Learning Through Play with Cerebral Palsy



Original Editor - Roelie Wolting and Estibaliz Garcia Recio
Top Contributors - Michelle Lee, Kim Jackson, Shaimaa Eldib, Laura Ritchie, Naomi O'Reilly, Admin, Rachael Lowe, Simisola Ajeyalemi, Rucha Gadgil, Jess Bell and Olajumoke Ogunleye


Introduction

Play is essential for the development of the child in every area: motor, cognitive, emotional, social.

We are playing when we sing a song to the child, make funny sounds or faces to elicit her laughter or when we allow her to explore objects and drop them to the floor.

Due to their difficulties with movement and posture, children with Cerebral Palsy have limited ability to explore the world. This does not mean that they are not willing to explore, as any other child does. Only that they may need more stimulation and an environment that facilitates play.

Children with Cerebral Palsy are often less active or irritable. As a result, they tend to get less attention and interaction from their caregivers, which results in a vicious circle of the child becoming even more apathetic or irritable. This severely hinders the development of the child and is a common problem that needs to be addressed. Through play and playful interactions, both the child and the caregiver engage in pleasurable activities without the pressure of having to achieve a result.

Often parents are expecting interventions that look like medical treatment or therapy, and forget that a child’s main activity is playing and that much learning and progression will be made through play. It is important that as a Healthcare Professional we reinforce this message, that play is vital for development of the child.

Learning Through Play

Play is an important part of any child's development. It can be defined as the building blocks of how a child interacts with their environment. It is an activity that makes a child happy and is enjoyable so that they want to do it again. Play is one of the most important ways that children develop mentally, socially and physically. It gives a chance for a child to practice doing activities in their own way so that the child can be successful, as the child grows the way of playing changes. The sequence in which play develops is the same for all children, whatever their abilities or handicap.

Children with cerebral palsy have shown positive results in their development when play therapy was incorporated in their daily life.

Sequence of Play

Play for children changes as a they grow to encourage holistic development in them. The sequential changes in Play can be described as:

1. Playing Alone (Till 1 Year): At first the child will play with his body and then will gradually begin to reach out to things he sees nearby and play with them. She will not be interested in other children or anything they are doing but she will like other people playing with him/her.
2. Watching Others Play (1.5 -2 Years): The child will stop with what she is doing and watch other children who are playing nearby. But she will not join them in their activities. She likes to repeat things many many times.
3. Playing Next to Others but Not with Other Children (2-3 Years): From a distance it can look as if they are playing together, but in fact there is no direct communication between the children and they are all playing their own games. The child will hate to share toys with others.
4. Beginning to Play with Others (3-4 Years): The child will begin to play and share toys with others. They will talk to each other about the game in progress, but the game has no specific shape or rules.
5. Cooperating with Others in Play (About 5 years, Normally When they Start School): The child will play structured games with other children, taking turns and using rules. Rules for games become very important at this stage.

Here are some examples of some games and what children learn from them:

Game	Learning
Peekaboo	Taking turns, learning something is not visible but it still exists , collaboration
Hide and Seek	Counting, waiting, taking turns, collaboration, gross motor, balance, body perception, memory, muscle strengthening, building vocabulary
Playing Families	Moving around (gross motor), fine motor, balance, vocabulary, memory, imitation, imagination, memory, communication, listening
Playing with ball	Fine motor, planning, eye hand coordination, balance, gross motor, distance, fast – slow, hard – soft, patience, solve problems, learning to comply with rules (if e.g. football), cause and effect
Chess	Fine motor, eye hand coordination, planning, problem solving, taking turns, patience, cause and effect

Play and Physical Development

Play is one of the ways that children learn to move from sitting, to crawling, and then to standing, and walking; they learn balance and coordination. The child learns to manipulate and handle objects and learn that objects are not part of their body; they first learn to hold objects and then to move them. Later they learn to use their eyes and hands at the same time. At the same time as learning to use the hands the child will be using mental abilities to learn about subjects; and develop imagination and creativity e.g. a comb can be a comb but also an aeroplane or a car.

Play and Social Skills

The child learns social skills through playing with others.Young children usually only think of themselves and in play they can learn basic ideas of sharing and what others want and need. The child will learn through talking, exploring possibilities and learning to express own ideas.

The child will learn to cooperate with friends; the ability to work together with others is important. Through play the child will experience the joy of winning - and learn to cope with losing.

Play and Emotional Development

Often children will use games to work through the things that frighten or worry them. They play out the roles and by doing this come to terms with their difficulties. e.g. a child who goes to the hospital often plays afterwards “hospital”, or “doctor”, or “nurse”. This may help to cope with the frightening experience. They also learn adult roles: children often play ‘father and mother’, teacher, etc. They also invent games to show skills like building houses or playing to cook.

Therapeutic Play

Often children will use games to work through the things that frighten or worry them. They play out the roles and by doing this come to terms with their difficulties e.g. a child who goes to the hospital often plays afterwards “hospital”, or “doctor”, or “nurse”. This may help to cope with the frightening experience. They also learn adult roles: children often play ‘father and mother’, teacher, etc. They also invent games to show skills like building houses or playing to cook.
Therapeutic play is:

• Using play to help children with a disability learn mental, social and physical skills and abilities.
• Using rehab goals to adapt exercises into play activities
• Often includes a component of competition against self or others

Therapeutic play can be harder to design than simple exercises as it takes more analysis and creativity. It needs to be challenging but at the same time the child needs to experience positive result and fun. The play should be adjusted according to the physical and the mental abilities of the child.

