Therapeutic Play

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

Introduction

An important aspect of childhood development is play. Play builds imagination and allows for exploration of both the interior and exterior world. It allows children to learn about their environment and themselves. Early forms of play begin in infancy through eye contact, mimicking sounds and smiling. As the child ages they are able to explore their environment learning and practicing skills that support their development. Increased motor skills promote cognitive growth.Lastly, play affords opportunities for families and caregivers to engage with their children.

**Play is fundamental to support the multiple development domains: motor, social-emotional, language, cognition and adaptive behaviour.

Stages of Play

There are six stages of play:

1. Unoccupied Play (0-3) months:
   • making movements with arms, legs and feet
   • learning about 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 s
   • not playing with others
5. Associate Play (3-4 years)
   • starts to interact with others
   • no cooperative play required
6. Cooperative Play (4+ years)
   • plays with others
   • interest in both the activity and other children playing

Therapy

The purpose of paediatric physiotherapy is to decrease impairments and facilitate movement and participation within their world. Physiotherapists will use therapeutic play to engage and motivate children during therapy with the goal to improve the childs physical condition and independent skills. . Targeting the child's specific motor impairments, the physiotherapists incorporates sensory-motor play activities to facilitate intended goals. Therapeutic play should include activities that cross multiple domains of motor-based and socio-emotional. Performing motor-based skills can create and environment for that initiates language, social and cognitive skills.

Children with motor delays require a supportive environment to fully engage in play. When developing intervention programs it is important to understand the impact the child's condition may have on play. This environment involves parent and caregiver support along with toys and/or adaptive equipment. The aim in this therapeutic environment is to use the strengths of the child rather than their deficits. Focusing on strength facilitates more positive 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 find the fine line where the child needs to focus their effort to master the skill but yet not too hard that they disengage. Once the skill has been attained, the therapist can increase the difficulty in small increments.

Exploratory Nature

Children are inherently exploratory, however, in a healthcare setting, this innate behaviour might be decreased. There are several ways for therapists to promote exploratory behaviour:

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

Positioning

Whenever possible the therapists should try to be face-to-face with the child to observe and monitor visual cues. This interaction increases attention and the interaction. Additionally, this form of interaction allows for mirroring back and forth between the therapist and child. Sometimes face-to-face is not possible if the child needs physical external support. However, in that case the use of an external support device may be applicable that would allow the therapist to remain face-to-face while still providing support for the child.

Signals

Once a child is actively involved in play, the physiotherapists must be mindful of the child's bodily signals such as distraction, etc. Sometimes it can be difficult to read the child's engagement or distress due to communication issues. It is necessary to observe communication signals such as gestures, eye movement, breathing patterns, vocalisations, over stimulation (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. Multiple prompting can be overwhelming. Allowing for additional time helps children take in the information, process it, respond, make choices or take a break. Individuals who would benefit from additional processing time include children who have difficulties with motor planning, attention and recognition.

Toys

Besides the child actively exploring and interacting with their environment, children play with the use of toys. Toys can be categorised into 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
   • coloring, clay
4. language
   • board games, toy letters, card games
5. gross motor
   • tricycles, push and pull toys, balls
   • promotes motor milestones
   • facilitates peer interaction

**.The optimal toy choice is one the coincides with the child's developmental skills and encourages new skill acquisition.

Children with developmental disabilities encounter obstacles to play de to physical and/or intellectual impairments. Their play may be aytpical in nature to those of their peers:

• playing with an object in a repetitive nature (lining up cars over and over again in the same manner)
• nonfunctionally (placing a toy phone in the toy refrigerator but not talking into it)
• playing with toys at a significant developmental level than their similar age peers (a 10 year old playing with a typical 2 year old toy)

Choosing toys for children with disabilities should correlate with ones that are most appropriate for their developmental age. This will help ensure growth and skill mastery. Sometimes toys will need to adapted to accommodate a visual, motor or other disability. Some examples of adaptations include:

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

In addition, toys can be used as an incentive during therapy sessions:

1. by placing a toy in a non-dominant hand to encourage use in that hand
2. to elicit verbalisations for children with language deficits
3. to encourage eye contact by placing a preferred toy near therapist or parents face

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 Computerized toys that teach phonics, reading, or math Construction sets Puzzles Action figures Barbies Costumes Transportation toys Board games 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