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The Impact of Occupational Therapy on a Child’s Playfulness Jane O’Brien, MSOT,OTR/L Patricia Coker, MHS, OTR/L Robyn Lynn, MHS, OTR/L Rachael Suppinger, MHS, OTR/L Tiffany Pearigen, OTR/L Sherrie Rabon, OTR/L Merrill St. Aubin, OTR/L Ann Thompson Ward, OTR/L
ABSTRACT. The constant changing health care system has made it imperative for occupational therapists (OTs) to examine the effectiveness of treatment interventions with children. Few studies exist examining play as the desired outcome of the intervention. Previous studies in occupational therapy (OT) have focused on the motor aspects of play in children (Anderson, Hinojosa & Strauch, 1987; Florey, 1981; Morrison, Bundy, & Fisher, 1991). In these studies, the researchers hypothesize that improving motor skills will improve play skills in children. OTs frequently evaluate play using the Preschool Play Scale (PPS) (Bledsoe & Shephard, 1982; Knox, 1997) which provides a developmental age for play skills. Therapists also use developmental assessments designed to examine the skills used during play (Bundy, 1991). Skills used in play are important but fail to look at a child’s approach or Jane O’Brien is Assistant Professor at the Medical University of South Carolina, Rehabilitation Sciences Department, Occupational Therapy program. Patricia Coker, Robyn Lynn, Rachael Suppinger, Tiffany Pearigen, Sherrie Rabon, Merrill St. Aubin and Ann Thompson Ward completed this study as part of their educational requirements for OT at the Medical University of South Carolina. The authors would like to thank Frank Howard, President of Southpaw Enterprises, Inc., for providing the equipment used in the Collaborative SI lab (CSIL) and thus, making this study possible. They would like to acknowledge Jeanne Solomon, co-coordinator of the CSIL, for her support of the study. A special thanks to all the children and families who participated in the study. Occupational Therapy in Health Care, Vol.12(2/3) 2000 E 2000 by The Haworth Press, Inc. All rights reserved.
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attitude during play. A child’s approach to activities of play is termed ‘‘playfulness’’ (Bundy, 1997). The Test of Playfulness (TOP) (Bundy, 1997) was developed to measure this construct. The TOP provides information that can assist therapists working with children in designing measurable playfulness goals. This study examined the playfulness of four children who received OT intervention specifically designed to improve play behaviors in comparison to four children who did not receive this intervention. The results provide therapists with information and insight for treating children with play deficits. This information will help therapists design effective treatment to increase playfulness in children. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: [email protected] ]
KEYWORDS. Playfulness, intervention, Test of Playfulness, Preschool Play Scale
LITERATURE REVIEW Play is the primary role of childhood and a desired outcome of pediatric OT practice. Through play, children learn gross and fine motor skills (Exner, 1992; Fagard & Jacquet, 1989; Fenson, Kagan, Kearsley, 1976). Play contributes to self-confidence, knowledge of social rules, and cognitive learning (Connolly & Doyle, 1984; McHale & Olley, 1982, Mindes, 1982; Phillips & Sellito, 1990). Children develop and enhance problem-solving abilities through play. Play enables children to express their inner feelings and form a sense of who they are as individuals (Parham & Primeau, 1997). Play is essential to a child’s development. Few studies exist examining play as the desired outcome of OT intervention. Morrison, Bundy, and Fisher (1991) evaluated the play skills of children with juvenile rheumatoid arthritis. The study suggested playful children would display more mature play skills (Morrison et al., 1991). Rastall and Magill (1994) studied the play of preschool children with autism in their homes. They supported the use of play as a modality to remediate social behaviors. Anderson, Hinojosa, and Strauch (1987) investigated the use of play in combination with neurodevelopmental treatment. The previous studies utilized gross motor, fine motor, and visual perceptual skills as outcome measures.
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While these studies examine play skills and support the use of play as a modality, the research did not determine the outcome of OT intervention on play. Knox developed the Preschool Play Scale (PPS) to assist OTs in measuring the outcome of intervention on play. The PPS is an observational scaled based upon Piaget and Parten’s development work. The scale consists of four domains: space management (sensorimotor), material management (fine motor), imitation and participation (Bledsoe & Shephard, 1982; Know, 1997). The PPS provides a play age score for each domain and an overall play age (in years). The PPS has been found to be reliable for use with special needs children (Harrison and Kielhofner, 1986). While the PPS examines the skills used during play, it does not address the playful manner in which the child approaches activities. Bundy (1993) defines this approach as playfulness. Theorists agree that play is spontaneous, fun, intrinsically motivating and provides the freedom to suspend reality (Bundy, 1993). Children experiencing difficulties in their attitude and approach to play may be at risk for low self-esteem and poor socialization skills. Consider a child who has the motor skills required for play, but does not appear to be having fun. The child may be going through the motions of play, while not being involved in the process of play. The Test of Playfulness (TOP) was developed to provide an objective measurement of playfulness across age and diagnostic groups. This tool is a sixty item observational assessment that measures three items of playfulness: internal control, intrinsic motivation, and freedom to suspend reality. Internal control encompasses initiation, modification, and engagement in challenges during play. A child’s exuberance, persistence, and engagement during play provide insight to his/her motivation. Suspension of reality is reflected in observations of the child pretending, engaging in mischief, or clowning. This assessment provides OTs with a measurement of playfulness (Bundy, 1997). The TOP defines playfulness in objective terms so therapists can identify deficit areas for intervention. The scale enables therapists working with children to design measurable goals targeting playfulness. In order to determine the success of OT intervention, therapists must evaluate the effectiveness of therapy. This study examined the effectiveness of OT intervention on the playfulness skills of four chil-
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dren who received OT intervention specifically designed to improve playfulness and four children who did not receive this intervention.