Healthcare Professionals where possible should always adapt exercises into play activities. This may be more difficult but is also more rewarding.

Play Scenario

A  therapy session for a child of 4 years (mental age) needs to incorporate walking in the parallel bars. The child has Cerebral Palsy and needs both hands to hold on for walk in the parallel bar. Here are some examples of how to make this boring task fun for the child:

The child is 4 years old, so making puzzles (with 5 - 20 pieces) can be incorporated. Have two chairs at each side of the parallel bar. Put all pieces of the puzzle on one chair. The child has to bring piece for piece as the other child and making their the puzzle. When finishes talk about the puzzle, praise the child etc. Maybe the child can put a piece of the puzzle in his trouser pocket, or tie something around his arm or neck to carry from one side to the other. You also can use: blocks and build a tower or a house; stones and make a house.

Another example of turning therapy into play is:

Trying to improve sitting balance in a 4 year old boy with Cerebral Palsy. He can not sit and play without falling over. Here is an example of a game to promote sitting balance and how to implement it:

Game: Ball throwing into a basket

How to implement it:

• The child can sit in a corner and roll the ball instead of throwing it.
• Someone else can sit behind the child with their legs in V shape. The boy can sit between the legs and roll or throw the ball.
• Use a balloon, which is slower. therefore easier to control and handle.
• At the same time: let him succeed at least 3 of the 4 times. Count the goals etc.

This game is not only good for sitting balance, but also for eye hand coordination, planning, strength, sense of direction and distance.

Therapeutic Play in the Family

As with all treatments it is essential to try and adapt treatments into normal daily routine to help with compliance. By turning boring treatments into games this can be rewarding for both the child and the family. Demonstrate and show these kind of activities to the family and analyse together what the child is learning from that game/play. Look at the goals (GAS) you want to achieve together and discuss together what kind of games and activities help to reach these goals. Practice and observe these games together with the family. It is a great idea to try and include other members of the family, especially other brothers and sisters, this may help other siblings feel included and that they are involved rather than feeling resentment towards their sibling for receiving 'more attention' 

Key Messages to Give Caregivers

• Place the child in a position where the child can look at their hands, at the caregiver or other children playing with them, and where they can grasp toys and bring them to their mouth. Change posture often and encourage the child to be active in each posture.
• Make play part of the daily routine. For instance, when you are bathing the child you can encourage him to splash water, or to play with a plastic toy as if it was a ship.
• Try to use play time to develop new skills, but remember it must be fun and pleasurable after all. Any good therapist should keep in mind that children learn better when they are having fun.

Suggestions for Toys

Children with Cerebral Palsy love the same toys as every other child. The child needs to be able to grasp them, though, so consider shape and size. For some children a small ball will be easier to handle, while for others a larger one. Regular toys can be easily adapted: a toy that is too small or hard to hold can be attached to a stick. Other toys can be held using an elastic band around the hand. Toys can be fixed to a table or the floor so the child with poor motor control can touch them or operate them. If a toy keeps falling to the floor, tie it to a piece of string so the child can bring it back.

You don’t need to have expensive toys: a cardboard box with objects of different sizes and textures e.g. marbles, seashells, pieces of cloth, is great to practice holding, release and transferring. And empty plastic bottle with pebbles inside will make a great rattle. Spoons and empty pots can be used to make music or play make believe. Children are fascinated with pieces of wrapping paper that shines and make crinkle noises.

Young children enjoy what is called sensory exploration. They are interested in colors, sounds and smells. Provide the child with interesting objects to look at, reach for, and eventually hold and explore with the hands and mouth.

If the child has a visual impairment, make sure they have access to toys that make noise such as rattles or crinkle toys.

You can find ideas on how to make your own toys with easily available resources here:

• Werner,D. Disabled Village Children. Hesperian

It is also possible to adapt toys using “Awitches”: A computer placed in a way that is usable for the particular child, and that can give access to many electronic devices: from video games to simple battery operated toys. Switches can also be used to access communication devices.

Some final suggestions

• Most caregivers know already how to play with children. It may only be more difficult if the child doesn’t respond as we expect, or if the caregiver is grieving. Try to encourage any attempt at being playful and remind the caregivers how important it is for the development of the child.
• In every culture there are traditional games that adults play with children, such as: Peek-a-boo (hiding games), musical games where the child can participate with some words or the end of the song, counting parts of the body such as fingers or toes,…
• As children grow, they start becoming more interested in other children. It is important that children with cerebral palsy have the opportunity to engage in games with other children. This is a great first step towards inclusion and also a great learning experience for all children about the diversity of the human being.

Summary

Overall play is an essential activity that is vital for the development and learning of any child, therefore it is paramount that a child with CP can participate in play as a therapeutic intervention. Play can be rewarding for both the child and the member of the family who are facilitating play. If therapy can be done through play, then play should be incorporated. If the treatment is fun the child and the relative are more likely to participate and the engagement of the child will aid development in many different areas.