Therapeutic Play for the Severely Disabled Population

Introduction

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

Partner-Assisted Play

Interventions that are peer implemented provide opportunities for social interactions between children with disabilities and their typically developing peers. In addition, it provides engagement in 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.

Children with disabilities spend more time with caregivers or adults rather than peers. espite their interest in being around peers.

The choice of play partner should be made by the child with disabilities. Play should be centred around the child's needs and wants. Multiple options should be offered with the child participating in the decision-making process of the the activity, toy and how to use it.

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

Playdates

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 (AT) p.8 chart

There are a variety of assistive services and devices that can be used to help improve the functional abilities of children with disabilities. Low-tech items are inexpensive, more readily available and easy to use. Three common low-tech adaptions categories include:

1. position and mobility items
2. adaptive toys
3. communication devices

** Each child and family needs are unique whereby several categories or combinations of assistive technology can be used

Modeling and Prompting Interventions

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:

1. adult follows child's lead
2. adult imitates the play
3. adults models and prompts a play behaviour
   • behaviour should be developmentally appropriate
   • behaviour should be geared towards child's attention and interests

Play Materials

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

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

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.

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