CHAPTER 18

Play

Susan H. Knox

OBJECTIVES

1 Describe the importance and relationship of play to occupational therapy.

2 Describe play theories in terms of form, function, meaning, and context.

3 Describe play assessments and determine their usefulness for assessment and treatment planning.

4 Describe environmental and individual qualities that facilitate or constrain play.

5 Describe how play is used in intervention.

6 Describe how occupational therapists can become advocates for play in our society.

KEY TERMS

Play forms

Play functions

Play meanings

Playfulness

Play assessments

Constraints to play

Play as a treatment modality

Play as an intervention goal

Adaptations

Parent education

Play…is the way the child learns what no one can teach him. It is the way he explores and orients himself to the actual world of space and time, of things, animals, structures, and people. Through play he learns to live in our symbolic world of meanings and values, of progressive striving for deferred goals, at the same time exploring and experimenting and learning in his own individualized way. Through play the child practices and rehearses endlessly the complicated and subtle patterns of human living and communication, which he must master if he is to become a participating adult in our social life (pp. v-vi).45

All children play, and it is through play that they learn about themselves and the world around them. Watching children play is like looking through a window into their very being. Play has been identified as one of the primary occupations in which people engage, according to the American Occupational Therapy Association (AOTA) Practice Framework.3 As defined by Parham and Fazio, play is “any spontaneous or organized activity that provides enjoyment, entertainment, amusement or diversion” (p. 448) and is “an attitude or mode of experience that involves intrinsic motivation, emphasis on process rather than product and internal rather than external control; an ‘as-if’ or pretend element; takes place in a safe, unthreatening environment with social sanctions” (p. 448).87

There are two sides of play: the science of play, in which play is a critical aspect of human development that deserves serious study, and the art of play, in which the therapist and the child are players, where there is joy, pleasure, and freedom. Occupational therapists need knowledge and skill in both aspects. This chapter describes play as the child’s occupation from a historical perspective, discusses why play is important to occupational therapists, describes methods of assessing play, and discusses play in intervention.

PLAY THEORIES

Clark et al. defined occupations as “the chunks of culturally and personally meaningful activity in which humans engage” (p. 310).31 People create or orchestrate their daily experiences through planning and participating in occupations.114 Occupational therapy generally considers work, self-care, leisure, play, and rest to be the major occupations of people. Occupations can be explained through the substrates of form, function, meaning, and context.31

Play can be viewed through these substrates of occupation:

• As an activity having certain characteristics (i.e., its form, including motor skill requirements and products)

• As a developmental phenomenon contributing to a child’s development and enculturation (i.e., its function, including purposes, processes, and experiences)

• As an experience or a state of mind (i.e., its meaning, including what motivates or satisfies the individual).

Play, like any other activity, takes place within context, which denotes the individual’s environments and the personal, physical, and social elements of each environment.

Form

Many play theorists describe play as categories of activities in which children engage.14,28,33,40 These include such activities as games, building and construction, social play, pretend, sensorimotor play, and symbolic or dramatic play. Children’s play activities change over time and reflect their development.14,83

Sensorimotor and exploratory play predominate in infancy (Figure 18-1) as infants develop mastery over their own bodies and learn the effect of their actions upon objects and people in the environment.90,100 Sensorimotor play peaks in the second year of life and then declines. Children continue to use sensory motor play when they learn new motor skills. Exploratory play begins in infancy, and by the end of the first year, infants actively explore their surroundings, demonstrate a beginning understanding of cause and effect, and are interested in how things work. In the second year, play centers on combining objects and learning their meaning. Children begin to classify objects and develop purpose in their actions. Exploratory play gradually declines through the preschool years, but it reappears when the child is learning new skills.14

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FIGURE 18-1 A first type of sensory motor-exploratory play is the infant’s exploration of his or her own body. Courtesy Dianne Koontz Lowman.

Constructive play has identifiable outcomes and predominates during the preschool years as practice. Constructive play remains high during middle childhood and adolescence but becomes more abstract. It may develop into arts and crafts. Symbolic play and pretense develop at the end of the first year and through the second, peaking at around 5 years of age and evolving into dramatic and sociodramatic play. During middle childhood, symbolic play and fantasy play are seen in mental games, secret clubs, and daydreaming, and in language play such as riddles or secret codes.14 Television, computer games, and movies are also ways of indulging in fantasy play.

Social play begins very early with interaction between the infant and mother, and by age 3, children are able to engage in complex social games. Children use role play to learn about social systems and cultural norms. Garvey described four types of roles seen in group play: (1) functional roles, such as pretending to be a doctor; (2) relational roles, such as pretending to be mother and baby; (3) character roles, such as those from television and movies; and (4) roles with no specific identity.46 Social play combined with motor play develops into rough-and-tumble play.14 Games with rules teach children to take turns and to initiate, maintain, and end social interactions.59 This type of play predominates during the school-age years.14,44 Social play and games with rules are particularly influenced by the culture. The physical environments available for play, peer groups, and the types of play encouraged by parents have changed as our society has become more urbanized.83 Currently, time, places, and types of play are more planned and structured, such as with organized sports and “play dates” (Figure 18-2).66

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FIGURE 18-2 Play today is often highly structured; for example, this play date takes place at the ice-skating rink. Courtesy Jill McQuaid.

Adolescents are concerned with autonomy and being socialized into adult roles. This is a period of transition as obligations, time available for play, changes and refinements of interests, family, and peer pressures all affect teen activity.83 In a study by Csikszentmihalyi and Larson, the most frequent single activity of adolescents was socializing.37 Second was television and third was sports, games, hobbies, reading, and music.

