Therapeutic Play for the Severely Disabled Population

Intro

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.

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

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.

1. Sensorimotor:
   • cause-effect toys
   • takes considerable amount of practice
   • high level of exploration
2. Symbolic:
   • use of objects to represent actual objects (toy phone represent real phone)
   • parallel play
3. Dramatic:
   • role-playing
   • cooperative play
4. Game with Rules:
   • competition
   • cooperative play
   • board games, puzzles, crafts, sport-related
5. Recreation:
   • team participation
   • sports, hobbies
   • dancing, team sports, music, tabletop games, books

Children with Disabilities

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 and the physical and social environment. . Children with severe disabilities can learn and master new skills with the right environment. An optimal environment would include the following:

1. activities that are accessible
2. assistance of a peer partner
3. use of repetition and practice
4. 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

The environment for play involves both social and physical surroundings.chart p.5

Social and Physical Arrangements

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

Peer-implemented

Peer implemented interventions provide opportunities for increasing social interactions among children with disabilities and their typically developing peers, that increases the social interactions between children with and without disabilities (English et al. 1997). Peer implemented interventions provide facilitation and training to the typically developing peers to initiate, prompt, and reinforce social interactions with their peer with disabilities, thereby resulting in improvements in social play behaviors of children with disabilities rather than simply having them in close proximity to their typically developing peers (Bass and Mulick 2007). Peer implemented interventions also provide multiple opportunities for children with disabilities to participate in social referencing, reciprocity, and initiation/responding. For example, the caregiver may prompt the typically developing peer to offer a preferred toy or object that is of interest to a child with disability to initiate an interaction which might increase the likelihood of a reciprocal play situation that involves turn taking and exchanges (e.g., reciprocity) between the two peers (Wong and Kasari 2012). By using simple strategies, children with disabilities can learn a variety of initiation and response strategies from their typically developing peers such as initiating play. The social initiation may include gestures, vocalizations, or words, (e.g., holding out a toy to a peer; vocalizing in a peer’s direction while making eye contact with them; reaching hand toward peer while gazing at a toy held by a peer) (Barton and Ledford 2018). However, placing too many demands on the typically developing peer is likely to be counterproductive. Spreading peer interactions throughout the day and across more than one peer may help to ease the demands and promote generalization across partners, settings, and activities (Wolfberg 2003). “Stay, Play, Talk” is a simple strategy that is designed to facilitate peer interactions between a child with disability and a typically developing peer (English et al. 1997). Typically developing peers are taught three simple steps: (a) stay with your friend, stay in the same area and observe what he or she does; (b) play with your friend, suggest things to play with or go along with what your friend likes to do; and (c) talk to your friend, talk about what you are doing and talk back to your friend, tell your friend if you do not understand (Goldstein and Thiemann-Bo

playdates

Playdates are scheduled time periods for children with disabilities to interact with another child in both structured and unstructured activities. Children with disabilities may not be able to generalize skills across environments and people, which means even when they have mastered a specific skill in one setting with one person, they may not be able to demonstrate the same skill in another setting with another person. Playdates provide children with disabilities the appropriate experience to generalize their skills with different peers and in a variety of environments as well as develop friendships and have fun (Rosenberg and Boulware 2005). Before the child with disability is ready for formal Playdates it is essential that they are involved with their peers even if they do not have independent play skills. Just learning to be in close proximity to others is supportive for children with disabilities in moving toward developing play skills (Barton and Pavilanis 2012). Also, teaching children with a disability how to move from one activity to another in a variety of settings is an important and essential skill to prepare them for the many transitions that can occur within a Playdate. Providing appropriate prompts and reinforcements can support smooth transitions when it is time for children with disabilities to engage in Playdates with a peer (Rosenberg and Boulware 2005).

assistive technology (AT) p.8 chart

devices and services can be used to increase, maintain, or improve the functional capabilities of children with disabilities. Although a range of AT items is available, many families of young children prefer low tech solutions since they are readily available, inexpensive, easy to use and offer a wide range of options (Lane and Mistrett 2002). Several categories of AT can be used in combination to create interactive play environments that is unique to each child and family needs. The mostly adopted low tech categories of AT include: adapted commercial toys, positioning and mobility items, specialize AT item, and communication AT items. Table 3 provides more details on these categories (adapted from Alper and Raharinirina 2006; Lane and Mistrett 2002).

