Therapeutic Play

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.

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

It also offers an ideal and significant opportunity for parents and other caregivers to engage fully with children using toys as an instrument of play and interaction

Therapy

Play therapy is a form of therapy that requires the therapist to come to the child’s level and speak in his own language. The most familiar mode of expression for a child is the play. In this therapy, therefore, toys are l

Paediatric physiotherapists use play when assessing and providing treatment interventions for infants and children. The use of play increases the child's engagement and motivation in therapy.

he core of pediatric physical therapy is to ameliorate these impairments and help children move, play, learn and participate as best they can in their enactment of their world. The concept of. o achieve this, the PT must find ways to incorporate therapeutic measures targeted to the child's specific motor impairments and combine these in engaging, interactive sensory-motor play activities. Fundamental to this successful merging of play and therapy is the development of shared intentions between PT and child. The PT must attend to the child's signs of intention, attention, and motivation so that therapeutic actions such as handling, choices of toys, and changes to the task or environment become “part of the play,” not a disturbance to it. This entails the incorporation of bodily know-how into the PT's clinical reasoning (1, 14), i.e., being sensitive to the child's bodily signals and accepting the child as an initiator and active agent of movement. As part of this concept, therapeutic handling can be a means by which children discover and explore new sensory-motor movement and play possibilities.

Infants and Toddlers

Children with motor delays require a supportive environment to fully engage in play. There may be differences in play for these children due to their underlying medical condition. 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 and may also include adaptive equipment or toys.

Respecting the Child’s Behavioral State and Cues

When working with children with developmental delays, it is important to give them time to process information, respond or make choices or take a break. Providing this increased time can help children that have difficulties with motor planning, attention and recognition. Multiple prompting can be overwhelming. Structured, rhythmic exchanges synchronised with the child's response will facilitate more participation.

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) in order to understand what message the child is relaying.

Tactile stimulation play an important role in play and can either increase or decrease a child's attention. Understanding the child's sensory processing and how much stimuli cant be overwhelming is important for keeping the child engaged.

3.1.2. Respecting the Child’s Autonomous Play Initiatives and Engagements

Providing simple and structured directions helps maintain the child's exploratory behaviour. Mutual play and allowing the child to direct play and time spent on a certain activity keeps the child engaged.

3.1.3. Including Activities across Developmental Domains

Therapeutic play should include activities that cross multiple domains of motor-based and socioemotional. Performing motor-based skills can create and environment for that iniates language, social and cognitive skills.

3.1.4. Supporting a Child’s Engagement in Play

The use of mirroring or mimicry allows for social connectiveness. This is an effective too for infants and young children.

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.

3.1.5. Adapting Play to Individual Child Differences

When working in a thereaputic environment, it is important to use the strengths of the child versus their deficits. This allows for more positive interactions with the therapist and with the parent and child for the home setting.

3.2.2. The Environmental Set-Up

The therapist should try as much as position to be face-to-face with the child to view visual cues and vice versa. Otten times, therapists or caregivers are behind the child giving external support. If there is an external support device that can be used to allow eye contact in a face-face interaction, the attention and intereaction can be increased.

3.2.3. The Use of Toys

There are many ways to engage in play.

1. Toys
2. social games (peak-a-boo
3. child actively exploring and interacting

When therapists try to use a toy to encourage movement without allowing child to fully explore the toy before the next request can lead to frustration and missed opportunities. Support the child with extended play and then request movement when they are ready. May need 4-5 toys to encourage movement and keep attention.

3.3.1. Understanding a Family’s Play Culture

Understanding family culture is important when incorporating play in the child's intervention. Some families have a wide variety of materials and space for play while others do not. Some families value play and physical activity while others do not. The values and cultural beliefs can affect play for the child. Many families of children with motor deficits underestimate their child's physical, developmental or play abilities. It is important to develop goals in partnership with the families. This helps ensure more mastery f skills and carryover of skills.

Other ideas:

1. play was used as a means of ensuring the child was motivated in intervention, but the goal was not a play goal, but a goal for developing independent skills. Th
2. ay was an essential part of the meetings with the child and family, where play was used as a way to familiarise oneself with the child. Participants highlighted the importance of building a trustworthy relationship with the child. As a participant said:
3. Observing the child play at the habilitation centre was another approach used that sometimes was enough to assess the child depending on the reason for the visit. One participant described:
4. focus was to use play as a means to observe body position, ambulation, side differences, fine motor skills and hand function while the child was playing. When asked if they had a focus on play itself the participants confirmed that their goal was to improve the children’s physical conditions instead of their actual ability to play. From these
5. he right assistive device was also a factor considered crucial for the child’s opportunity to perform play activities with other children. Assistive devices to compensate or give the child opportunities to participate in the playground were central and something wished for by parents because their children were becoming too heavy to ca