Another way to look at the forms of play is through their characteristics. Scholars of play have not identified a single characteristic common to all kinds of play but have suggested many qualities or characteristics of play that differentiate play from non-play. These characteristics include intrinsic motivation, suspension of reality, internal locus of control, and being spontaneous, fun, flexible, totally absorbing, vitalizing, an end in and of itself, non-literal, and challenging.33,40,55,71,84,96 According to Rubin et al., play is characterized by the following traits: it (1) expresses intrinsic motivation and self-direction; (2) focuses on means rather than ends; (3) is organism-centered rather than object-centered; (4) is noninstrumental or symbolic; (5) shows freedom from externally imposed rules; and (6) reveals active engagement in the activity.100 Takata defined the following principles of play: (1) it is a complex set of behaviors characterized by “fun”; (2) it involves sensory, neuromuscular, or mental processes; (3) it involves repetition of experience, exploration, experimentation, and imitation; (4) it proceeds within its own time and space boundaries; (5) it functions as an agent for integrating the internal and external worlds; and (6) it follows a sequential developmental progression.109

Function

Another way of looking at play is in relation to function, or how play influences adaptation. Play functions include processes, experiences, and purposes. Historically, play has been described as the way a child develops the skills necessary for life,49,100 as a way of working off surplus energy,102 or for recreation and relaxation.100 Modern or contemporary theories emphasize the value of play in contributing to the child’s development or to enculturation. They include using play to achieve optimal arousal15,40 and develop ego function41 and cognitive skills.21,90,112 Sociocultural explanations include the development of social abilities,88,106 role development,96 and play’s contribution to culture.55,103 Johnson et al. identified three ways to consider play and development: (1) play reflects development; (2) play reinforces development; and (3) play is an instrument for developmental change.59

Miller and Kuhaneck conducted interviews on the perceptions of play experiences and play preferences in 10 children between the ages of 7 and 11.78 The children described “fun” as the core category explaining their choices of play activities. The authors developed a dynamic model for play choice describing the interplay of four characteristics—child, activity, relational, and contextual—that affected the perception of fun.

Meaning

Play meaning refers to the quality of the experience or to a person’s state of mind. The attitude a person assumes during play is usually termed playfulness. Liebermann felt that each person has an internal disposition to play that could be described along five dimensions: physical spontaneity, cognitive spontaneity, social spontaneity, manifest joy, and sense of humor.72 Barnett8,9 and Barnett and Kleiber10,11 further related playfulness to the development of cognitive abilities. In the occupational therapy literature, Bundy defined the qualities of playfulness as a person’s intrinsic motivation, internal control, and the ability to suspend reality.23,24 These three elements are best regarded as a continuum, and “it is the sum contribution of these three elements that tips the balance toward play or nonplay, playfulness or nonplayfulness” (p. 219).24 In addition to these three elements, children give and receive social cues to denote that they are playing.

Knox, in a qualitative study of preschool children’s play, identified actions and behaviors that characterized playful children.64 The playful children showed flexibility and spontaneity in their play and in social interactions, curiosity, imagination, creativity, joy, the ability to take charge of situations, the ability to build on and change the flow of play, and total absorption. Non-playful children were less flexible and had difficulty with transitions or changes, expressed negative or immature affect or speech, often withdrew either physically or emotionally from play sequences, did not have control over situations, and tended to prefer adults or younger children for play.

Blanche explored persons’ motivations to engage in meaningful play and identified six motivations: (1) restoring a sense of well-being through quiet activity; (2) exposing oneself to novelty; (3) seeking short-term diversion through light-hearted spontaneous activity; (4) increasing the intensity of involvement in physically and/or mentally stimulating activity; (5) enjoying the ability to master an activity; and (6) creating novelty.16 She suggested that these motivations can act as potential guides to treatment.

Context

Play also obtains meaning through context. Children’s activities can never be isolated from the environment within which they are playing, nor from familial, social, and cultural influences. The presence or absence of other persons, animals, the physical setting, and the availability of toys and other objects upon which to interact all have a profound effect on children’s play (Figure 18-3). Play context includes cultural and societal expectations of play. Yerxa et al. stated, “The environment provides physical, psychological, social, cultural, and spiritual demands and resources” (p. 7).114

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FIGURE 18-3 “Reading” books is an early play activity even before the child is able to actually read. Courtesy Dianne Koontz Lowman.

A number of authors have studied the effects of the environment, quality of care, and types of interactions between caregivers and children on play behavior.11,14,54,58 They found that higher socioeconomic status correlated with greater levels of imaginary play, that permissive home environments encouraged creativity, and that high program quality improved children’s social interaction and level of play. The variety of materials and opportunities for children to explore and interact with and their ability to control their activities were associated with improved quality of play. In addition, caregivers and peers who were emotionally and verbally responsive helped to improve the child’s quality of play. Cultural and ecologic factors also influence the way children play.59,100 The cultural factors include child-rearing and parental influences, peer experiences, the physical environment, the schools, and the media (Figure 18-4).12,104 Ecologic influences on play include the effects of stimulus novelty on play, object and material influences, play space density, and indoor versus outdoor play space.

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FIGURE 18-4 Mom’s enthusiasm and encouragement add to the playfulness experienced in bowling. Courtesy Jill McQuaid.

All environments offer affordances for and constraints to an individual’s behavior. Knox63 and Michelman77 described factors in the environment that either promote or inhibit play. Factors that promote play include the availability of objects and persons, freedom from stress, provision of novelty, and opportunities to make choices. Factors that may inhibit play include external constraints, self-consciousness, too much novelty or challenge, limited choices, and over-competition.

Contextual components that appear to promote play include (1) familiar peers, toys, and other materials; (2) freedom of choice; (3) adults who are nonintrusive or directive; (4) safe and comfortable atmosphere; and (5) scheduling that avoids times of fatigue, hunger, or stress.100 These elements appear to facilitate playfulness (i.e., the expression of internal motivation and internal control to explore or pretend).

