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 an important aspect of childhood development as it builds imagination and allows for exploration. Play provides opportunities for children 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 practicing skills that support their development. With motor skills attainment cognitive growth increases. Play is fundamental to support the multiple development domains: motor, social-emotional, language, cognition and adaptive behaviour.

Stages of Play

As the child moves from infancy through childhood, their play moves through various stages. The six stages of play are listed below:

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

Physiotherapy and Play

The purpose of paediatric physiotherapy is to decrease impairments and facilitate movement and participation within the child's world. Targeting the child's specific motor impairments, the physiotherapists incorporates sensory-motor play activities to facilitate intended goals. Goal-making are a collaborative effort with the family ensuring their values and wants for the child are heard. Goals are centered around improving the child's physical condition and gaining more independent skills. Physiotherapists will use therapeutic play to help achieve those goals. Performing motor-based skills can create an environment that promotes language, social and cognitive skills.

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 programs. Understanding what the child is capable of will allow the physiotherapist to set up a successful play environment for therapy. This environment could toys and/or adaptive equipment an should include parent and caregiver support. Having a parent or caregiver present allows for emotional support and also carryover of therapy to the home environment. During therapy, the physiotherapist will focus 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, but yet the task can not be too hard that the child disengages. Once the skill has been achieved, the therapist can increase the difficulty in small increments.

Exploratory Nature

Children are inherently exploratory. 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

Whenever possible the therapists should aim to be face-to-face with the child to observe and monitor visual cues. This interaction increases attention and the interaction between therapist and child. Additionally, this form of interaction allows for mirroring which is another form of play. Sometimes face-to-face interactions are not possible if the child needs physical external support. In this case scenario, using an external support (if available) would allow the therapist to remain face-to-face while the child is physically supported.

Signals

Every child will not be able to verbally communicate whether they are happily engaged in the activity. During therapeutic play, the physiotherapists 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, 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. 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 them. Individuals who would benefit from additional processing time include children who have difficulties with motor planning, attention and recognition.

Toys

When children are playing and actively exploring and interacting with their environment, often times they are using toys. There are a variety of toys that children play with throughout their childhood. 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

Children with developmental disabilities can encounter obstacles to play when using toys. Their play may be aytpical in nature to those of their peers. Some of the variations in play can appear as the following:

• playing with an object in a repetitive nature (lining up cars over and over again in the same manner)
• non-functionally (placing a toy phone in the toy refrigerator and not using it as a phone)
• playing with toys at a significantly different developmental level than their similar age peers (a 10 year old playing with a typical 2 year old toy)

Toys are geared towards a specific age range. For children with disabilities, the optimal toy choice is one the 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 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

Toys might need to be adapted to accommodate a visual, motor or other disability. 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

Lastly, toys can be used as an incentive during therapy sessions. Three incentive ideas are listed below:

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

Resources:

• Physical Activity, Sport and Recreation for Young People with Physical Disabilities
• Characteristics and Categories of Risky Play