Therapeutic Play for the Severely Disabled Population
Top Contributors - Robin Tacchetti and Jess Bell
Introduction[edit | edit source]
Children learn best in an environment which provides discovery, exploration and play. Playful interactions allow children to express their curiosity and creativity. Play facilitates independence and participation while fostering relationships with care-givers and peers.  Playing facilitates gross and fine motor, language, social, pre-academic and psychosocial skills and is fundamental to support the multiple development domains: motor, social-emotional, language, cognition and adaptive behaviour.
Play should include the element of free choice by the child and being personally directed. Intrinsic factors of play include flexibility, voluntary, spontaneity, and the use of the childs natural environment.
Stages of Play[edit | edit source]
Children will naturally move through various stages of play based on their cognitive development. The Takata Play Taxonomy divides play into 5 stages based on Paiget's stages of cognitive development. The interactions and complexities in activities progressively increases as children move through the stages. 
- Sensorimotor: (0-2 years)
- cause-effect toys
- takes considerable amount of practice, repetition
- high level of exploration
- Symbolic: (2-4 years)
- use of objects to represent actual objects (toy phone represent real phone)
- parallel play
- Dramatic: (4-7 years)
- cooperative play
- Game with Rules: (7-12 years)
- cooperative play
- board games, puzzles, crafts, sport-related
- Recreation: (12-16 years)
Children with Disabilities[edit | edit source]
Children with disabilities have a clear disadvantage when it comes to play. Mobility, visual and cognitive impairments can impose barriers to play. It can be difficult for them to move, see and understand play. This leads to children with disabilities participating in less complex play and playing less often than their typically developing peers. Sensory development is likely impacted as well due to their limitation to physically interact with toys/objects.  Children with disabilities often require adaptive devices and toys to assist them with interactions and play.
Children with severe disabilities are typically dependent on their family or caregivers to play. If they are not able to express their wants clearly, they will be presented with limited options of toys or activities to explore. As a result, they will miss opportunities to expand their development. The decreased opportunity to self-direct play can further impact their interest in play and their self-esteem. 
Research shows that children with severe disabilities have similar interests to typically developing children despite their medical needs and barriers. They want to engage in physical play, read books, watch movies, socialise and play with electronics. Understanding their developmental level can provide insight regarding activities of interest for them. This in turn will promote a more positive play experience.
Positive social play experiences can be limited due to skill deficits along with the physical and social environment.  However, these children with severe disabilities can learn and master new skills given the right environment. An optimal environment would include the following:
- activities that are accessible
- assistance of a peer partner
- use of repetition and practice
- use of assistive technology if needed
** When the task is too difficult or beyond their developmental level, they will not be able to learn
Environment[edit | edit source]
Social and Physical Arrangements[edit | edit source]
The following are suggestions for setting up a positive social and physical environment for children with disabilities:
- effective groupings of children
- providing children with disabilities the guided assistance they require to socially engage
- appropriate play materials
- toys encouraging shared and cooperative play
- adult facilitation
- interactive activities
- with a peer
- arranging play materials
- interactive activities
Partner-Assisted Play[edit | edit source]
Children with disabilities spend more time with caregivers or adults rather than peers despite their interest in being around peers. Partnering a child with disabilities affords them the opportunity to learn from their peers. Interventions that are peer implemented provide opportunities for social interactions between children with disabilities and their typically developing peers. In addition, it allows reciprocity, social referencing and initiation/responding. The goal of the play partner is to facilitate interactions between the child and another child or the child and their environment.
The choice of play partner should be made by the child with disabilities. Play should be centred around the child's needs and wants. The child with disability should be included in the decision-making process regarding the activity, the toys used and how to play with it. Multiple options should be offerred.
Play partners typically do not see themselves as reciprocal playmates, but more as play enablers. The play partner's role is to encourage and to create an environment where the child with disabilities plays the central role in the activity. 
Playdates[edit | edit source]
Playdates can be both structured and unstructured time for children with disabilities to interact with another child. During playdates children with disabilities have the opportunity to demonstrate learned skills from another environment. Before initiating playdates, it is important that the child with the disability to be involved with their peers. The child does not have to have independent play skills, but comfortable being in close proximity to others. Another important skill to have prior to a playdate it learning how to transition from one activity to another. This can be accomplished with appropriate prompts and reinforcement.