PLAY IN OCCUPATIONAL THERAPY

Play has always been a part of the pediatric occupational therapist’s repertoire, although its importance has altered over the years. Adolph Meyer wrote of work, play, rest, and sleep as being the four rhythms that shaped human organization.76 In one of the earliest articles on play in the occupational therapy literature, Alessandrini referred to play as a “serious undertaking, not to be confused with diversion or idle use of time. Play is not folly. It is purposeful activity, the result of mental and emotional experiences” (p. 9).1 Richmond spoke of play as the vehicle for communication and growth of the child.97 Play in the early years of occupational therapy was used for a variety of purposes such as diversion, development of skills, or remediation.

Mary Reilly was instrumental in bringing play into the forefront of occupational therapy in the late 1960s. She described play along a continuum that she called occupational behavior.96 Through play, children learn skills and develop interests that later affect choices and success in work and leisure. Play is the arena for the development of sensory integration, physical abilities, cognitive and language skills, and interpersonal relationships. In their play, children practice adult and cultural roles and learn to become productive members of society.14,71,96 Reilly felt that play is a multidimensional system to adapt to the environment and that the exploratory drive of curiosity underlies play behavior. This drive has three hierarchical stages: exploration, competency, and achievement. Exploratory behavior is seen most in early childhood and is fueled by intrinsic motivation. Competency is fueled by effectance motivation, a term defined by White as an inborn urge toward competence.113 This stage is characterized by experimentation and practice to achieve mastery. Achievement is linked to goal expectancies and is fueled by a desire to achieve excellence. Using this frame of reference, other scholars studying under Reilly expanded the concepts of play. Florey offered a developmental framework of play and explored the concept of intrinsic motivation as being central to play.43 Takata developed a taxonomy of play and described play epochs based on Piagetian stages,108,110 and Knox examined play in relation to development for the purposes of evaluation.63 Robinson described how play is used for the child to learn rules and roles.98

In researching the relationship between play and sensory integration, Clifford and Bundy found that children with sensory integration dysfunction differed in play scores on the Preschool Play Scale but that many of their play skills were within normal expectations.32 This led Bundy to conclude that there were other foundations for play than sensory integration or physical capabilities, and this led to her studies on playfulness.23–25,105

Occupational science developed in the late 1980s as an academic discipline to study the nature of occupation and how it influences health. Because play is the primary occupation of children, a number of researchers have studied various aspects of play. Primeau studied parent-child routines and how play is orchestrated into daily routines.93 She proposed that parents use two types of play strategies: segregation and inclusion. In the segregated strategy, play times were separate from other daily routines, whereas in the inclusion strategy, play was incorporated into other daily routines. Parents use play routines to support their children’s learning. Pierce studied object play in infants.91,92 She described three types of object rules learned by children: (1) object property rules (that is, the child’s internal representation of the properties of objects); (2) object action rules (the repertoire of actions on the objects); and (3) object affect rules (those factors affecting object choice and keeping play enjoyable).

Knox expanded the concept of playfulness to study the play styles of preschool children.66 Four dimensions of play style were identified using grounded theory methods: preferences, attitudes, approach, and social reciprocity. Within these dimensions, elements of style were determined. Preferences included setting, toys, types of play, roles, and playmates. Attitudes included mood, consistency, and humor. Approach included direction, focus, and spontaneity. Social reciprocity included social orientation, responsivity, and flexibility. The children were described in terms of their unique play style and the elements of style were analyzed across the children. Knox found that play style differed among all the children and the way they approached play episodes was dependent on their play style.

PLAY ASSESSMENT

Even though play is considered the child’s major occupation, and most occupational therapists would agree that it is important to the child, few therapists routinely evaluate it.34,36,70 Couch found that 62% of pediatric occupational therapists who responded to her questionnaire stated that they evaluated play, but less than 20% used criterion-referenced play assessments. Play was usually evaluated through clinical observations or as a part of developmental tests.34

Play assessments are usually of four types: (1) those that assess skills in a particular area through play; (2) those that assess developmental competencies; (3) those that assess the way a child plays, including playfulness and play style; and (4) narratives.

Skills

Most of the play assessments described in the literature are designed to evaluate a particular skill area, such as cognition or social interaction. These assessments use structured play settings, materials, and activities or play observations. The assessments described here include those most often cited in the occupational therapy literature. Rosenblatt99 and Hulme and Lunzer56 assessed play in relation to language and reasoning. The Piagetian stages of cognitive development have formed the basis of a number of play assessments.101,106 The classic assessment of the social aspects of play was developed by Parten. She assessed social participation in play of preschool children by examining two dimensions: degree of participation and degree of leadership.88 Degree of participation included the social interaction during play and was rated as unoccupied, solitary, onlooker, parallel, associative, and organized supplementary play. Degree of leadership included how much the child depended on or directed others in play.

Development

A few assessments rate the developmental skills of the child through play. Linder developed a transdisciplinary play-based assessment that assesses the child in cognitive, social-emotional, language, physical, and motor development through naturalistic play.73

Two assessments developed by occupational therapists explore play in its developmental aspects: the Play History108–110 and the Knox Preschool Play Scale.19,62,63,65,67 Takata described play developmentally within time and space and felt that play reflected the interaction between the individual and the external environment. The Play History is a semistructured interview and play observation, yielding information on the child’s daily activity schedule. She identified two elements of play: form and content. Form parallels changes in development and includes the choice of play materials, amount and nature of playfulness, and organization in play. Content reflects life’s situations and is the expression of the child’s immediate needs, impulses, and physical and emotional state. Takata developed a taxonomy of play epochs based on the Piagetian stages to analyze the interview and play observation. Behaviors are classified as evident, not evident, encouraged, and not encouraged. As a result of the analysis, a play prescription can be developed. Behnke and Fetokovich conducted reliability and validity studies on the Play History and found it to be a reliable and valid instrument for assessing children’s play behavior.13 Bryze discussed the play history as a guide to using narrative in assessment of past and present play behavior.22