HYPOTHESES The hypotheses of this study were that children receiving OT intervention designed to improve playfulness would show an increase in:
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S playfulness behaviors, as measured by TOP scores, and; S play skills as measured by PPS scores.
SUBJECTS The children invited to participate in this study were between four and six years of age and were experiencing difficulty playing per parent report. They were referred by physicians at the Vince Moseley Diagnostic Center at the Medical University of South Carolina in Charleston, South Carolina. The children were healthy and had no known physical impairments. Sample selection was not based upon gender, race, ethnicity, or socioeconomic status. Eleven parents were contacted to have their child participate in this study. Three children were not able to participate due to scheduling conflicts or transportation problems. Eight children participated in the study (five boys and three girls). The children were randomly assigned into a treatment or control group. The treatment group consisted of four children between the ages of four and six years with a mean age of fifty-five months. The children were diagnosed with autism, communication disorder, and two children were diagnosed as having pervasive development disorder. Two of the children in the treatment group were receiving medication during the time the research was conducted. Three children in the treatment group were receiving additional OT services. Each child was scheduled to participate in OT intervention for one hour weekly for ten weeks. Children were transported to the therapy sessions by their parents. Therapy was provided at the Medical University of South Carolina and Trident Technical College’s Collaborative Lab in Charleston,
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South Carolina. The treatment was provided free of charge by OT senior students under the direct supervision of a registered and licensed OT (board certified in pediatrics). Treatment was designed to increase play skills. The therapy consisted of play activities designed to facilitate developmental motor milestones and integration of play deficits. Sessions were playful in nature. Therapy followed standard OT practice guidelines for pediatric treatment. Parents and/or guardians were present at each session and were provided with activities to promote play skills at home. The control group consisted of four children between the ages of four and six years with a mean age of fifty-seven months. Diagnoses of the children were: autism, DiGeorge’s syndrome resulting in developmental delays, and two children were diagnosed with pervasive developmental disorder. The children received no play intervention from the occupational therapy students, however they received a home program with activities to promote play skills at home. One child in the control group was receiving medication during the time the research was conducted. Three children were receiving additional occupational therapy services. METHODOLOGY The Institutional Review Board (IRB) at the Medical University of South Carolina granted approval for the study. Intrarater and interrater reliability was established for the seven student researchers in use of the Test of Playfulness (TOP). Using first names of children insured confidentiality of all participants. Videotapes of play sessions were coded and erased upon completion of the study. Researchers, in pairs, obtained written parental consent from each child’s caregiver. They completed an interview to determine concerns for the child in order to develop the treatment plan or home program. Each child was videotaped during an initial visit in free play with a peer for fifteen minutes indoors and fifteen minutes outdoors per TOP and PPS guidelines. All children were videotaped again at the end of ten weeks in a familiar free play setting, using the fifteen-minute time frame indoors and outdoors. These same researchers provided therapy to the children in the treatment group for one hour weekly. The OT intervention was designed to increase playfulness skills. Therapy goals were based upon
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the initial home visit and parent interview. Goals were designed to improve playfulness skills of children per TOP deficit areas. (See Table 1.) The children in the control group were provided with a home program to improve playfulness skills. Upon completion of the study, a different pair of students viewed and scored the initial and final videotapes. In order to assure objectivity and to prevent bias, this pair of students did not know to which group the child belonged or if they were viewing the initial or final videotape. Each tape was scored using the TOP. Results were analyzed using Rasch analysis, a statistical program that requires that raters be consistent, but does not require two raters to score each child exactly the same. The statistical program makes adjustments for the different scoring styles of the raters.
TABLE 1. Playfulness Goals Goals
Examples
Child will participate in turn taking game with therapist or playmate for a minimum of five minutes within four weeks.
Board games, sharing swing, ball games, Follow-the leader (turns being leader).
Child will transition from one activity to another (initiated by therapist or playmate) two times during a one hour treatment session within one week
Sandbox to ball game, slide to parachute, swing to obstacle course, rolling on ball (large) to playing catch with small balls.
Child will initiate play activity of choice by gesturing or using 1-2 word verbalizations at least 3 times during play session with adult
‘‘Play cars,’’ pointing to toy, picking up object, ‘‘tugging’’ on OT to indicate choice.
Child will wait (pause) for playmate’s response (turn) during 15 minute interactive play three times within three weeks.
Allowing playmate to pick new game, taking turns with cars or sandbox toys, or waiting turn, watching playmate to know when to throw the ball again.
Child will provide verbal cues to let playmate know what they want to do at least 3 times during play session.
Praising playmate (i.e., good job, yes) , responding ‘‘yes or no’’ to questions from playmate, requesting playmate play in a particular manner (i.e. ‘‘Do this’’). Letting playmate know they did not like something.