Toys

Traditional (physical) toys can be categorized in a variety of ways: (1) symbolic and/or pretend (eg, dolls, action figures, cars, cooking and/or feeding implements, etc); (2) fine motor, adaptive, and/or manipulative (eg, blocks, shapes, puzzles, trains, etc); (3) art (eg, clay and coloring); (4) language and/or concepts (eg, card games, toy letters, and board games); and (5) gross motor and/or physical (eg, large toy cars, tricycles, and push and pull toys).²³ High-quality toys in each of these categories can facilitate caregiver-child interactions, peer play, and the growth of imagination. It should be emphasized that high-quality toys need not be expensiv

oys are important in early child development in relation to their facilitation of cognitive development, language interactions, symbolic and pretend play, problem-solving, social interactions, and physical activity, with increasing importance as children move from infancy into toddlerhood.¹ Pretending through toy characters (eg, dolls, animals, and figures) and associated toy objects (eg, food, utensils, cars, planes, and buildings) can promote the use of words and narratives to imitate, describe, and cope with actual circumstances and feelings. Such imaginative play ultimately facilitates language development, self-regulation, symbolic thinking, and social-emotional development.²⁶ Problem-solving through play with the “traditional favorites,” such as blocks and puzzles, can support fine motor skills and language and cognitive development and predicts both spatial and early mathematics skills.^27,28 The use of toys in physical activity (such as playing with balls) has the potential to facilitate gross motor development together with self-regulation and peer interaction because of the negotiations regarding rules that typically take place. The aforeme

neral, the best toys are those that match children’s developmental skills and abilities and further encourage the development of new skill

Children with developmental delays or disabilities may face a variety of difficulties or obstacles in their play because of factors such as intellectual limitations or physical restrictions. One of the greatest difficulties is when the play itself becomes atypical in nature. For example, they may play with objects repetitively (eg, stacking blocks in the same way over and over again but not constructing anything per se) or nonfunctionally (eg, tapping a toy phone on the floor versus talking into it) or engage with toys at a significantly different developmental level than that of peers of a similar age (eg, 3 toddlers are having their toy dinosaurs chase one another, whereas a fourth is standing aside chewing on the toy dinosaur’s tail). Furthermore, atypical behaviors among children with disabilities may themselves disrupt social interactions in addition to the play itself. These differences in developmental capacities are exhibited across domains,³ and in turn, how children play with their toys may limit their ability to learn and develop maximally from parent-child and peer play opportunities.

The choice of toys may be especially complex for children with special needs given that recommendations on packaging are usually based on age and not developmental capacities. For instance, caregivers of children with special needs may be more likely to choose functional toys (eg, toys that are easily activated and often respond with lights and sounds)³³ over symbolic toys that encourage pretend play, creativity, and interactions (eg, toy animal farm).³⁴ Thus, caregivers of children with special needs may benefit from additional guidance from specialty therapists (eg, speech, occupational, or physical therapists) in choosing which toys, activities, and interactions are most appropriate for the developmental age of their child to ensure continued growth and skill mastery.

Adaptations of toys to accommodate a motor, visual, or other disability can be important for children with special needs. This can be accomplished by combining easy access with multisensory feedback,³⁵ such as light and sound when a toy is powered on. Examples of adaptations in design include Velcro strips to help a child hold a toy,³⁶ adding a piece of foam around a marker or paintbrush to make the art utensil easier to hold for a child with an inability to grasp the utensil independently,³⁷ and the use of a larger push button to activate a toy for a child with fine motor difficulties who cannot easily manipulate a small switch.³⁵ Technology has played a particularly important role in supporting the use of toys, and it is anticipated that the role of technology in addressing developmental interventions will increase over time with the guidance of research. As with children who are typically developing, children with special needs maximally benefit from play with toys in the context of caregiver interaction.

Toys can be used as a mode of incentive in the context of early intervention services and physical therapy more generally. For example, therapists often use toys to stimulate the use of a nondominant hand by placing the toy on that side of the body. Alternatively, using a toy as a reward may help elicit verbalizations in a child with a language disability. Novel or preferred toys can be held near an adult’s face to encourage eye contact for a child with autism spectrum disorder.^38,39

Toys and the Promotion of Parenting, Positive Caregiving, and Child Development

There has been a broad range of scientific- and policy-based efforts to enhance early development by promoting caregivers and children to play together with toys. These efforts are especially important for children growing up in poverty, for whom there is both reduced access to developmentally appropriate toys and barriers to caregiver-child interaction.^4,14,15 Such initiatives complement existing programs seeking to enhance early literacy within the pediatric medical home (eg, Reach Out and Read⁴⁰). Efforts to promote play with toys have taken place across diverse platforms, including in (1) preschools (eg, Tools of the Mind⁴¹), (2) home visiting (eg, Parent-Child Home Program and Play and Learning Strategies⁴²), (3) public health (eg, Building Blocks²⁹ and Blocktivities⁴³), and (4) pediatric primary care (eg, Video Interaction Project²⁹), to name a few. Findings from these programs strongly suggest that toys are most likely to facilitate developmental advances in the context of interactions³ with and support by caregivers (including scaffolding and guided play rather than as a result of the toy itself³¹), early childhood educators, and other providers.⁴⁴ Pediatric health care providers’ knowledge and awareness of these programs can inform anticipatory guidance to parents, provide opportunities for integration within the medical home enhancement, and function as potential sources of referral depending on availability within the communities they serve. Furthermore, the selection of toys offered to children should reflect the diverse and multicultural world we live in (ie, selecting dolls of various ethnicities in the pediatric office waiting area).⁴⁵