The Knox Preschool Play Scale is an observational assessment designed to describe developmental skills as seen during play for children through 6 years of age.62,63,65,67 This assessment was revised by Bledsoe and Shepherd19 and more recently by Knox.65 The scale describes play in terms of 6-month increments through age 3 and yearly increments through age 6. Four dimensions are examined: space management, material management, pretense/symbolic, and participation. Space management is the manner in which the child learns to manage his or her body and the space around it. Material management is the way in which the child manages his or her material surroundings. The pretense/symbolic dimension is the way in which the child learns about the world through imitation and the development of the ability to understand and separate reality from make-believe. Participation is the amount and manner of social interaction. Children are observed indoors and outdoors and rated on all four dimensions (Case Study 18-1.). Bledsoe and Shepherd examined reliability and validity on the first revision with typically developing children.19 Harrison and Kielhofner did the same with children with disabilities.50 Both studies found the scale to be highly reliable and valid. Many studies have been conducted using the Knox Preschool Play Scale, and these have been summarized by Knox.65,67

imageCASE STUDY 18-1   Ellen

Ellen is a 1-year, 3-month-old girl who was referred for home-based occupational therapy for developmental delay. She was born 1 month premature. She has a history of feeding problems with reflux after meals and when she is upset. At the time she was referred, the reflux had partially resolved with small frequent feedings and alternate positioning; however, her mother was reluctant to let her be upset, because she was afraid Ellen would vomit. Ellen is an only child and she lives with her parents in a single-family home.

Ellen’s mother was interviewed using the Play History to provide information about her environment, daily schedule, and play experiences and interactions. She was also evaluated with the Knox Preschool Play Scale to provide information about developmental skills as observed in free and facilitated play. Ellen’s mother’s primary concerns were her reflux, her developmental skills, and her own lack of knowledge about how to play with Ellen. Other mothers seemed to know what to do with their children, and she did not. Her preferred play with Ellen was to read her books.

The information gathered on the Play History is analyzed in terms of what is evidenced or not evidenced in the home environment and what is encouraged or discouraged by her parents. The child’s play is compared with the appropriate “epoch” for her age. Ellen’s play status worksheet is depicted in Box 18-1.

BOX 18-1   Play Status Worksheet

EXPECTED DESCRIPTION

Epoch: Sensorimotor

Emphasis: Toys, objects for sensory experiences; cause and effect; container play; trial and error; gross motor—stand, sit, walk, pull, climb, pick up; fine motor—bang, carry, open/close, put in and take out, push, pull, relate two objects; people—parents, familiar adults; imitation—of simple actions: setting—home, yard

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Experience

The third way therapists assess play is to analyze the child’s experience or state of mind when playing (i.e., playfulness and play style). Barnett devised a rating scale based on Liebermann’s playfulness concepts.8,9 Children were rated on items representing the five playfulness traits: physical spontaneity, manifest joy, sense of humor, social spontaneity, and cognitive spontaneity.

Bundy developed the Test of Playfulness (ToP), designed to assess the individual’s degree of playfulness.24,25 The scale contains 68 items representing four elements of playfulness: intrinsic motivation, internal control, ability to suspend reality, and framing. The child is rated on scales of extent, intensity, and skill. The ToP can be scored from direct observations or videotapes of children engaged in free play. Bundy and her associates have also developed an assessment of the environment’s capacity to support playfulness, the Test of Environmental Supportiveness (TOES).105

The previous assessments are based on behavioral observation and parent interviews. Because play is unique to the individual, it is important to obtain the child’s own perspective of his or her play, and this is usually done through self-report. Henry developed the Pediatric Interest Profiles, three age-appropriate profiles of play and leisure interests and participation for children from 6 to 9 years of age, from 9 to 12 years, and from 12 to 21 years.51 The profiles assess what activities the child is doing, the child’s feelings about the activity, how skilled they perceive themselves, and with whom they play. They can be used in evaluation in three ways: (1) to conduct a play interview, (2) to identify children and adolescents who may be at risk for play-related problems, and (3) to set play-related goals and identify play or leisure activities to use in intervention.

BOX 18-2   Knox Preschool Play Scale

SPACE MANAGEMENT: 6- TO 12-MONTH LEVEL

Ellen crawls, pulls to stance, and cruises. She sits with good balance and easily shifts weight in sitting. She plays in either sitting or supported stance against the coffee table. She is beginning to stand unsupported but flops down when balance is challenged. She walks with support from an adult.

MATERIAL MANAGEMENT: 12 TO 18 MONTHS

Ellen puts toys into and takes them out of containers. She pulls and pushes, opens and shuts, bangs, stacks, and puts simple toys together. She puts together familiar single-shape puzzles.

PRETENSE/SYMBOLIC: 12-MONTH LEVEL

Ellen imitates simple actions and novel movements. She is beginning to imitate schemas such as putting a spoon to the doll’s face.

PARTICIPATION: 12 MONTHS

Ellen seeks attention from adults and seems to need the attention to prolong her play. She imitates, shows toys, and shares toys. Her expressive language is minimal.

Ellen’s weaknesses included the following: she was behind in all areas of development; she showed some mild hypersensitivity to tactile and auditory sensory stimuli; her mother lacked expertise and knowledge in facilitating development and was apprehensive about Ellen’s reflux, and she rarely allowed Ellen to challenge herself or become upset. Ellen’s mother had few social and emotional supports.

The following goals were established for treatment: (1) improve developmental skills through play; (2) improve play and playfulness; (3) enable Ellen’s mother to play with her, incorporate play into their daily routines, and scaffold play to encourage new skills and abilities; and (4) increase Ellen’s mother’s knowledge of developmentally appropriate play.

The intervention plan included weekly sessions with Ellen and her mother to teach them both play skills and playfulness. Her mother was also encouraged to seek out other resources in the community such as Mommy and Me classes and gym classes. She was also encouraged to set up play dates with other mothers. Ellen’s father was included whenever he was available.

