special
groups of children and adolescents. Children and adolescents are vulnerable to mental health
problems after a disaster. Most teenage victims only display transient psychological
symptoms as a normal reaction to traumatic events (8). Children who survive earthquakes
may have many psychological problems, such as stress, depression and anxiety (9). While
other psychological impacts are prolonged sadness, substance abuse disorders, distorted
perceptions, pessimism, and suicide attempts (10).
Re-exposure of disasters has a worse effect on the mental health of children and
adolescents. Children and adolescents who have been exposed to disasters will be more
sensitive to the negative impacts of subsequent disasters (3). The psychological impact of
mass catastrophes in developing countries is rarely evaluated systematically (11).
Interventions to reduce anxiety or stress are feasible after trauma. Play therapy is
based on the belief that play is a universal language for children to express their emotions and
thoughts without relying on verbalization (12). The findings showed that children and
adolescents who received play therapy interventions showed better results than children who
did not get these alternative interventions. The most common intervention is drawing. Play
therapy with the use of images is a more powerful tool than therapy to play with other
methods because most children tend to enjoy the pictures without showing signs of tension
(13).

OBJECTIVE

This study aimed to determine the effect of play therapy on reducing traumatic stress
in children affected by earthquakes.

METHOD

A quasi-experimental study design, pre and post test with equivalent control group.
This research was conducted at the elementary school in North Lombok Regency. Ninety

International Journal of Nursing and Health Services (IJNHS), Volume 3, Issue 1, February 20 th 2020 134
students were selected using inclusion criteraia into treatment group (n=45) and control group
(n =45). We conducted the multistage random. The inclusion criteria including grade 3 to
grade 5 elementary school students, get written approval from parents, children can
communicate verbally, children can cooperate, and children have received trauma healing
beforehand.
The instrument used to measure traumatic stress in children was the Child Trauma
Screening Questionnaire (CTSQ) which consists of 10 question items. The instrument has
been tested for validity and reliability before the research was conducted. Data obtained from
questionnaires were analyzed using the Independent test to test and Paired t test with a
significance level of 0.05.
The participants were recruited on the basis of the Ethical Approval of ethic
committee, Faculty of nursing Erlangga university with the certificate number of 1294-KEPK.
Descriptive analysis was used to determine the frequency distribution of traumatic
stress assessment before and after play therapy interventions. The different test of the effect
given from the intervention on the variables concerned in the two groups is the T-test which
aims to determine the significant difference between variables and groups. The independent
sample t test is used to determine the significance of the mean difference between two groups
as one variable against another variable.

RESULTS

Characteristic of respondents
Table 1 shows that the respondent characteristics based on age in the treatment
group were mostly 10 years old, 17 respondents (38%) and respondents with 12 years old
were the least respondents (7%). Whereas in the control group, respondents with 9 years of
age (18%) were the most respondents with respondents who were at least 12 years old,
namely 6 respondents (13%). Characteristics of respondents by sex both in the treatment
group and in the control group were the same, namely dominated by female respondents 23
respondents (51%) and men 22 respondents (49%). Characteristics of respondents based on
the presence or absence of the respondent's family who died during the earthquake showed
that 2 respondents (4%) had families who died during the earthquake in the treatment group
and 11 respondents (76%) in the control group had families who died in the earthquake.
Table 1 showed the characteristic of respondents based on age, the results showed
the p-value was greater than α 0.05 (0.180), which means there was no influence of age on the
occurrence of traumatic stress in children. Gender also has no effect on the occurrence of
traumatic stress in children because the value of P value (0.665) was greater than α 0.05.
demographic data of a family who edited during the earthquake has a value of P Value
smaller than α 0.05 which means that a family who is edited during the earthquake has an
influence on the occurrence of traumatic stress in children.

