Australian Occupational Therapy Journal (2014) 61, 259–267
doi: 10.1111/1440-1630.12118
Research Article
Playfulness and prenatal alcohol exposure: A comparative study Jordan Louise Pearton,1,2 Elelwani Ramugondo,1 Lizahn Cloete1 and Reinie Cordier3,4 1 Occupational Therapy Division, Department of Health and Rehabilitation Sciences, University of Cape Town, Cape Town, South Africa, 2Oxford University Hospitals NHS Trust, London, UK, 3School of Occupational Therapy and Social Work, Curtin University, Perth, Western Australia, Australia and 4School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, Queensland, Australia
Background/aim: South Africa carries a high burden of alcohol abuse. The effects of maternal alcohol consumption during pregnancy are most pronounced in poor, rural communities. Earlier research suggests that children with prenatal alcohol exposure have poor social behaviour; however, to date, no research has investigated their playfulness. This study investigated the differences in playfulness of children with and without prenatal alcohol exposure. Methods: Grade one learners with a positive history of prenatal alcohol exposure (n = 15) and a reference group without a positive history of prenatal alcohol exposure (n = 15) were filmed engaging in free play at their schools. The Test of Playfulness was used to measure playfulness from recordings. Data were subjected to Rasch analysis to calculate interval level measure scores for each participant. The overall measure scores and individual Test of Playfulness social items were subjected to paired samples t-tests to calculate if significant differences existed between the groups. Results: Children with prenatal alcohol exposure had a significantly lower mean overall playfulness score than the reference group (t = 2.51; d.f. = 28; P = 0.02). Children with prenatal alcohol exposure also scored significantly lower than the reference group on 5 of the 12 Test of Playfulness items related to social play.
Jordan Louise Pearton MSc (OccTher), BSc (OccTher); Masters Student. Elelwani Ramugondo PhD (OccTher), MSc (OccTher), BSc (OccTher); Head of Division. Lizahn Cloete PhD; Lecturer. Reinie Cordier PhD; Associate Professor. Correspondence: Associate Professor Reinie Cordier, School of Occupational Therapy and Social Work, Curtin University, Perth, WA 6845, Australia. Email: reinie.cordier@ curtin.edu.au Accepted for publication 21 January 2014. © 2014 Occupational Therapy Australia
Conclusions: This research suggests that children with prenatal alcohol exposure are more likely to experience poorer overall quality of play, with particular deficits in social play. Considering play is a child’s primary occupation, this finding becomes pertinent for occupational therapy practice, particularly in post-apartheid South Africa, where high prenatal alcohol exposure prevalence rates are couched within persistent socio-economic inequalities. KEY WORDS foetal alcohol syndrome, poverty, psychological, resilience, rural health, socio-economic status.
Introduction South Africa is a country marked by extreme inequalities across livelihoods, access to public services and standards of living (National Planning Commission, 2011). These inequalities are exacerbated in some rural areas by high unemployment rates, a poor quality of education, inadequate infrastructure and an ailing public health system. Although the crippling impact of high HIV/AIDS prevalence rates on the public health-care system is well-documented, the devastating effect of alcohol abuse has yet to receive adequate attention (National Planning Commission). South Africa has high levels of risky drinking behaviour patterns (Pelzer & Ramlagan, 2009), including the highest recorded prevalence rates of foetal alcohol spectrum disorders (FASD) in the world, peaking at 68–89/ 1000 in some rural areas (Rendall-Mkosi et al., 2008). The legacy of prenatal alcohol exposure (PAE) in South Africa spans back to the 1700s when Europeans began wine farming in the Cape (McKinstry, 2005). To save costs, farmers paid their workers a portion of their wages in alcohol. This system became known as the ‘dop’ system, and resulted in local communities staying trapped in cycles of poverty and alcohol dependence. Although the system has long since been abolished, a
260 culture of alcoholism remains in some communities across the centuries (Cloete, 2012; McKinstry). In addition to the burden of alcohol abuse, a recent survey involving school principals from poor rural communities in the Western Cape highlighted their concerns regarding the impacts of high levels of poverty, unemployment and crime on learners’ development and educational outcomes (de Villers et al., 2012). The principals reported that poorly resourced rural schools struggled to engage parents and communities in school governance, particularly in addressing limited sports facilities and playground equipment with school playgrounds described as consisting mostly of sand and rocks. FASD is an umbrella term describing the range of a spectrum of physical, mental, behavioural and/or learning disabilities which are caused by maternal alcohol consumption during pregnancy (Murthy, Kudlur, George & Mathew, 2009). The term FASD is thus not intended for use as a clinical diagnosis, but