Both Ellen and her mother made striking gains with therapy. Ellen’s development improved and she became very playful with both her mother and the therapist. Her mother became an active participant in the therapy sessions and became involved in community activities. Individual therapy was terminated when Ellen and her mother enrolled in an early intervention program. A few months later, the therapist visited Ellen and her mother and was pleased with her progress. Ellen was speaking a few words, and she showed the therapist some of the toys and games she played with her mother. Ellen’s mother also seemed much happier and appeared to enjoy her daughter more. The experiences they described were typical, playful, and rewarding for both of them.

In this case, play was the primary goal as well as the therapeutic medium used. It illustrates how effective an occupation-based approach can be.

The information on the Knox Preschool Play Scale is described in terms of four dimensions: space management, material management, pretense/symbolic, and participation. Ellen’s play age in each of the dimensions is described in Box 18-2.

Physical or neurologic conditions were not interfering with her development, and it was felt that her delayed skills were primarily a result of lack of experience or stimulation. Her feeding problems were resolving. Her home environment was conducive to play in terms of space, objects, and people. The parent-child relationships were warm and loving, and her mother was eager to learn new ways to stimulate Ellen’s play.

Advantages and Disadvantages of Evaluating Play

Observing children at play is like looking through a window into their lives. An analysis of children’s play is helpful in assessing their physical and cognitive abilities, social participation, imagination, independence, coping mechanisms, and environment.14,20,46 An evaluation of play and of the child’s abilities as seen through play provides important information regarding the child’s occupational performance as well as performance skills and patterns.

Play is most often evaluated in routine, self-chosen, familiar activities in naturalistic settings, providing the therapist with a picture of everyday competencies. Play assessments based on identifying what the child can do in play enable the therapist to focus on the child’s abilities rather than disabilities.

Some of the disadvantages of play assessments have been summarized by Knox,66 and Bundy.24 Because play is an interaction between the child and the environment, the human and physical factors in the environment can substantially influence the child’s play.66 Play assessments that are designed to take place in standardized settings with standardized toys significantly alter and may inhibit the child’s play. In addition, although play specifies its own purpose, observed behaviors may have different meanings and serve different purposes for different people. It is difficult for an observer to assess the meaning of play to the participant.

Another limitation is in the amount of time available for observation of the child. The therapist must determine whether the sample of behavior is sufficient, typical, and representative of true play. Knox found that over a prolonged time, a child’s play could be vastly different at different times.66 Also, children engaged in play episodes for prolonged periods (up to 1 hour in some cases). To capture a variety of play behaviors, a therapist needs to observe a child multiple times and in a variety of settings.

Interpreting Play Assessments

Assessment of play should be a part of every occupational therapy evaluation to develop a complete picture of an individual’s competence in his or her occupational performance and to plan adequate intervention that focuses on helping that individual participate in meaningful and self-satisfying occupations. Such assessments provide the therapist with a picture of how the individual uses play in his or her daily life. An analysis of play also provides the therapist with a picture of the child’s skills in motor, cognitive, and social areas (Figure 18-5). This is especially helpful in assessing a child who does not respond well to standardized developmental testing.

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FIGURE 18-5 The occupational therapist assesses motor, cognitive, and social skills during a play activity. Courtesy Jayne Shepherd.

Some of the newer assessments of affect, playfulness, or play style indicate how the individual approaches and gives meaning to the gamut of activities during the day. These instruments hold much promise in helping to determine how an individual balances his or her daily occupations in a meaningful way.

Evaluation in occupational therapy leads to intervention planning. Intervention should capitalize on abilities of the individual to remediate the deficits. Knowledge of the individual’s skills, interests, and play style assists in this planning and guides treatment. Bundy offered a number of considerations in observing an individual’s play that are useful in developing treatment goals. These include the following24:

• In what activities does the child become totally absorbed?

• What does the child get from these activities?

• Does the child engage routinely in activities in which he or she feels free to vary the process and outcome in whatever way he or she sees fit?

• Does the child have the capacity, permission, and support to do what he or she chooses to do?

• Is the child capable of giving and interpreting messages that convey “this is play; this is how you should interact with me now”?

CONSTRAINTS TO PLAY

As discussed earlier, play is always influenced by the environment. The effects of the environment on play can be seen in children who have experienced neglect or long hospitalizations. Extreme examples of constraints to play have been seen in some of the reports of children in Romanian orphanages.29,38 These children showed severe sensory problems, extreme delay in developmental skills, and difficulties in interacting with others. Other characteristics of the play of deprived children included self-stimulation, limited repertoire of activities, decreased social play, and either increased or decreased fantasy play.

When children are hospitalized, they often experience stress of separation, fear of illness, painful procedures, enforced confinement, and disruption of routines.60 Some of the effects on play behavior include regression to earlier stages of development; decreased endurance and movement; decreased attention span, initiative, and curiosity; decreased resourcefulness and creativity; qualitative decrease in playfulness; decreased affect; and increased anxiety.61

Knox, in her study of play styles of preschool children, discussed the importance of the environment on children’s play.66 She found that when children’s play styles matched the expectations of the environment, play flourished. When there was a mismatch between play style and the environment, play was stifled.

Effects of Disability on Play Behavior

The play of children with varying disabilities has been described often in the literature.60,80 However, problems arise in attempts to generalize across or within disabilities. Children are individuals and respond uniquely in different situations, whether or not they have a disability. Descriptions of the play of children with disabilities must be interpreted cautiously.60 Although it is helpful to examine some of the problems that certain conditions may impose on the child, in actual practice, each child must be considered individually. Bundy stated that although a child’s play may not be typical, it was more important for “children to be good at what they want to do” (p. 218).24

Some diseases and conditions limit physical interaction with the environment, with toys and other objects, and, to some extent, with people. The child with a physical impairment may display limited movement, strength, and pain when performing daily activities. Social contacts with family and peers may be disrupted by hospitalizations. The play characteristics of children with physical limitations may include fear of movement, decreased active play, and preferences for sedentary activities. The child may also have problems with manipulating toys and show decreased exploration (Figure 18-6). Opportunities for social play are often decreased because of hospitalizations or routines that do not allow for social interaction.59

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FIGURE 18-6 Impaired fine-motor skills limit exploratory play of this infant with cerebral palsy. Toys that activate to imprecise (full arm) movements are a good choice in play activities. Courtesy Jayne Shepherd.