International Journal of Nursing and Health Services (IJNHS), Volume 3, Issue 1, February 20 th 2020 135
Table 1. Characteristic respondents
Characteristics Experimental Group Control Group P Value
of respondents (45) (45)
n % n %
Age (year) 0.180
9 11 24 18 40
10 17 38 8 18
11 10 22 13 29
12 7 16 6 13
Total 45 100 45 100
Gender 0.665
Male 22 49 22 49
Female 23 51 23 51
Total 45 100 45 100
A family who 0.012
died during the
earthquake
Exist 2 4 11 24
Not exist 43 96 34 76
Total 45 100 45 100

Mean different of traumatic stress among intervention group and the control group
before and after play therapy implementation
Table 2 shows that there was a decrease in the average value of traumatic stress before
and after intervention in the treatment group than in the control group. The results showed
that the P value was smaller than the value of α 0.05 so it was stated that there were
differences in traumatic stress between the treatment group and the control group after being
given intervention. The difference in the values of the two groups after being given an
intervention showed the influence of play therapy on reducing traumatic stress in children
affected by the earthquake

Table 2. Mean different of traumatic stress among intervention group and the control group before and
after play therapy implementation

Pre Test Post Test

Variable Group (Mean + SD) (Mean + SD) Delta ∆ P Value
Min-Max Min-Max
Experimental 6.15+1.127 4.42+0.811
1.73
Traumatic (n=45) 2-8 2-6
stress Control 5.06+1.009 5.17+0.911 0.000
0.11
(n=45) 3-7 3-7
Independent Samples T Test 0.000 0.000

DISCUSSION

Disasters cause disruption to the socioeconomic life of affected communities.

Earthquakes that destroy homes and buildings and hurt even make children lose their parents

International Journal of Nursing and Health Services (IJNHS), Volume 3, Issue 1, February 20 th 2020 136
and other families will cause stress and trauma. After the disaster, children are also forced to
live in new places such as refugees, which can exacerbate the stress experienced by children
because they have to live together with many people and with improper facilities. One of the
most important impacts after a disaster occurs in children is post-disaster stress.
Symptoms of traumatic stress mainly occur after trauma. It is therefore important to
provide psychosocial support to identify those who experience symptoms of traumatic stress,
give them a plan of follow-up and refer to further treatment if symptoms do not subside (14).
This research was conducted in the school environment. The school is the environment
of the two children after the family where the school is a learning tool and can also be used as
a place to carry out an intervention involving children and adolescents. Outside the family
unit, school is one of the main support systems for children, if left to function intact, schools
can be the most natural support system for children and adolescents in implementing
psychosocial interventions. According to C. Fu & Underwood (2016) the implementation of
interventions through schools is considered a practical approach to public health initiatives
because it can reach a larger population target. Interventions relating to mental health and
psychosocial support carried out in schools can help to prevent the medicalization of the
normal reaction to traumatic stress and a low feeling of stigma among children (15).
The intervention used in this study involving the population of children and carried out
in the school environment is a play therapy intervention in the form of drawing, writing and
telling stories. Playing can be used as a therapeutic therapy because it focuses on the needs of
children to be able to express themselves through fun activities in play activities so that they
can be used to reduce stress that occurs in children. This is in line with the research from
Alfiyanti, Hartati & Samiasih (2007) that therapeutic play has been identified as an effective
intervention for preparing children for hospitalization, coping, understanding, and stress due
to hospitalization (16) .
Drawing can be the most comfortable media for storytelling for children. previous
study showed that research of Farokhi & Hashemi (2011) when children draw, they are free to
express themselves, to send messages without speaking and things that they think are
important in their life experiences (13).
Another study also suggested that asking children to draw and write stories about what
they have experienced is a common therapeutic communication technique that is used that
provides an opportunity to express their perceptions of their illness and feelings visually and
verbally (17). School-age children prefer to express their feelings and thoughts by drawing
rather than words. in consistent with previous study showed there was a decrease in the
anxiety level of children undergoing cancer treatment in hospitals through intervention with a
combination of techniques of drawing, writing and telling stories (18).
When a traumatic event occurs, it can cause traumatic stress. This traumatic stress is
also affected by the serious injury felt from death. In this study, several families of
respondents died during the earthquake. The families of respondents who died included
mothers, siblings, uncles, grandmothers, or cousins. This can affect the height of traumatic
stress experienced by respondents after being exposed to a disaster. Research from Levers
(2012) is in line with the results of this study that traumatic stress is generally caused by
perceived serious injuries from death, or threats to the physical integrity of oneself or others
that can cause potentially chronic and debilitating diseases called PTSD (19).
This study also uses a type of game in the form of storytelling. Respondents told what
they had drawn. The goal is so that respondents can express their feelings without harboring
themselves what they feel. Sharing stories can train respondents to encourage each other,
fellow disaster victims to be able to strengthen each other in the face of traumatic events they
experience. This is consistent with the research conducted by Swalm (2005) that speech
therapy or story sharing can ease the burdens of the buried mind and psyche (20) and also