rather a description of a spectrum of the consequences of PAE (Astley & Clarren, 2000). Alcohol is a known teratogen which easily crosses the placenta and can interfere with the normal growth and development of the foetus (Woods, 2002). PAE can lead to the development of FASD and a range of primary and secondary disabilities, and has profound socio-economic implications for the families and communities struggling with alcohol abuse (McKinstry, 2005; Rasmussen, Pei, Manji, Loomes & Andrew, 2009). Although PAE poses vast social, educational and health challenges to South Africa (Pienaar & Molteno, 2010), many professionals are not sufficiently trained to identify the conditions related to PAE (May et al., 2009). As such, many of the underlying occupational determinants associated with PAE are under-diagnosed in clinical settings (Cloete, 2012). Although some research is directed towards prevention, South Africa is faced with the reality of current generations of people with FASD who are not adequately afforded the opportunity to develop to their fullest potential (Pienaar & Molteno). Children affected by PAE have been shown to be at risk of a wide range of neurobehavioural problems (Carr, Agnihotri & Keightley, 2010; Urban et al., 2008). The majority of neurobehavioural problems relate to higher order cognitive functions, such as the ability to reason and problem-solve, as well as behavioural problems related to poor social skills. These neurobehavioural characteristics first become noticeable between the ages from six to seven years, the same age when children begin to construct concrete friendship circles and start to play ‘games with rules’. Thus far, research on the effects on play of the neurobehavioural problems associated with PAE has been limited to the assessment of play in infants and rats exposed to alcohol prenatally – both of which were found to be significantly less skilled in their ability to play than their matched
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counterparts (Kelly, Day & Streissguth, 2000; Molteno, Jacobson, Carter & Jacobson, 2010). Play is the primary occupation of children (Parham, 2008). Occupational therapists traditionally used play as a means to understand and improve the functional outcomes of children with a broad range of disabilities (Parham). Recent developments in occupational therapy have seen the profession move towards an occupational perspective of play, where play as an occupation is the outcome measured (Parham). Cognisant of the emerging occupational perspective of play, Skard and Bundy (2008) refined their concept of ‘playfulness’. They define playfulness as a child’s disposition to play, which remains constant over time and relates to a child’s ability to cope in later life (Skard & Bundy). The construct of playfulness comprises four fundamental elements: intrinsic motivation; internal control; the freedom to suspend reality; and framing (Skard & Bundy). These elements occur on a continuum and, when viewed in context, identify a child’s playfulness profile. Although play often seems to be referring to the ‘doing’ of play, playfulness points to the very ‘being’ of play (Royeen, 1997). Playfulness is a key aspect of play to explore in children with impairments, as it focuses on the quality of play and the adaptability and coping mechanisms of a child, regardless of ability (Hamm, 2006). Given the importance of play in childhood, the United Nations has recognised play as a basic human right. Participating in play is accepted to fundamentally protect children’s freedom to explore, discover, and interact with their physical and social environments (David, 2006). An occupational justice approach promotes the vision of an equitable society in which everyone has the opportunities and rights to participate in occupations of their choice to achieve their highest potential (Townsend & Wilcock, 2004). This should include play as the main occupation of childhood (Parham, 2008). Research has begun to explore how occupational therapists can promote occupational justice by creating and enhancing play opportunities for children. A study by Bundy et al. (2008) showed how broad environmental adaptations – such as positioning inexpensive play materials on a school playground – can significantly improve children’s playfulness. An inability to play well with others can lead to children developing a negative self-concept and becoming socially isolated (Greene, 1997). Furthermore, play in the social context of peer-to-peer interactions, hereafter termed social play, is the central medium through which children learn and practise the social skills and adaptive behaviours that support them throughout life (Greene). Studies have revealed that children who have been prenatally exposed to alcohol have poor social behaviour (Kelly et al., 2000). However, to date, no research has examined the playfulness of children who have been prenatally exposed to alcohol. In the present study, the
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Test of Playfulness (ToP) was used to test the following hypotheses: Hypothesis 1: The mean overall ToP measure score of children who have been prenatally exposed to alcohol will be significantly lower than that of children not prenatally exposed to alcohol.