Child will use object or toy in an unconventional manner two times during play session within two weeks.
Using a block as a car, phone, animal or person, pretending ball is a rocket, hiding under swing (pretending it is a bridge).
Wthin five treatment sessions, child will successfully enter into an activity with playmates without disrupting the play process.
Joining parachute games, sandbox, or block activites without fighting or interrupting, joining activity without making the children upset or causing an adult to intervene.
Child will pretend to be a ”character’’ one time during play session within one month
Puppet play, dress-up, animal, pretending to be a superhero, assuming adult role (i.e., teacher).
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At this point, a new researcher was introduced to the study who was blind to all aspects of the study. The researcher was trained in the scoring procedures of the PPS. She viewed all videotapes and used the PPS to score the children’s play skills. Each child received a total play age, indicating the developmental age of the child’s play skills.
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RESULTS All raters were found to be reliable in administering the TOP. Acceptable goodness-of-fit of the rater is indicative of both interrater and intrarater reliability (Park, Fisher & Velozo, 1994). All subjects demonstrated acceptable mean square goodness-of-fit statistics as reported by Rasch analysis. The criterion for acceptable fit was set at a mean square values less than 1.4 and a standardized fit less than 2, simultaneously (Park, Fisher & Velozo, 1994). Each subject’s TOP score, plus or minus the standard error, was graphically plotted to determine if there were any differences between the initial and final measures. Traditionally, psychometric procedures calculate the standard error of measurement based on the variance of the average person sample (Wright & Stone, cited in Park et al., 1994). The estimated playfulness measure, plus or minus the standard error, delineates the range in which the person’s true ability is most likely to fall. If these ranges do not overlap, a statistically significant difference in performances has occurred (Silverstein, Kilgore, & Fisher, cited in Park, 1994). Two children in the control group and two children in the treatment group demonstrated a significant increase in TOP scores. (See Figures 1 and 2.) There were no significant changes in TOP scores for any of the remaining children. PPS scores were determined to be clinically significant if a difference of one year was found. Within a three-month study, a gain of one year or more would demonstrate changes above normal maturation or margin of error. Analyses of the PPS scores indicate that only one child showed a significant increase in play skills. (See Table 2.) This child was in the treatment group and also showed improvements in playfulness scores. None of the other children showed improvements of equal or greater than one year.
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FIGURE 1. Treatment Group -- TOP Scores
DISCUSSION The results indicated that two children in the treatment group made significant improvements in their play behaviors as measured by TOP scores. These two children attended the greatest number of sessions (9 and 8 sessions). However, two children in the control group also made improvements in play behavior according to TOP scores. None of the children showed a decrease in playfulness. The children in the control group were receiving therapy to improve their behaviors; specifically three children received Lovaas therapy and therapeutic horseback riding. The children in the control and treatment groups were not identical in age, diagnosis, severity of diagnosis and home environment. It should be noted the initial scores for the control children were significantly lower than the initial scores for the three out of four children in the treatment group. Therefore, it may not be possible to compare the control and treatment groups. Only one child met the criteria of showing a 1-year difference in PPS scores. This child also showed a significant improvement in TOP
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FIGURE 2. Control Group -- TOP Scores
TABLE 2. Preschool Play Scale Scores (years) Before
After
Treatment Group 1
2.79
2.91
2
2. 67*
3. 78*
3
2.95
2.16
4
1.8
1.89
5
1.75
1.67
6
2.17
2.81
7
2.31
1.97
8
2.44
2.15
Control Group
* Significant increase (more than 1 year).
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scores. This child was in the treatment group. The data may indicate that therapists targeting playfulness may be able to impact motor skills. The results warrant further attention as they suggest another approach to therapy may be effective. This study showed that playfulness goals could be developed and written in measurable and observable terms. The researchers were able to develop goals and objectives after a thirty-minute free play observation and brief discussion with the caregiver. These goals were used to design the therapy session (see Table 1). The skills learned through OT targeting playfulness may generalize to other settings. Parents reported children receiving therapy showed more interactions with peers both at school and home and that the children enjoyed coming to the treatment sessions. One parent reported an increase in appropriate play behaviors with siblings and school playmates. There was an increase in turn taking and cooperation at home. One child in the treatment group received student of the month at school while participating in the study. However, one parent did report an increase in the number of tantrums at home. The limitations to our study must be noted. Due to the small sample size of only eight children, variables such as diagnosis and use of medications were not controlled. The children in the treatment group participated in as few as five or as many as nine therapy sessions due to scheduling conflicts and missed appointments. Children in both groups received outside OT services. However, the outside therapy goals focused more on increasing the child’s performance skills such as fine motor manipulation, not on improving the child’s playfulness. Two of the children in the control group participated in Lovaas therapy, a treatment involving behavior modification. CONCLUSION Additional research studies increasing the sample size, treatment time, and the variety of diagnoses would be valuable to the profession. It may prove beneficial to explore the attitudes of therapists in treating playfulness. Further studies of OT approaches toward promoting playfulness are needed. An examination of the environmental factors influencing a child’s play would be useful to expand current research. This study was conducted within one semester. Thus, children were only scheduled for ten treatment sessions. This did not allow for