Children with cognitive impairment often show delayed or uneven skills, difficulty in structuring their own behavior, or lack of sustained attention. These characteristics may be manifested in play in preferences for structured play materials, limited or inflexible play repertoires, decreased curiosity, destructive or inappropriate use of objects, decreased imagination, decreased symbolic play, decreased social interaction, decreased language, and increased observer play.60,80 These children may need more structure and external cues to develop their play skills.

A number of studies have examined the effects of sensory impairment on play, particularly of children with visual or hearing impairments. Kaplan-Sanoff et al.60 and Mogford80 noted that children with visual impairment have delays in developing an integrated perception of the world caused by lack of vision and delayed motor exploration of surroundings and objects. The play characteristics of these children are difficulty in constructive play, delays in developing complex play routines with others, and decreased imitative and role play.

The child with a hearing impairment is believed to have problems with decreased inner language, decreased social interactions, and decreased understanding of abstract concepts. These are manifested in play in that imagination becomes more restrictive with age and increased time is spent in noninteractive construction play. Children with hearing impairments demonstrate decreased symbolic play and increased solitary play.60,80

Children who have difficulty interpreting and integrating sensory input often have a limited or distorted perception of themselves and of their world, decreased ability to plan and execute motor and cognitive tasks, and poor organization of behavior. Play characteristics of these children include either excessive movement or avoidance of movement, decreased exploration, decreased gross motor or manipulative play, increased observation or solitary play, increased sedentary play, a restricted repertoire of play, resistance to change, distractibility, or destructiveness.5,6,23,80

Children with autism often have severe sensory integrative problems, as well as social and language deficits. Their play is characterized by a lack of inner and expressive language, stereotyped movements or types of play, decreased imitation and imagination, lack of variety in play repertoires, motor planning problems, decreased play organization, decreased manipulation of toys, decreased construction and combining of objects, and decreased social play.7,107 Children with autism appear to have a fundamental deficit in play greater than what would be expected in examining specific skills.

Children with cerebral palsy show difficulties in many areas (Figure 18-7). They may show limited and abnormal movement, sometimes have decreased cognitive abilities, have sensory impairments, and often lack opportunities for social play.42 In play, cognitive abilities are the most decisive factor in limiting play, and children with good cognitive abilities can make adaptations to their physical limitations. Other problems include decreased physical interaction with environment and less interactive play time.17,18

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FIGURE 18-7 Matthew, who has cerebral palsy, participates in the pregame rally by playing the drum. Courtesy Jill McQuaid.

Most of the studies of the play of children with disabilities stress the obstacles that the disabling conditions place on the children. Mogford summarized the problems that different disabling conditions have on children’s play by stating that all children with disabilities have one thing in common—that their ability to explore, interact with, and master their environment is impaired, depriving them of a normal childhood experience.80 The occupational therapy practitioner needs to explore supports for play. With adaptations, a child can overcome great obstacles to engage in a favorite activity (Figure 18-8).

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FIGURE 18-8 Matthew takes to the ice using an adapted sled. Courtesy Jill McQuaid.

PLAY IN INTERVENTION

What differentiates free play from therapeutic play? Free play is intrinsically motivated, fun, and is performed for its own sake rather than having a purpose. The child directs the play. However, in therapy, goals and objectives are established by the therapist and the parents, who usually direct the play. When external constraints are placed on play, it is perceived as work and no longer contains playful elements. How then can play be used successfully in treatment? Rast stated:

Play offers a practical vehicle to enlist a child’s attention, to practice specific motor and functional skills, and to promote sensory processing, perceptual abilities, and cognitive development. It also serves to support social, emotional, and language development. In the therapeutic setting, play often becomes a tool used to work towards a goal, despite the fact that the goal-oriented, externally controlled aspects of the therapy situation conflict with the essence of play itself (p. 30).95

For play to be used successfully in intervention, the child should feel that he or she is choosing or directing the play episode. This is particularly important when the goal is to increase competence in play development. Play and leisure activities are important methods for promoting a child’s performance and skills because they have meaning to the individual.

In a study by Couch, Deitz, and Kanny investigating how pediatric occupational therapists use play in intervention, 91% of the therapists rated play as very important.35 For 95% of the respondents, play was used primarily to elicit motor, sensory, or psychosocial outcomes; only 2% used play as an outcome by itself. The therapists also primarily used adult-directed play versus child-directed play.

The way play is used in intervention is influenced by a number of factors: the therapist’s frame of reference, the institution’s emphasis on improving performance components and skills, and the family’s values and concerns for the physical aspects of the child’s disability. Goals and objectives are established in accordance with how the child’s disability affects his or her daily occupations and on analysis of occupational performance.3 Play and leisure activities are used in occupational therapy in three ways: (1) as intervention modalities (to improve specific skills); (2) as an intervention goal (to improve play occupations); and (3) to facilitate playfulness.

Play as a Modality

Three frames of reference that use play as an intervention modality are the developmental, functional, and sensory integrative approaches. Play is most often used when a specific skill needs to be taught or when a specific goal needs to be met. Goals and objectives are established depending on how the disability affects the role performance of the child. Playful activities are used in a more structured or defined sense as a means to achieve the desired goal.