International Journal of Nursing and Health Services (IJNHS), Volume 3, Issue 1, February 20 th 2020 137
research from Anonim (2005) which says that exchanging stories makes children feel they are
in the same boat, even feeling themselves better than others. This condition triggers a person
to rise from the trauma suffered and fight anxiety.
Play therapy in this study is effective for reducing traumatic stress in children after a
disaster. Many things can influence the effectiveness of play therapy, including children being
able to communicate through games and play therapy according to the stage of child
development. In addition, rural culture can also influence the effectiveness of play therapy
carried out in the school environment, namely children in their families are still taboo to
express what is felt verbally so that children are more comfortable with their peers who also
feel the same. Parents in the culture in which research is conducted tend to be busy working
rather than playing with children.
Children will be left to play with their peers rather than gather with family to share
stories. Children also feel embarrassed to tell what their parents feel. For example, when
children experience problems in school such as fights, children prefer not to tell parents
because they believe that parents will blame them for the fights that occur. So they prefer not
to tell stories compared to those who are to blame. Parents in the culture of the research place
feel that if the child's material needs are met, then there is no need to know what events the
child experiences in his daily life. Culture like this is one of the reasons why effective play
therapy is carried out in the school environment with the same age child respondents. This is
consistent with the research conducted by Maspupatun (2017) that play is used as a therapy
for children as counseling is used as therapy for adults (21).
The conditions at the time of the study also influenced the effectiveness of this play
therapy, where, when the research was carried out, in February 2019 there was no trauma
healing performed on children. Trauma healing is only done at the beginning of the
earthquake, which is in a refuge such as playing and singing. Whereas when they returned to
school, trauma healing was only done once in the form of walking to the local tourist area. In
addition, no trauma healing has been carried out so that the presence of play therapy is
expected to reduce traumatic stress experienced even more that earthquakes still exist today

CONCLUSION

Play therapy can help reduce traumatic stress in children. The effectiveness of play
therapy is because children can communicate through games. Play therapy carried out in the
school environment is more effective because the school is the second environment after the
family. Schools can be a place for children to express their feelings by sharing stories with
peers who they think have the same feelings they experience.

STRENGTH AND LIMITATION

Play therapy is the main choice of therapy in children who experience traumatic stress.
But in its application, often play therapy is only done in refugee camps and there is no further
therapy when they have returned home to evaluate symptoms of stress in children after
exposure to the disaster. So that symptoms of advanced stress, such as PTSD are difficult to
detect early because there is no further treatment if symptoms of stress are found in children
who do not decline.

ACKNOWLEDGEMENT
The research environment is not conducive because it is in emergency schools with
makeshift buildings and facilities such as the absence of halls, lack of writing desks and
respondents not focusing on research because of the large number of students outside the class

International Journal of Nursing and Health Services (IJNHS), Volume 3, Issue 1, February 20 th 2020 138
playing because the teaching and learning process is not maximized. A conducive
environment is needed in this study such as a calm and comfortable environment.

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