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missed appointments due to transportation problems, illness, and other circumstances. Furthermore, the time constraints only allowed the researchers one session to build rapport and trust before beginning therapy. There are many children in need of therapy to improve playfulness. Parents were very concerned about their child’s lack of enthusiasm for play. They cited difficulties at home and school. Many parents remarked that they were frustrated and worried that their child could not get along with their siblings and playmates. OT is one of the few professions that target playfulness skills. Playfulness is important in all settings (i.e., home, school, and community). Therefore, if therapists can improve a child’s playfulness, a substantial impact can be made towards improving a child’s ability to function within many social environments. The fact that significant changes occurred in four children in a short time is important. Further evaluation is needed to explore why the two children in the control group showed significant increases. Did the medications, environment, school system, and/or Lovaas training make a difference? Was it just natural developmental progression? What factors influenced these children during this time period? It should be noted that two children in the treatment group received the highest final playfulness scores. In conclusion, we encourage OTs working in pediatric settings to incorporate playfulness goals and treatment into their current practices. This can be accomplished by: S Providing a playful environment, S Making treatment sessions unstructured and child directed, S Using activities requiring interaction between playmates, S Demonstrating appropriate play behaviors that can be imitated, and S Using positive reinforcement, verbal and body cues during play sessions. Traditional OT focuses on using play to develop fine, gross motor, cognitive, self-care, and sensory integrative skills. This study indicates
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that OT may be able to impact a child’s skills (i.e., fine, gross, cognitive) while targeting playfulness in therapy sessions. This approach provides OTs with an alternative method of treating play deficits. Therapists are encouraged to explore the use of playfulness as a treatment approach.
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REFERENCES Anderson, J., Hinojosa, J., & Strauch, C. (1987). Integrating play in neurodevelopmental treatment. The American Journal of Occupational Therapy, 41(7), 421-426. Bledsoe, N. P. & Shephard, J. T. (1982). A study of reliability and validity of a preschool play scale. The American Journal of Occupational Therapy, 36(12), 783-788. Bundy, A. C. (1991). Play theory and sensory integration. In A .G. Fisher, E. A. Murray, & A. C. Bundy, (Eds.), Sensory Integration: Theory and Practice (pp. 48-68). Philadelphia: F.A. Davis. Bundy, A. C. (1993). Assessment of play and leisure: Delineation of the problem. American Journal of Occupational Therapy, 47, 217-222. Bundy, A. C., (1997). Play and playfulness: What to look for. In D. Parham & L. Fazio (Eds.). Play in Occupational Therapy for Children. St. Louis: Mosby-Year Book, Inc. Connolly, J. A., & Doyle, A. (1984). Relation of social fantasy play to social competence in preschoolers. Developmental Psychology, 20(5), 797-806. Exner, C. (1992). In-hand manipulation skills. In J. Case-Smith & C. Pehoski (Eds.). Development of Hand Skills in Children, Rockville, MD: American Occupational Therapy Association. Fagard, J., & Jacquet, A. (1989). Onset of bimanual coordination and symmetry versus asymmetry of movement. Infant Behavior and Development, 12, 229-235. Fenson, L., Kagan, J. & Kersley, R.B. (1976). The developmental progression of manipulative play the first two years. Child Development, 47, 232-244. Florey, L. (1981). Studies of play: Implications of growth, development, and for clinical practice. The American Journal of Occupational Therapy, 35, 519-524. Harrison, H., & Kielhofner, G. (1986). Examining the reliability and validity of the preschool play scale with handicapped children. American Journal of Occupational Therapy, 40(3), 167-173. Knox, S. (1997). Development and current use of the Knox Preschool Play Scale. In D. Parham & L. Fazio (Eds.) Play in Occupational Therapy for Children. St. Louis: Mosby-Year Book, Inc. McHale, S. M. & Olley, J. G. (1982). Using play to facilitate the social development of handicap children. Topics in Early Childhood Special Education, 2(3), 76-86. Mindes, G. (1982). Social and cognitive aspects of play in young handicapped children. Topics in Early Childhood Special Education, 2(3), 39-65. Morrison, C. D., Bundy, A. C., & Fisher, A. G. (1991). The contribution of motor
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skills and playfulness to the play performance of preschoolers. The American Journal of Occupational Therapy, 45 (8), 687-694. Parham, D. & Primeau, L. (1997). Play and occupational therapy. In D. Parham & L. Fazio (Eds.). Play in Occupational Therapy for Children. St. Louis: Mosby-Year Book, Inc. Park, S., Fisher, A. G. Velozo, C. A. (1994). Using the Assessment of Motor and Process Skills to compare occupational performance between clinic and home settings. American Journal of Occupational Therapy, 48(8), 697-709. Phillips, R. D., & Sellito, V. A. (1990). Preliminary evidence on emotions expressed by children during solitary play. Play and Culture, 3, 79-90. Rastall, G., & Magill, J. (1994). Play and Preschool children with autism. The American Journal of Occupational Therapy, 48(2), 113-120.