In the developmental frame of reference, play activities are used to develop physical, cognitive, emotional, or social abilities. The play materials are used to entice the child, such as when a toy is used to encourage a child to crawl or when a busy box is used to teach cause-and-effect concepts. Difficulty preserving the qualities of play may arise when therapy goals or techniques require a more structured “hands-on” approach, such as when using a neurodevelopmental treatment technique. Use of play as a modality requires skill and imagination on the part of the therapist to combine approaches successfully and creatively. Anderson, Hinojosa, and Strauch4 and Blanche17 provided helpful suggestions for incorporating play into neurophysiologic treatment approaches. Munier, Myers, and Pierce discuss using object play to enhance motivation, address the development of motor skills, facilitate process skills, develop environmental negotiation, facilitate temporal awareness, promote social skills, and support engagement in occupation.82 Florey and Greene offer strategies for treating children with behavior and emotional problems.44 Baranak et al.7 and Spitzer107 present play engagement strategies for children with autism. These strategies included respecting the child’s sensory processing capacities, scaffolding play, using imitation and modeling, and expanding play routines. They also offer suggestions for optimizing attention and organization and augmenting communication.

In the functional frame of reference, play is also used to meet a therapeutic end by adapting the activity, environment, or in therapeutic handling of the child while he or she is engaged in the activity. For example, a child’s favorite toy may be positioned in such a way to improve the child’s range of motion or adapted to increase the child’s strength. In this sense, play is often used as a motivator for action. However, therapists need to be careful in how much they handle or direct the child’s play. Germain and Dwyer studied play levels of children with cerebral palsy under two conditions: (1) handled, where the therapist facilitated postural responses while the child played; and (2) unhandled, where the child was engaged in free play.47 In the handled condition, the children’s level of play was lower because the children depended more on the therapist for direction and showed less self-directed play. This study showed the need for balance between giving the child enough support or assistance and giving too much.

In sensory integration, play is valued as the arena through which sensory integration develops.5,6 To play successfully, children must have adequate sensory integration and be able to make adequate adaptive responses to environmental demands. In therapy, the therapist sets up and manipulates the environment (setting, objects, people) so that the child can choose among activities that potentially offer the “just right” challenge. During treatment, the therapist constantly adjusts the environment, child, or activity to bring about successful adaptation. Bundy provided an excellent description of the role of play within a sensory integrative framework. She concluded:

Play is a powerful tool for treatment. For many individuals, the most important byproduct of occupational therapy may be the improved ability to play. If it is carefully planned and conducted, therapy using the principles of sensory integration may be very helpful in facilitating the development of play. Likewise, play as a part of a well orchestrated treatment plan, can result in improvements in sensory integration (p. 67).23

Mack, Lindquist, and Parham synthesized the commonalities of play from the occupational behavior and sensory integrative viewpoints. They stated:

In practice, both approaches deem the therapist responsible for structuring adaptive behavior from the child. Thus, the potency of the environment’s influence on development is confirmed by both. But from neither perspective does therapy rely solely on environmental manipulation. The child’s initiative and active involvement are critical to the therapeutic process. From both perspectives, the intrinsic motivation or self direction of the child is primary in guiding therapy, for importance is placed on the child’s inner drive toward mastery. Play, then, is the process through which therapeutic goals are achieved (p. 367).75

Play as an Intervention Goal

Burke stated, “An occupation-based view of play is built on basic notions concerning the importance of an occupation to an individual” (p. 201).27 The use of play as an intervention goal has been described within the occupational science and sensory integration frames of reference, and most recently in the AOTA Practice Framework.3 In occupational behavior and science, play is viewed as an occupation, determined by the individual and his or her interaction with the environment. The improvement of play skills and playfulness enables competent interaction with the world. Parham stated that enhancement of play itself may be effective in promoting health and well-being.86

In an interesting study of the effects of peer play level on preschool children who had delayed play skills, Tanta, Deitz, White, and Billingsley showed that when children were paired with peers who had higher developmental play skills, they showed more initiation and response to initiation than when playing with children with lower play skills.111 This study suggested that using peers as role models is helpful in developing social play skills.

In Primeau’s study of play patterns in families, she suggested that parents modify the environment, incorporate play into the family’s routine, and provide verbal suggestions to improve and increase the child’s play.93 Knox emphasized the importance of considering children’s play styles in choosing or setting up play environments.66

Facilitating Playfulness

The third way play is used therapeutically is to facilitate playfulness in the child. As was stated in the section on assessment of play and leisure, often what individuals play with and how they play may not be as important as the affective quality of their play. Some children with significant or multiple disabilities manage to get great joy and benefit out of play. On the other hand, therapists often see children who are not playful and do not derive pleasure out of even the simplest play interaction. Facilitating playfulness in the child can be an important goal of therapy. Morrison and Metzger stated:

The more playful child may generalize this flexible approach into environmental interaction beyond play and into other aspects of his or her life. For the child with a condition that impedes his or her ability to interact with the social or physical environment, a flexible (playful) approach may enable the child to succeed more frequently in these difficult situations (p. 540).81

Parham suggested strategies that a therapist can use to create a playful atmosphere.85 The therapist should express a playful attitude through speech, body language, and facial expressions (Figure 18-9). Also, novelty and imaginary play should be used to facilitate playful participation on the part of the child. Bundy stated that the therapist must know how to play to be able to model play for the child.23 To develop playfulness, the child must develop intrinsic motivation, internal control, ability to suspend reality, and ability to give and read cues.

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FIGURE 18-9 Mom adapts kickball so that Matthew can play with his brother. Courtesy Jill McQuaid.

Facilitating playful interactions is important for any age child with or without a disability. Holloway suggested strategies to encourage playfulness in parents and children within a neonatal intensive care unit.53 Helping parents learn to read their infant’s cues and adapt to the infant’s behavioral tempo helps to develop mutually positive experiences that form the basis for playful processes as the infant matures.

