Therapeutic Play

Original Editor - Robin Tacchetti based on the course by Dana Mather
Top Contributors - Robin Tacchetti, Jess Bell and Kim Jackson

Introduction

Play is essential for childhood development as it builds imagination and allows for exploration. Play provides opportunities for a child to learn about their body and the environment. Early forms of play begin in infancy through eye contact, mimicking sounds and smiling. As the child ages, they explore their environment, learning and practising skills that support their development. With motor skill attainment, cognitive growth increases. Play is fundamental to support the multiple developmental domains: motor, social-emotional, language, cognition and adaptive behaviour.

Stages of Play

As a child moves from infancy through childhood, their play moves through six stages:

1. Unoccupied play (0-3) months:
   • making movements with arms, legs and feet
   • learning about the environment
   • discovering how their body moves
2. Solitary play (0-2 years)
   • plays alone
   • not interested in playing with others
3. Spectator/onlooker behaviour (2 years)
   • watches others playing
   • not playing with others
4. Parallel play (2+ years)
   • plays alongside others
   • not playing with others
5. Associate play (3-4 years)
   • starts to interact with others
   • no cooperative play required
6. Cooperative play (4+ years)
   • most advanced stage of play
   • plays with others
   • interested in both the activity and the other children playing

Physiotherapy and Play

The purpose of paediatric physiotherapy is to decrease impairments and facilitate movement and participation of the child in their environment. By focusing on the child's abilities and identifying specific impairments, the physiotherapist incorporates sensory-motor play activities to facilitate intended goals. Goal-making is a collaborative effort between the therapist and the family. This helps ensure the family's values and wants for the child are heard. Goals are centred around improving the child's physical condition and gaining more independent skills. Physiotherapists use therapeutic play to help achieve those goals. Performing motor-based skills, like sitting and reaching, can create "developmental cascades in language, social, visual-perceptual, and/or cognitive skills as the child engages with the environment or others."

Children with physical disabilities require a supportive environment to fully engage in play. Physiotherapists must fully understand the impact of the child's impairment when developing play-based intervention programmes. Understanding what the child is capable of allows the physiotherapist to set up a successful play environment for therapy. This environment could include toys and/or adaptive equipment. Parents or caregivers should provide support during therapeutic play. Having a parent or caregiver present allows for emotional support and carryover of therapy to the home environment. During therapy, the physiotherapist focuses on the strengths of the child rather than their deficits. This facilitates better interactions with the therapist and with the parent and caregivers.

Determining the right amount of challenge is important to keep the child engaged during the session. If the intervention is too challenging, the child may lose interest. If it is too easy, the therapeutic intention may not occur. The therapist needs to create a task where the child has to focus their effort to master the skill. However, the task should not be too hard as this could cause the child to disengage. Once the skill has been acquired, the therapist can increase the difficulty in small increments.

Exploratory Nature

Children tend to be more exploratory than adults. However, in a healthcare setting, the child might be less inclined to explore their environment. There are several ways for therapists to promote exploratory behaviour:

1. allow the child to direct play
2. provide simple and structured directions
3. provide mutual play between therapist and child
4. allow the child to determine the amount of time spent on a certain activity

Positioning

The therapist should aim to be face-to-face with the child to observe and monitor visual cues whenever possible. This increases attention and enhances the interaction between therapist and child. Additionally, this form of interaction allows for mirroring, which is another form of play.

It can be more difficult to achieve face-to-face interactions for children who require physical external support. In these situations, using an external support (if available) allows the therapist to remain face-to-face while the child is physically supported.

Signals

Not every child will be able to communicate verbally when they are engaged in an activity. During therapeutic play, the physiotherapist must be mindful of the child's body signs and cues. It is necessary to observe communication signals, such as gestures, eye movement, breathing patterns, vocalisations, and overstimulation (sensory processing issues), in order to understand what message the child is relaying.

Processing

When providing directions to children with developmental delays, therapists need to provide ample time for information processing. Some children will require additional time to take in the information, process it, respond, make choices or possibly take a break. Multiple or repetitive prompting can be overwhelming for these children. Individuals who would benefit from additional processing time include children who have difficulties with motor planning, attention and recognition.

Toys

Children often use toys when they play, actively explore, and interact with their environment. There are many different types of toys, and they can be grouped into the following five categories:

1. Pretend:
   • dolls, cars, action figures, cooking
   • promote the use of words when imitating
   • facilitates social-emotional development
2. Fine motor
   • puzzles, trains, blocks, shapes
   • support language and cognitive development
   • promotes spatial and early mathematics skills
3. Art
   • colouring, clay
4. Language
   • board games, toy letters, card games
5. Gross motor
   • tricycles, push- and pull-toys, balls
   • promotes motor milestones
   • facilitates peer interaction

Children with developmental disabilities can encounter obstacles to play when using toys. Their play may be different to that of their peers. Some variations in play may include the following:

• playing with an object in a repetitive nature (lining up cars over and over again in the same manner)
• non-functional play (placing a toy phone in the toy refrigerator and not using it as a phone)
• playing with toys that are usually used by different-aged children (i.e. a 10-year-old child playing with a toy usually used by a 2-year-old)

Toys are geared towards a specific age range. For children with disabilities, the optimal toy choice is one that coincides with their developmental skills and encourages new skill acquisition to ensure growth and skill mastery.

Toy Ideas by Age

0-12 months	1 year old	2-3 year olds	4-5 years old	6-7 years old	8+
Rattle Floor gyms Unbreakable mirrors Mobiles Activity boards Soft, washable stuffed animals Dolls with a smiling face	Stacking rings Nesting cups Push- or pull-toys Hammering sets Musical instruments Shape sorters Play vehicles Puzzles with four or five pieces Rubber ducks	Dolls Stuffed animals Props for make-believe play, such as a toy telephone, a tea-party set, a play kitchen, or a doll stroller Ride-on toys Musical instruments Large transportation toys Puzzles Construction toys	Art supplies, Play-Doh Blocks of different shapes Computerised toys that teach phonics, reading, or maths Construction sets Puzzles Action figures Barbies Costumes Transportation toys Board games Football / soccer balls and basketballs Active games Bicycles	Basic science kits Slime Magnets, magnifying glasses, telescopes Art supplies Nintendo, PlayStation, or Xbox games Computer tablets Legos Sports equipment Remote-control cars Barbies Chess, checkers	More elaborate science kits Tablet or computer for online games Nintendo, PlayStation, and Xbox games Craft kits Slime Outdoor sporting equipment Intricate construction sets Scrabble, Monopoly, Chess, checkers Model kits

Toys might need to be adapted for children with visual, motor or other disabilities. Some examples of adaptations include:

1. using velcro strips to help the child hold the toy
2. turning on multi-sensory feedback buttons for lights and sound
3. adding foam around a paintbrush or marker to make it easier for them to grasp independently
4. using a larger button toy for children who have difficulty with fine motor skills

Lastly, toys can be used as an incentive during therapy sessions. Examples include:

1. place a toy in the child's non-dominant hand to encourage use of that hand
2. use the toy to elicit verbalisations for children with language deficits
3. encourage eye contact by placing a preferred toy near the therapist or the child's caregiver's face

Resources

• Physical Activity, Sport and Recreation for Young People with Physical Disabilities
• Characteristics and Categories of Risky Play
• Inclusion of Children with Disabilities in Free Risky Play
• Gross Motor Function Classification System - Expanded and Revised
• Cerebral Palsy General Assessment