Modeling and Prompting Interventions

Modeling Adult modeling and prompting have been documented to increased play behaviors in young children with disabilities including children with ASD (Barton 2016). In naturalistic approaches, the adult follows the child’s lead in play, often contingently imitating his/her play actions, and models and prompts a play behavior that is both developmentally appropriate and related to the child’s attention and interests (Barton 2015). Different schedules of prompting can be used. Modeling can also be done through video. With video modeling (VM), first a video recording of the model demonstrating the behavior is created. The child observes the video recording of the model, and then the child is given the opportunity to imitate the modeled behavior (Barton and Wolery 2008). Video modeling can be more effective than live modeling because (a) the adult has more control over the model, (b) multiple exemplars can be created to promote generalization, (c) the videos can be repeatedly shown to a child and reused across children, (d) the video removes the social aspect of modeling which might be important for children with ASD, and (e) the videos can be edited to remove extraneous or distracting contextual variables (Barto

Play Materials

Other environmental arrangement strategy involves arranging play materials. Children with disabilities need more time and opportunity to become familiar with toys, materials, and equipment in order to discover the different ways to interact with them. In particular, to teach children with disabilities, much repetition is required for them to learn from the materials. Therefore, toys, materials, and other equipment should not be changed or removed too often. Children with disabilities should be given the opportunity to interact with this equipment until they have had a chance to master it completely (Klein et al. 2001). Size, density, organization, and thematic arrangement are all considerations with play materials. A wide range of highly motivating sensory, motor, exploratory, constructive and socio-dramatic props with high potentials for interactive and imaginative play are suggested as play materials. The types of material should also vary in degree of structure and complexity to afford opportunities to support children who present diverse interest, learning styles and developmental levels. The important point is to identify play materials that are motivating, allowing for mutual enjoyment between typically developing peers and children with disabilit

DIR Floortime Developmental,

individual differences, relationship-based model (DIR) or, in practice, “Floortime” emphasizes that success with any child is based on the ability of the play partner to meet the child on his/her developmental level, strengthens potential underlying neurological elements that may be impeding development and emphasizes the critical emotional connection between the impacted child and the play partner (Greenspan and Wieder 2009). The term “Floortime” refers to the actual process through which therapists, parents, and other caregivers make a special effort to tailor interactions to meet the child at his/her unique functional level and within the context of his/her processing difficulties. This model clarifies the basis of children’s behaviors, with Floortime sessions supporting the reciprocal relationship between child and caregiver (Davis et al. 2014; Greenspan and Wieder 2009). The technique involves having play partners get down on the floor and follow the child’s lead to encourage the child’s initiative and purposeful behavior, deepen engagement, lengthen mutual attention, and develop symbolic capacities. In Floortime, therapists and parents engage children through the activities each child enjoys. They enter the child’s games. They follow the child’s lead. Therapists teach parents how to direct their children into increasingly complex interactions, help the child maintain focus to sharpen interactions and abstract, logical thinking. For example, if the child is tapping a toy truck, the parent might tap a toy car in the same way. To encourage interaction, the parent might then put the car in front of the child’s truck or add language to the game. As children mature, therapists and parents tailor the strategies to match a child’s developing interests and higher levels of interaction. For example, instead of playing with toy trucks, parents can engage with model airplanes or even ideas and academic fields of special interest to their child (Greenspan and Wieder 2009). This process, called “opening and closing circles of communication,” remains central to the Floortime approach (Davis et al. 2014).

Play Books and Play Scripts S

cripts also have been used to teach young children with disabilities to engage in social and object play. Many children with ASD may find it challenging to play with toys appropriately or in the manner in which they were intended for use. Playbooks and play scripts are visual strategies that are used to support children with ASD increase play skills. Play scripts are visual prompts that help guide the play (Neville and Bachor 2002). For play scripts to be effective the child needs to be able to attend to others actions and imitate them in a sequence of multiple actions (for example, you’re able to say “copy me”, do several motor movements such as unzip coat, hang up hat and place shoes in closet, and the child copies your actions). Prepared script playbooks and play scripts are very similar tools for teaching play in that they show simple sequences of steps in a play routine (Petursdottir et al. 2007). For both strategies a book format may be used and each page of the book represents one step in a play sequence. In a playbook, only pictures are used to illustrate the sequence (for example, stacking Legos, or coloring a picture). However, in a play script both pictures and words are used to illustrate the sequence (e.g., playing with a doll house, driving toy trains). Play scripts can be short or long, based on a child’s current skills. Typically, the script starts out in a short form that the child can quickly learn. Once a child is successful with the interactions in the short script, additions are made to facilitate spontaneous and creative responses during the play (Neville and Bachor 2002; Petursdottir et al. 2007).

Sensory

evere disabilities have a ripple effect on the development of sensory processing and the ability to enact active patterns in response to sensory input. Limited gross motor movement restricts opportunity to explore the environment, which leads to limited sensorimotor experience needed to make sense of the objects. This then delays fine motor skill development and restricts play, which further restricts sensory development. These motor impairments further restrict access to the active strategies required by some of the sensory seeking and sensation avoiding patterns by Dunn (2007). Participatory sense making is one means of supporting purposeful sensory experience and patterns of sensory processing, but it is vital to also support children with severe disabilities in independent play and sense making. Interacting with toys in whatever way they independently can and exploring their environment by touch, sound, mouth, or vision should be combined with learning through the process of engaging with others to support their efforts to pursue desired outcomes or complete tasks. These are just as important and meaningful for children with severe disabilities as they are for any child.