Hypothesis 2: The mean scores of children who have been prenatally exposed to alcohol will be significantly lower than those of children not prenatally exposed to alcohol on items that reflect the social dimensions of play.
Autism or Cerebral Palsy. Previous studies have shown that these other disabilities or illnesses can affect children’s playfulness (Hamm, 2006; Okimoto, Bundy & Hanzik, 2000).
Group 2: Reference group This group included 15 children who did not have a history of PAE. No history of PAE was confirmed by parents or guardians during a semi-structured interview discussing the children’s developmental history. The same exclusion criteria were used for this group as were used for the group with PAE. The demographic information of the participants can be found in Table 1.
Instruments
Method
ToP
Participants
The ToP (version four) was used to measure the children’s playfulness. The ToP is designed to assess the playfulness of children and adolescents between the ages of six months and 18 years (Skard & Bundy, 2008). Scores are recorded on the ToP protocol sheet after 15 minutes of free play is observed. The ToP comprises of 30 items that are rated on a four-point scale and which can be scored directly or through the use of video-recording (Skard & Bundy, 2008). Each score reflects the extent (0 = rarely/never, 3 = almost always), intensity (0 = not, 3 = highly) or skilfulness (0 = unskilled, 3 = highly) of play behaviours outlined by the ToP (O’Brien & Shirley, 2001; Skard & Bundy). Space is provided alongside each item on the scoring sheet for the raters to comment on any behaviours or observations made. The ToP has been found to have high inter-rater reliability (96% of raters have met the assumptions of the Rasch model) and moderate test–retest reliability (interclass correlation of 0.67 at P < 0.01) (Brentnall, Bundy & Kay, 2008). Bundy, Nelson, Metzger and Bingaman (2001) report that the ToP has strong construct validity (98% of respondents and 93% of the items conform to the Rasch expectations). Furthermore, the ToP has been found to be valid across cultural groups and sexes, as well as among children with disabilities (Okimoto et al., 2000; Skard & Bundy, 2008).
Thirty grade one children aged between six and seven years participated in the study. The children were divided into two groups: group 1 consisted of children who had positive histories of PAE whereas group 2 consisted of typically developing children with no history of PAE. This age group was deemed most appropriate to explore how children with PAE approach social play, as it is the age in which this aspect of play comes to the fore, as well as the age that the neurobehavioural problems associated with PAE can be more easily observed (Greene, 1997; Sood et al., 2001). Afrikaans was the first language of all participants. Participants attended four schools located within a rural municipality in the Western Cape of South Africa; a geographical area that has been identified as having high PAE prevalence rates. The local education department assisted with identifying schools that were be matched on socio-economic status and play contexts.
Group 1: Children with PAE This group included 15 children who had positive histories of PAE. A history of PAE was obtained from one of their parents or guardians during a semi-structured interview discussing their child’s developmental history. To be included in the PAE group, participants needed to have a history of minimal to heavy PAE, as research has indicated that any amount of PAE can increase the chance of disruptive behaviour (Sood et al., 2001). Children were excluded from the study if they had histories of exposure to other drugs in utero, except nicotine, because previous research has indicated that the majority of South African mothers who consume alcohol when pregnant have been shown to smoke prenatally (Urban et al., 2008). Children were also excluded from the study if they currently or previously received treatment for play or socio-behavioural problems. Furthermore, children were excluded if they had known major neurodevelopmental or psychiatric disorders, such as
Background information questionnaire A questionnaire was used to determine which children met the inclusion and exclusion criteria as well as for inter-group comparisons on demographic information. The questionnaire was modelled on a history-taking questionnaire the primary researcher had developed previously while working with children at risk for PAE. It was tested and refined during the pilot study, prior to being administered for the main study. Questions were designed to elicit participants’ demographic information, birth history, medical history, early childhood development and social situation. © 2014 Occupational Therapy Australia
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TABLE 1: Comparison of the prenatal alcohol-exposed group and the reference group biographical information PAE group (n = 15) Gender n (%) Men Women Age Mean (SD) Custodian n (%) Parent Guardian Years in grade 1 n (%) 1st year Repeat Alcohol intake n (%)† Non Minimal Moderate Heavy Exposure to nicotine n (%) Smoking Non-smoking Unknown
Reference group (n = 15)
Statistic
P-value
Pearson v2 = 0
1.00
t = 1.19
0.24
8 (53.3) 7 (46.7)
7 (46.7) 8 (53.3)
7.05 (0.50)
6.81 (0.58)
11 (73.3) 4 (26.7)
15 (100) 0 (0)
Pearson v2 = 4.62
0.03*
10 (66.7) 5 (33.3)
14 (93.3) 1 (6.7)
Pearson v2 = 3.33
0.07*
15 0 0 0
–‡
0 5 5 5
(0) (33.3) (33.3) (33.3)
9 (60.0) 5 (33.3) 1 (6.7)
(100) (0) (0) (0)
Pearson v2 = 10.64
1 (6.7) 14 (93.3) 0 (0)
–‡
0.00*
*Significant at P < 0.05. †Alcohol intake is classified in units of alcohol equal to 10 mL of absolute alcohol (AA): minimal (< 5 units AA/week); moderate (5–10 units AA/week or binges 5–10 units AA/episode); heavy (> 10 units AA/week or binges > 10 units AA/episode) (Croxford & Viljoen, 1999). ‡Unable to calculate statistics for alcohol intake due to lack of cell density.