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The Impact of Occupational Therapy on a Child’s Playfulness Jane O’Brien, MSOT,OTR/L Patricia Coker, MHS, OTR/L Robyn Lynn, MHS, OTR/L Rachael Suppinger, MHS, OTR/L Tiffany Pearigen, OTR/L Sherrie Rabon, OTR/L Merrill St. Aubin, OTR/L Ann Thompson Ward, OTR/L
ABSTRACT. The constant changing health care system has made it imperative for occupational therapists (OTs) to examine the effectiveness of treatment interventions with children. Few studies exist examining play as the desired outcome of the intervention. Previous studies in occupational therapy (OT) have focused on the motor aspects of play in children (Anderson, Hinojosa & Strauch, 1987; Florey, 1981; Morrison, Bundy, & Fisher, 1991). In these studies, the researchers hypothesize that improving motor skills will improve play skills in children. OTs frequently evaluate play using the Preschool Play Scale (PPS) (Bledsoe & Shephard, 1982; Knox, 1997) which provides a developmental age for play skills. Therapists also use developmental assessments designed to examine the skills used during play (Bundy, 1991). Skills used in play are important but fail to look at a child’s approach or Jane O’Brien is Assistant Professor at the Medical University of South Carolina, Rehabilitation Sciences Department, Occupational Therapy program. Patricia Coker, Robyn Lynn, Rachael Suppinger, Tiffany Pearigen, Sherrie Rabon, Merrill St. Aubin and Ann Thompson Ward completed this study as part of their educational requirements for OT at the Medical University of South Carolina. The authors would like to thank Frank Howard, President of Southpaw Enterprises, Inc., for providing the equipment used in the Collaborative SI lab (CSIL) and thus, making this study possible. They would like to acknowledge Jeanne Solomon, co-coordinator of the CSIL, for her support of the study. A special thanks to all the children and families who participated in the study. Occupational Therapy in Health Care, Vol.12(2/3) 2000 E 2000 by The Haworth Press, Inc. All rights reserved.
39
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Occup Ther Health Downloaded from informahealthcare.com by McMaster University on 10/31/14 For personal use only.
attitude during play. A child’s approach to activities of play is termed ‘‘playfulness’’ (Bundy, 1997). The Test of Playfulness (TOP) (Bundy, 1997) was developed to measure this construct. The TOP provides information that can assist therapists working with children in designing measurable playfulness goals. This study examined the playfulness of four children who received OT intervention specifically designed to improve play behaviors in comparison to four children who did not receive this intervention. The results provide therapists with information and insight for treating children with play deficits. This information will help therapists design effective treatment to increase playfulness in children. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: [email protected] ]
KEYWORDS. Playfulness, intervention, Test of Playfulness, Preschool Play Scale
LITERATURE REVIEW Play is the primary role of childhood and a desired outcome of pediatric OT practice. Through play, children learn gross and fine motor skills (Exner, 1992; Fagard & Jacquet, 1989; Fenson, Kagan, Kearsley, 1976). Play contributes to self-confidence, knowledge of social rules, and cognitive learning (Connolly & Doyle, 1984; McHale & Olley, 1982, Mindes, 1982; Phillips & Sellito, 1990). Children develop and enhance problem-solving abilities through play. Play enables children to express their inner feelings and form a sense of who they are as individuals (Parham & Primeau, 1997). Play is essential to a child’s development. Few studies exist examining play as the desired outcome of OT intervention. Morrison, Bundy, and Fisher (1991) evaluated the play skills of children with juvenile rheumatoid arthritis. The study suggested playful children would display more mature play skills (Morrison et al., 1991). Rastall and Magill (1994) studied the play of preschool children with autism in their homes. They supported the use of play as a modality to remediate social behaviors. Anderson, Hinojosa, and Strauch (1987) investigated the use of play in combination with neurodevelopmental treatment. The previous studies utilized gross motor, fine motor, and visual perceptual skills as outcome measures.
Occup Ther Health Downloaded from informahealthcare.com by McMaster University on 10/31/14 For personal use only.
O’Brien et al.
41
While these studies examine play skills and support the use of play as a modality, the research did not determine the outcome of OT intervention on play. Knox developed the Preschool Play Scale (PPS) to assist OTs in measuring the outcome of intervention on play. The PPS is an observational scaled based upon Piaget and Parten’s development work. The scale consists of four domains: space management (sensorimotor), material management (fine motor), imitation and participation (Bledsoe & Shephard, 1982; Know, 1997). The PPS provides a play age score for each domain and an overall play age (in years). The PPS has been found to be reliable for use with special needs children (Harrison and Kielhofner, 1986). While the PPS examines the skills used during play, it does not address the playful manner in which the child approaches activities. Bundy (1993) defines this approach as playfulness. Theorists agree that play is spontaneous, fun, intrinsically motivating and provides the freedom to suspend reality (Bundy, 1993). Children experiencing difficulties in their attitude and approach to play may be at risk for low self-esteem and poor socialization skills. Consider a child who has the motor skills required for play, but does not appear to be having fun. The child may be going through the motions of play, while not being involved in the process of play. The Test of Playfulness (TOP) was developed to provide an objective measurement of playfulness across age and diagnostic groups. This tool is a sixty item observational assessment that measures three items of playfulness: internal control, intrinsic motivation, and freedom to suspend reality. Internal control encompasses initiation, modification, and engagement in challenges during play. A child’s exuberance, persistence, and engagement during play provide insight to his/her motivation. Suspension of reality is reflected in observations of the child pretending, engaging in mischief, or clowning. This assessment provides OTs with a measurement of playfulness (Bundy, 1997). The TOP defines playfulness in objective terms so therapists can identify deficit areas for intervention. The scale enables therapists working with children to design measurable goals targeting playfulness. In order to determine the success of OT intervention, therapists must evaluate the effectiveness of therapy. This study examined the effectiveness of OT intervention on the playfulness skills of four chil-
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dren who received OT intervention specifically designed to improve playfulness and four children who did not receive this intervention.