Partner-Assisted Play

Partner-assisted play involves the child’s play partner, whether is it a self-chosen partner based on the assessment or an individual that is in the child’s day-to-day environment (i.e., parent, paraprofessional, teacher, therapist) that assists with facilitating play activities and opportunities. Partner-assisted play can be used to support autonomy and encourage voluntary action from the child (self-determination process). A play partner who is familiar with the child can help train new people on the team or facilitate interactions with new individuals. When possible, it is important for the child to have a decision about their play partner, play preferences, and desires. Partner-assisted play should always be focused on the child’s wants and needs and provide the child with options. The child should participate in the decision-making of the play activity, such as which toy to use, where they would like to put the toy, what they want to do with the toy, etc. The child’s play partner should facilitate interactions between the child and another child or adult, or the child and their environment. Children with SMD often spend more time with adults, such as paraprofessionals at school or caregivers at home, rather than with peers. However, many children with SMD relish the opportunity to be around peers to play with or observe their play. Vygotsky (1978) stated that children benefit from learning from their peers when pairing them with someone that has mastered an activity; it creates opportunities to provide scaffolding to master the activity. Moreover, providing children with a choice of a play partner can also differ between contexts. Based on the HAAT model, types of AT can differ across different contexts. In a new environment, a child with SMD may want a familiar adult to help set up toys and assistive devices or help positioning them in a way that will help them succeed. In a familiar environment, the same child may w

Play partners viewed themselves as play enablers more than reciprocal playmates. Positive play experiences were more associated with the centrality of the child in the play partnership and less associated with equal exchange and negotiating play preferences. In one event the child enjoyed throwing a ball and the teacher, acting as play enabler, complemented and elaborated on the play-action by turning it into a target game. The perceived role of the play enabler was fundamentally ‘to encourage them’ (Teacher C). Encouragement was

Assistive Technology

The “I CAN” part of the intervention should focus on grading the activities with the use of AT and creating as many successful play opportunities as possible. The grading of activities and providing the just right challenge aligns with Vygotsky’s (1978) theory of learning and development of starting with the child’s abilities and scaffolding more advanced activities to further learning. When starting with a child’s strength (i.e., one access method), the therapist can provide various play opportunities (different games, same access method) and repetition until they have mastered the skill. From there, the therapist can expand on a particular physical movement to incorporate various adaptations. Principles of the HAAT model place emphasis on participation and not on the device itself and on-going need for assessment is crucial to this stage of intervention (Cook & Hussey, 2002). The use of AT can be a range from low-technology adaptations, mid-technology adaptations, and high-technology adaptations. Lowtechnology adaptations are simple adaptations that do not require electronics; this can be a built-up holder, PVC pipe, or stylus. Mid-tech adaptations are items such as a switch, Powerlink, switch interface, and accessible toys; and high-tech adaptations are computers and gaze-based devices. With the help of AT and grading of activities, children with all physical abilities should be able to engage in play more actively and become an active participant in choosing their activities to interacting with materials despite their physical limitations. Thus, eliminating or decreasing the use of hand assistance during play 10 THE OPEN JOURNAL OF OCCUPATIONAL THERAPY – OJOT.ORG https://scholarworks.wmich.edu/ojot/vol8/iss3/8 DOI: 10.15453/2168-6408.1696 and increasing self-efficacy and confidence. The physical interaction and exploration between the child and a toy or an activity should be emphasized during the intervention. Development and Learning Through Play Takata’s Play Taxonomy serves as a developmental guide through the iCan-Play assessment and the iCan-Play profile for intervention. The taxonomy guides the therapist by providing possible task modifications, grading of activities, or future activities to work toward. A crucial aspect of intervention of play in children with SMD is engaging them with developmentally appropriate activities. Results from the iCan-Play assessment will provide information about the developmental level of play that the child is in or would like to expand on further. When children are presented with activities that are not developmentally appropriate, there is a risk of disengagement from the activity. Meeting the child at his or her developmental level can have many benefits, such as increased comprehension of the activity sequence and feelings of success and mastery. The iCan-Play profile will encourage therapists to create a list of toys and games that are selected by the child or are in the same developmental level and can be accessed by the child during their leisure time

Ideas of games:

https://raisingchildren.net.au/guides/activity-guides/children-with-diverse-abilities

therapists

rents and professionals state that providing therapy on the level of participation in real-world situations is crucial but is not at present embedded in regular therapy: “Yes … we were always here in the practice [setting] … But I’d rather that the therapist tells me there (in the playground) … what I can do with my daughter, or that what I do is good” [parent 5]. Some professionals feel fostering play as part of the everyday life of children with PD should be the aim of long-term therapy. However, therapists also experience a financial barrier when treating childrenSolutions mentioned were: home-based therapy in the playground, coaching and empowering parents to overcome social/emotional barriers, early-age intervention focusing on outside play starting around the age of 2 years, teaching children their own capabilities and boundaries and increasing self-esteem. These elements coincide with implications Palis

Additional resources:

https://iris.unito.it/retrieve/handle/2318/1746530/631583/Bulgarelli_2020_Perspectives%20and%20research%20on%20play%20for%20children%20with%20disabilities.pdf