Procedure Ethics approval was granted by the University of Cape Town’s Human Research Ethics Committee. Permission was granted by the Western Cape Education Department to approach the schools involved in the study and thereafter school principals granted permission for their schools to take part in the study. Participant information letters and consent forms were sent to the parents/ guardians of all the grade one learners. Interviews were conducted (in person or telephonically) with the parents/guardians who gave consent and were contactable (n = 77; 11.9%). Of those contacted, 13.0% (n = 10) were unable to participate due to exclusion criteria. Of the remaining participants, 15 children met the inclusion criteria for PAE; parents/guardians were asked for permission for their child to be included in the study. Learner assent was obtained before commencing with data collection. Data were collected by video-recording 15 minute observations of each of the participants engaging in free play on their school playground during break time. Approximately 14 hours were required to complete © 2014 Occupational Therapy Australia
filming. A research assistant who was familiar with the context and use of recording equipment was hired to assist with the filming. Some degree of responder bias was expected due to the novelty of being exposed to film equipment in the lower socio-economic areas in which the schools were located. However, most of the responder bias was observed to wear off approximately five minutes after filming began. It was noted that the grade one learners scarcely seemed to notice that they were being filmed, whereas the older children on the playground appeared to be more interested in the filming that took place. All the video tapes were mixed and divided into three groups of 10, before being given to three trained and calibrated raters of the ToP for scoring. The raters were blinded to the identification of which child had a history of PAE, but not to the purpose of the study.
Data analysis To attain interval level scores for each participant, raw ToP scores were subjected to Rasch analysis using the Facets program (version 3.62.0; http://www.winsteps.com). Prior to further calculations, however, the goodness-of-fit
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statistics for people and items were examined to ensure that they were within an acceptable range set a priori (MnSq < 1.4; standardised value < 2; Bond & Fox, 2007); this ensured that the measure scores were true interval level measures. The resulting ToP measure scores and participants’ biographical information was then entered into SAS/JMP (version 10; SAS Institute, Cary, NC, USA). The data were verified by performing a frequency analysis upon nominal/ordinal variables and measures of location and dispersion, as well as the distributions of continuous data. Erroneous/anomalous data were identified by inspection and corrected. No validation was performed because the ToP is a standardised and calibrated instrument. Descriptive analysis was performed on the PAE group and the reference group to determine similarities and differences between them. Chi-squared tests were performed on categorical variables and t-tests were performed on the continuous variables. To investigate whether or not there was a difference in the overall playfulness scores between the PAE group and reference group, the ToP measure scores were subjected to a paired samples t-test. To investigate differences in scores on the individual ToP items, data were analysed and either subjected to parametric or non-parametric tests. In cases where the data were normally distributed, the scores were analysed using the one-way ANOVA test (Hicks, 2009). Non-parametric statistics were used when the data were not normally distributed (i.e. Pearson v2). All significance levels were set at P < .05.