HYPOTHESES The hypotheses of this study were that children receiving OT intervention designed to improve playfulness would show an increase in:
Occup Ther Health Downloaded from informahealthcare.com by McMaster University on 10/31/14 For personal use only.
S playfulness behaviors, as measured by TOP scores, and; S play skills as measured by PPS scores.
SUBJECTS The children invited to participate in this study were between four and six years of age and were experiencing difficulty playing per parent report. They were referred by physicians at the Vince Moseley Diagnostic Center at the Medical University of South Carolina in Charleston, South Carolina. The children were healthy and had no known physical impairments. Sample selection was not based upon gender, race, ethnicity, or socioeconomic status. Eleven parents were contacted to have their child participate in this study. Three children were not able to participate due to scheduling conflicts or transportation problems. Eight children participated in the study (five boys and three girls). The children were randomly assigned into a treatment or control group. The treatment group consisted of four children between the ages of four and six years with a mean age of fifty-five months. The children were diagnosed with autism, communication disorder, and two children were diagnosed as having pervasive development disorder. Two of the children in the treatment group were receiving medication during the time the research was conducted. Three children in the treatment group were receiving additional OT services. Each child was scheduled to participate in OT intervention for one hour weekly for ten weeks. Children were transported to the therapy sessions by their parents. Therapy was provided at the Medical University of South Carolina and Trident Technical College’s Collaborative Lab in Charleston,
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South Carolina. The treatment was provided free of charge by OT senior students under the direct supervision of a registered and licensed OT (board certified in pediatrics). Treatment was designed to increase play skills. The therapy consisted of play activities designed to facilitate developmental motor milestones and integration of play deficits. Sessions were playful in nature. Therapy followed standard OT practice guidelines for pediatric treatment. Parents and/or guardians were present at each session and were provided with activities to promote play skills at home. The control group consisted of four children between the ages of four and six years with a mean age of fifty-seven months. Diagnoses of the children were: autism, DiGeorge’s syndrome resulting in developmental delays, and two children were diagnosed with pervasive developmental disorder. The children received no play intervention from the occupational therapy students, however they received a home program with activities to promote play skills at home. One child in the control group was receiving medication during the time the research was conducted. Three children were receiving additional occupational therapy services. METHODOLOGY The Institutional Review Board (IRB) at the Medical University of South Carolina granted approval for the study. Intrarater and interrater reliability was established for the seven student researchers in use of the Test of Playfulness (TOP). Using first names of children insured confidentiality of all participants. Videotapes of play sessions were coded and erased upon completion of the study. Researchers, in pairs, obtained written parental consent from each child’s caregiver. They completed an interview to determine concerns for the child in order to develop the treatment plan or home program. Each child was videotaped during an initial visit in free play with a peer for fifteen minutes indoors and fifteen minutes outdoors per TOP and PPS guidelines. All children were videotaped again at the end of ten weeks in a familiar free play setting, using the fifteen-minute time frame indoors and outdoors. These same researchers provided therapy to the children in the treatment group for one hour weekly. The OT intervention was designed to increase playfulness skills. Therapy goals were based upon
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the initial home visit and parent interview. Goals were designed to improve playfulness skills of children per TOP deficit areas. (See Table 1.) The children in the control group were provided with a home program to improve playfulness skills. Upon completion of the study, a different pair of students viewed and scored the initial and final videotapes. In order to assure objectivity and to prevent bias, this pair of students did not know to which group the child belonged or if they were viewing the initial or final videotape. Each tape was scored using the TOP. Results were analyzed using Rasch analysis, a statistical program that requires that raters be consistent, but does not require two raters to score each child exactly the same. The statistical program makes adjustments for the different scoring styles of the raters.
TABLE 1. Playfulness Goals Goals
Examples
Child will participate in turn taking game with therapist or playmate for a minimum of five minutes within four weeks.
Board games, sharing swing, ball games, Follow-the leader (turns being leader).
Child will transition from one activity to another (initiated by therapist or playmate) two times during a one hour treatment session within one week
Sandbox to ball game, slide to parachute, swing to obstacle course, rolling on ball (large) to playing catch with small balls.
Child will initiate play activity of choice by gesturing or using 1-2 word verbalizations at least 3 times during play session with adult
‘‘Play cars,’’ pointing to toy, picking up object, ‘‘tugging’’ on OT to indicate choice.
Child will wait (pause) for playmate’s response (turn) during 15 minute interactive play three times within three weeks.
Allowing playmate to pick new game, taking turns with cars or sandbox toys, or waiting turn, watching playmate to know when to throw the ball again.