Whether the goals of therapy are to use play a medium, to develop play skills, or to develop playfulness, planning intervention must always take into account the interaction among the therapist, the child, and the equipment and play objects in the environment. The therapist needs to create a playful atmosphere and attitude for the child to respond playfully. Six abilities important to facilitating play in a child appear to be that the adult can (1) apply theories of play, (2) analyze activities, (3) let go and let the child lead, (4) empathize, (5) demonstrate spontaneity, and (6) display creativity.68 Knox, Ecker, and Fitzsimmons developed a program to help therapists and parents follow the child’s lead and develop the spontaneity and creativity necessary to weave play and therapy together.68

Knowing what is motivating and pleasurable to the child is essential to accomplish goals through play episodes. Knox and Mailloux stated, “When the therapist can make the match between an activity that is highly conducive to achieving a goal and is at the same time attractive to the child as a play experience, then the achievement of goals through play is most likely to occur” (p. 198).69

Adaptations

Critical to creating a play atmosphere for children is considering the environment and the objects within it. To foster play, environmental spaces, toys, and equipment should have some flexibility in usage. In an intriguing study, Bundy et al. examined changes in playfulness in a group of typically developing children, ages 5 to 7 years, after new materials (e.g., cardboard boxes, bicycle tires, hay bales, plastic barrels, wood, foam) were introduced to the playground.26 They found that scores on the Test of Playfulness rose significantly after the intervention and the teachers felt that the children’s play had become more active, creative, and social as a result.

In addition, toys and play equipment may need to be adapted for the child to access them optimally. Adaptation of toys and the environment is an important role of the occupational therapist, particularly for the severely involved child. Play spaces should offer a variety of experiences and allow for creativity, illusion, change, and chance. Children need to be able to control the space, i.e., have objects, toys, and people to move and change and freedom to move.30 The therapist must know the properties of toys as well as how to adapt them appropriately. Switches, adaptive keyboards, or provisions for sensory impairment may be necessary for the child to benefit from and be more independent in play. Play can be enhanced through a variety of augmentative devices ranging from very simple adaptations to complex electronic devices.39

Parent Education and Training

Working with parents in relation to play is vitally important if there is to be carryover of the skills and abilities learned in therapy into the child’s everyday life. Parents of children with disabilities often attempt to structure therapy into the child’s routines. Children with physical disabilities may be involved in therapeutic regimens throughout the day and consequently are deprived of play opportunities. Four barriers to free play are (1) limitations imposed by caregivers, (2) physical and personal limitations of the child, (3) environmental barriers, and (4) social barriers.79 Interventions that support the child’s free play and include recommendations about playthings help support the importance of play in overall development.

A goal of therapy is parent education—that is, helping parents understand the importance of play for their child and helping them to interact with their child playfully. Often the parents need help in knowing how to create a balance between doing things for their child and allowing the child to form and carry out his or her own intentions. The therapist may need to model play behavior for the parent, encourage the parent to enter into and contribute to play sequences without directing or controlling them, and help the parent organize or adapt the play environment to meet the needs of the child. By actively involving the parents or caregivers, the therapist helps them appreciate their child’s strengths, learn the fun of playing with their child, and develop play skills that will serve them well.

Hinojosa and Kramer stressed the importance of helping families to incorporate play into their lifestyles in order to strengthen interaction with their children and provide typical childhood experiences.52 They offered a framework for analyzing and understanding family play and provide suggestions to facilitate the inclusion of all members of the family in playful activities.

Societal Concerns

In the last few years, play for all children has diminished. Since 1980, the amount of unscheduled time in the day of an average school-aged child has dropped by 15%.74 Because of changing family lifestyles, challenges in education, technology, and safety concerns, children today have little time and space for free play. Singer et al. examined the role of play and experiential learning in 16 nations divided into developed countries, newly industrial countries, and developing countries.104 They gathered information from mothers of 2400 children. They found similarities in all nations, with mothers describing the lack of free play and experiential learning opportunities. A major portion of children’s free time was spent watching television.

Other studies have shown many barriers to play. One is over-structuring and over-scheduling of the child’s day.48,66,74,89 Children’s afterschool hours are filled with classes, planned activities, and homework. Another barrier is an over-emphasis on early academic achievement. Schools are increasingly moving to eliminate the “playful” parts of school, including recess, gym, sports, and art programs.48,89 Some states have eliminated recess altogether because it is not considered academic. Academics are being stressed earlier and earlier in our educational systems and parents often feel that, for play to be worthwhile, the adults need to “teach” things during play. A third barrier to play results from parents’ concerns for the safety of their children in a culture they perceive as increasingly violent. Outdoor play has decreased markedly and parents schedule “play dates” or planned play experiences. Places for play have decreased also. Many metropolitan areas are severely lacking in park space,74 and many school playgrounds are often asphalt pads with no playground equipment.

Children are taking part in more organized sports and activities. Although organized activities can be fun and playful, the amount of time and energy children have for less structured free play is reduced. Structured sports do not promote the creativity that is part of play.

The decreases in unstructured, physical play have had a dramatic effect on children. The rise in childhood obesity, as well as in the health problems that accompany obesity, is a major problem facing parents. The over-reliance on television and computers has changed the type of play that children choose and leads to more passivity and reliance on others for entertainment. The increased media exposure has also exposed children to violent themes and content, often without the benefit of parental supervision.

Many organizations including the American Academy of Pediatrics (Ginsburg, 2007),48 the Association for Childhood Education International, and the American Association for the Child’s Right to Play2 (Isenberg & Quisenberry, 2002)51 have issued declarations promoting the importance of and need for active play for children.

Occupational therapy practitioners are in a unique position to act as advocates for play, not only for their clients but also for children in general. In 2008, AOTA published a societal statement on play including the following recommendations:

Occupational therapy practitioners support, enhance, and defend children’s right to play as individuals and as members of their families, peer groups, and communities by promoting recognition of play’s crucial role in children’s development, health, and well-being; establishing and restoring children’s skills needed to engage in play; adapting play materials, objects, and environments to facilitate optimal play experiences; and advocating for safe, inclusive play environments that are accessible to all (p. 707).94

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