Assistive Technology[edit | edit source]
There are a variety of assistive services and devices that can be used to improve function in children with disabilities. Using assistive technology can afford children with disabilities that ability to play more actively and participate in activities of their choosing. Adaptive devices can be categorised into the following:
- adapted toys:
- assist with stabilising, attaching, extending or confining toys
- shoelaces, elastic ribbon to bring a toy within reach
- velcro, nonslip material to hold objects in place
- box tops, hula hoops to help keep toys from getting out of the child’s reach or visual field
- positioning devices:
- designed for those that have difficulty changing positions or need assistance in moving while playin devices
- semi-reclined (sling seat)
- side-lying (towels)
- prone (wedges, towels)
- kneeling (floor tables, stairs)
- sitting (corner chairs)
- standing positions
- speciality AT items
- assist with manipulating play objects
- develop and extend cause and effect relationships
- cooperative play skills with siblings and peers
- battery adapters
- latch devices
- series adapters (turn a toy on and off with a movement of a body part against a switch)
- communication devices:
- devices that help incorporate children with communicative deficits to express themselves
- photos or line drawings to help children select what they want to say
- tablet computers with touchscreens to help the child navigate through pages of icons
- range from very easy to use through very complex
** As each child and family needs are unique different combinations of assistive technology can be used
Modelling and Prompting Interventions[edit | edit source]
Research shows that the use of adult modeling has increased play behaviours in children with disabilities. Modeling can be successfully performed in the following steps:
- adult follows child's lead
- adult imitates the play
- adults models and prompts a play behaviour
- behaviour should be developmentally appropriate
- behaviour should be geared towards child's attention and interests
Play Materials[edit | edit source]
Typically children with disabilities need more time and opportunities to interact with equipment, materials and toys. In addition to time, they require repetition to master a new skill. Therefore, equipment and materials should strategically not be removed or changed often. Play materials can vary in size, theme, density, complexity, etc. In order to increase interact and imaginative play, a variety of sensory, constructive, motor, exploratory and socio-dramatic toys should be used as play materials. The best play material is one that is motivating and allows for mutual play between children with disabilities and their typically developing peers. 
Floortime Development[edit | edit source]
Floortime development refers to the ability of the play partner to meet the child at their developmental level. The elements of floortime involve:
- having the play partner on the floor and follow the child's lead
- engage the child through activities they enjoy
- direct child to more complex interactions
- help the child to maintain focus
Sensory[edit | edit source]
Children with disabilities who have limited gross motor development have restrictions on exploring their environment. This can lead to decrease sensorimotor experiences. This in turn can delay fine motor development further restricting sensory development. To support participatory sense making, children should interact with toys however they can independently and explore their environment by sound, touch and vision.
Resources:[edit | edit source]
References:[edit | edit source]
- Movahedazarhouligh S. Teaching play skills to children with disabilities: Research-based interventions and practices. Early Childhood Education Journal. 2018 Nov;46(6):587-99.
- Hui S, Dimitropoulou K. iCan-Play: A practice guideline for assessment and intervention of play for children with severe multiple disabilities. The Open Journal of Occupational Therapy. 2020;8(3):1-4.
- Fiss AL, Håkstad RB, Looper J, Pereira SA, Sargent B, Silveira J, Willett S, Dusing SC. Embedding Play to Enrich Physical Therapy. Behavioral Sciences. 2023 May 24;13(6):440
- Bulgarelli D, Bianquin N. 3 Conceptual Review of Play. Play development in children with disabilities. 2017:58-70.
- O’Connor D, Butler A, Lynch H. Partners in play: Exploring ‘playing with’children living with severe physical and intellectual disabilities. British Journal of Occupational Therapy. 2021 Nov;84(11):694-702.
- Agostine S, Erickson K, D’Ardenne C. Sensory experiences and children with severe disabilities: Impacts on learning. Frontiers in Psychology. 2022 Apr 29;13:875085.
- Danniels E, Pyle A. Inclusive play-based learning: Approaches from enacting kindergarten teachers. Early Childhood Education Journal. 2022 Jun 22:1-1.