Child will provide verbal cues to let playmate know what they want to do at least 3 times during play session.
Praising playmate (i.e., good job, yes) , responding ‘‘yes or no’’ to questions from playmate, requesting playmate play in a particular manner (i.e. ‘‘Do this’’). Letting playmate know they did not like something.
Child will use object or toy in an unconventional manner two times during play session within two weeks.
Using a block as a car, phone, animal or person, pretending ball is a rocket, hiding under swing (pretending it is a bridge).
Wthin five treatment sessions, child will successfully enter into an activity with playmates without disrupting the play process.
Joining parachute games, sandbox, or block activites without fighting or interrupting, joining activity without making the children upset or causing an adult to intervene.
Child will pretend to be a ”character’’ one time during play session within one month
Puppet play, dress-up, animal, pretending to be a superhero, assuming adult role (i.e., teacher).
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At this point, a new researcher was introduced to the study who was blind to all aspects of the study. The researcher was trained in the scoring procedures of the PPS. She viewed all videotapes and used the PPS to score the children’s play skills. Each child received a total play age, indicating the developmental age of the child’s play skills.
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RESULTS All raters were found to be reliable in administering the TOP. Acceptable goodness-of-fit of the rater is indicative of both interrater and intrarater reliability (Park, Fisher & Velozo, 1994). All subjects demonstrated acceptable mean square goodness-of-fit statistics as reported by Rasch analysis. The criterion for acceptable fit was set at a mean square values less than 1.4 and a standardized fit less than 2, simultaneously (Park, Fisher & Velozo, 1994). Each subject’s TOP score, plus or minus the standard error, was graphically plotted to determine if there were any differences between the initial and final measures. Traditionally, psychometric procedures calculate the standard error of measurement based on the variance of the average person sample (Wright & Stone, cited in Park et al., 1994). The estimated playfulness measure, plus or minus the standard error, delineates the range in which the person’s true ability is most likely to fall. If these ranges do not overlap, a statistically significant difference in performances has occurred (Silverstein, Kilgore, & Fisher, cited in Park, 1994). Two children in the control group and two children in the treatment group demonstrated a significant increase in TOP scores. (See Figures 1 and 2.) There were no significant changes in TOP scores for any of the remaining children. PPS scores were determined to be clinically significant if a difference of one year was found. Within a three-month study, a gain of one year or more would demonstrate changes above normal maturation or margin of error. Analyses of the PPS scores indicate that only one child showed a significant increase in play skills. (See Table 2.) This child was in the treatment group and also showed improvements in playfulness scores. None of the other children showed improvements of equal or greater than one year.
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FIGURE 1. Treatment Group -- TOP Scores
DISCUSSION The results indicated that two children in the treatment group made significant improvements in their play behaviors as measured by TOP scores. These two children attended the greatest number of sessions (9 and 8 sessions). However, two children in the control group also made improvements in play behavior according to TOP scores. None of the children showed a decrease in playfulness. The children in the control group were receiving therapy to improve their behaviors; specifically three children received Lovaas therapy and therapeutic horseback riding. The children in the control and treatment groups were not identical in age, diagnosis, severity of diagnosis and home environment. It should be noted the initial scores for the control children were significantly lower than the initial scores for the three out of four children in the treatment group. Therefore, it may not be possible to compare the control and treatment groups. Only one child met the criteria of showing a 1-year difference in PPS scores. This child also showed a significant improvement in TOP
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FIGURE 2. Control Group -- TOP Scores
TABLE 2. Preschool Play Scale Scores (years) Before
After
Treatment Group 1
2.79
2.91
2
2. 67*
3. 78*
3
2.95
2.16
4
1.8
1.89
5
1.75
1.67
6
2.17
2.81
7
2.31
1.97
8
2.44
2.15
Control Group
* Significant increase (more than 1 year).
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scores. This child was in the treatment group. The data may indicate that therapists targeting playfulness may be able to impact motor skills. The results warrant further attention as they suggest another approach to therapy may be effective. This study showed that playfulness goals could be developed and written in measurable and observable terms. The researchers were able to develop goals and objectives after a thirty-minute free play observation and brief discussion with the caregiver. These goals were used to design the therapy session (see Table 1). The skills learned through OT targeting playfulness may generalize to other settings. Parents reported children receiving therapy showed more interactions with peers both at school and home and that the children enjoyed coming to the treatment sessions. One parent reported an increase in appropriate play behaviors with siblings and school playmates. There was an increase in turn taking and cooperation at home. One child in the treatment group received student of the month at school while participating in the study. However, one parent did report an increase in the number of tantrums at home. The limitations to our study must be noted. Due to the small sample size of only eight children, variables such as diagnosis and use of medications were not controlled. The children in the treatment group participated in as few as five or as many as nine therapy sessions due to scheduling conflicts and missed appointments. Children in both groups received outside OT services. However, the outside therapy goals focused more on increasing the child’s performance skills such as fine motor manipulation, not on improving the child’s playfulness. Two of the children in the control group participated in Lovaas therapy, a treatment involving behavior modification. CONCLUSION Additional research studies increasing the sample size, treatment time, and the variety of diagnoses would be valuable to the profession. It may prove beneficial to explore the attitudes of therapists in treating playfulness. Further studies of OT approaches toward promoting playfulness are needed. An examination of the environmental factors influencing a child’s play would be useful to expand current research. This study was conducted within one semester. Thus, children were only scheduled for ten treatment sessions. This did not allow for
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missed appointments due to transportation problems, illness, and other circumstances. Furthermore, the time constraints only allowed the researchers one session to build rapport and trust before beginning therapy. There are many children in need of therapy to improve playfulness. Parents were very concerned about their child’s lack of enthusiasm for play. They cited difficulties at home and school. Many parents remarked that they were frustrated and worried that their child could not get along with their siblings and playmates. OT is one of the few professions that target playfulness skills. Playfulness is important in all settings (i.e., home, school, and community). Therefore, if therapists can improve a child’s playfulness, a substantial impact can be made towards improving a child’s ability to function within many social environments. The fact that significant changes occurred in four children in a short time is important. Further evaluation is needed to explore why the two children in the control group showed significant increases. Did the medications, environment, school system, and/or Lovaas training make a difference? Was it just natural developmental progression? What factors influenced these children during this time period? It should be noted that two children in the treatment group received the highest final playfulness scores. In conclusion, we encourage OTs working in pediatric settings to incorporate playfulness goals and treatment into their current practices. This can be accomplished by: S Providing a playful environment, S Making treatment sessions unstructured and child directed, S Using activities requiring interaction between playmates, S Demonstrating appropriate play behaviors that can be imitated, and S Using positive reinforcement, verbal and body cues during play sessions. Traditional OT focuses on using play to develop fine, gross motor, cognitive, self-care, and sensory integrative skills. This study indicates
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that OT may be able to impact a child’s skills (i.e., fine, gross, cognitive) while targeting playfulness in therapy sessions. This approach provides OTs with an alternative method of treating play deficits. Therapists are encouraged to explore the use of playfulness as a treatment approach.
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REFERENCES Anderson, J., Hinojosa, J., & Strauch, C. (1987). Integrating play in neurodevelopmental treatment. The American Journal of Occupational Therapy, 41(7), 421-426. Bledsoe, N. P. & Shephard, J. T. (1982). A study of reliability and validity of a preschool play scale. The American Journal of Occupational Therapy, 36(12), 783-788. Bundy, A. C. (1991). Play theory and sensory integration. In A .G. Fisher, E. A. Murray, & A. C. Bundy, (Eds.), Sensory Integration: Theory and Practice (pp. 48-68). Philadelphia: F.A. Davis. Bundy, A. C. (1993). Assessment of play and leisure: Delineation of the problem. American Journal of Occupational Therapy, 47, 217-222. Bundy, A. C., (1997). Play and playfulness: What to look for. In D. Parham & L. Fazio (Eds.). Play in Occupational Therapy for Children. St. Louis: Mosby-Year Book, Inc. Connolly, J. A., & Doyle, A. (1984). Relation of social fantasy play to social competence in preschoolers. Developmental Psychology, 20(5), 797-806. Exner, C. (1992). In-hand manipulation skills. In J. Case-Smith & C. Pehoski (Eds.). Development of Hand Skills in Children, Rockville, MD: American Occupational Therapy Association. Fagard, J., & Jacquet, A. (1989). Onset of bimanual coordination and symmetry versus asymmetry of movement. Infant Behavior and Development, 12, 229-235. Fenson, L., Kagan, J. & Kersley, R.B. (1976). The developmental progression of manipulative play the first two years. Child Development, 47, 232-244. Florey, L. (1981). Studies of play: Implications of growth, development, and for clinical practice. The American Journal of Occupational Therapy, 35, 519-524. Harrison, H., & Kielhofner, G. (1986). Examining the reliability and validity of the preschool play scale with handicapped children. American Journal of Occupational Therapy, 40(3), 167-173. Knox, S. (1997). Development and current use of the Knox Preschool Play Scale. In D. Parham & L. Fazio (Eds.) Play in Occupational Therapy for Children. St. Louis: Mosby-Year Book, Inc. McHale, S. M. & Olley, J. G. (1982). Using play to facilitate the social development of handicap children. Topics in Early Childhood Special Education, 2(3), 76-86. Mindes, G. (1982). Social and cognitive aspects of play in young handicapped children. Topics in Early Childhood Special Education, 2(3), 39-65. Morrison, C. D., Bundy, A. C., & Fisher, A. G. (1991). The contribution of motor
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skills and playfulness to the play performance of preschoolers. The American Journal of Occupational Therapy, 45 (8), 687-694. Parham, D. & Primeau, L. (1997). Play and occupational therapy. In D. Parham & L. Fazio (Eds.). Play in Occupational Therapy for Children. St. Louis: Mosby-Year Book, Inc. Park, S., Fisher, A. G. Velozo, C. A. (1994). Using the Assessment of Motor and Process Skills to compare occupational performance between clinic and home settings. American Journal of Occupational Therapy, 48(8), 697-709. Phillips, R. D., & Sellito, V. A. (1990). Preliminary evidence on emotions expressed by children during solitary play. Play and Culture, 3, 79-90. Rastall, G., & Magill, J. (1994). Play and Preschool children with autism. The American Journal of Occupational Therapy, 48(2), 113-120.
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