Results Before the data could be analysed, person response validity and item validity were investigated. Unexpected ratings on individual items occurred on 30 of the 930 (3.23%) items scored in the study. Unexpected scores occurred when the participants scored low on
easy items and/or when they scored high on more difficult items. Most of the higher-than-expected scores were recorded on the items ‘clowns/jokes’ and ‘mischief/ teasing’, whereas the majority of the lower-thanexpected scores were recorded on the items ‘interacts with objects’ and ‘safety’. The biographical profiles of the groups were then analysed to determine how well matched the groups were. Results can be found in Table 1. The PAE group and the reference group were found to be similar with regard to their ages and gender. However, significantly more PAE participants lived with guardians (rather than their biological parents) compared with the reference group. Significantly more PAE participants were also found to be repeating grade 1. Mothers of the PAE group reported drinking varying amounts of alcohol during their pregnancies. Almost one-third of all participants were exposed to nicotine prenatally and the majority of these participants belonged to the PAE group.
Hypothesis 1 The PAE group were found to have significantly lower overall mean playfulness scores than the reference group (t = 2.51; d.f. = 28; P = 0.02). The research hypothesis was therefore accepted.
Hypothesis 2 Items related to social play in the ToP are defined as those that require two or more children to interact in order for the item to be scored (Cordier, Bundy, Hocking & Einfeld, 2009). The PAE group was found to have scored significantly lower on 5 of the 12 ToP items related to social play than their reference group counterparts. These items were the extent to which participants clowned or joked with others; the skill with which participants clowned or joked with others; the intensity of the participants’ social play; the skill with which
TABLE 2: Significant scores related to social playfulness
Item
Description
Engages in Social Play (Intensity)
The depth of the player’s interactions with playmates The skill with which the player interacts with playmates Ease with which the player initiates a new activity Proportion of time when players engage clowning and joking The ease or cleverness with which a player clowns or jokes
Engages in Social Play (Skill) Initiates play with others (Skill) Clowns or jokes (Extent) Clowns or jokes (Skill)
PAE mean
Reference mean
t-test
P-value
1.47
2.20
7.00
0.01*
1.40
2.00
4.85
0.04*
0.77 0.33
1.80 1.00
8.47 7.00
0.01* 0.01*
0.62
1.14
5.33
0.03*
*Significant at P < 0.05. © 2014 Occupational Therapy Australia
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participants engaged in social play; and the skill with which participants initiated play (see Table 2 for item descriptions). There was no significant difference in the following 7 of the 12 ToP items related to social play: the skill with which participants negotiated with others to have their needs met; the extent to which participants engaged in social play; the skill with which participants supported the play of others; the skill with which participants entered a group already engaged in an activity; the skill with which participants shared; the extent to which participants gave readily understandable cues; and the skill with which participants responded to other’s cues (see Table 3 for item descriptions). In addition, children with PAE were found to score significantly lower than the reference group on two other items not exclusively related to social play, namely ‘Transitions’ from one play activity to another (t = 7.74; d.f. = 1; P = 0.01), and ‘Modifies’ activity to maintain challenge or make the activity more fun (t = 5.60; d.f. = 1; P = 0.03).
Discussion PAE is rife in South Africa’s impoverished rural areas. It is known to cause a multitude of neurobehavioural problems, which could negatively affect a child’s ability to engage in the occupation of play. This study presents research on the implications of PAE on children’s disposition to play: their playfulness. The primary research hypothesis was supported as results indicated that the PAE group performed significantly worse on their overall playfulness scores than the
reference group. Although causality cannot be determined, the result recognises a link between PAE and lower levels of playfulness. This is a new finding in research regarding PAE and suggests that children with PAE are more likely to experience a lowered disposition to play than their non-PAE counterparts. This research is of particular relevance when play is recognised as a child’s primary occupation and in light of persistently high levels of PAE in South Africa. Interestingly, children with PAE were found to score similar to children with no history of PAE on more than half of the ToP items related to social play. These items mainly relate to the fourth element of playfulness: framing (i.e. giving and responding to cues). Framing requires an understanding of social rules and gives players the possibility to support their playmates. These findings suggest that children with PAE have the potential to navigate social play contexts for inclusion, as well as an ability to support the play of others. Although these children may lack in many other areas, such as the ability to alter objective reality by stretching the rules through clowning or joking with others, they clearly demonstrate play skills that could inform a strengths-based approach when designing interventions that aim to improve the social play skills of children with PAE. Analysis of the participants’ biographical data identified that significantly more PAE participants lived with guardians (rather than their biological parents) compared to the reference group. This result echoes local and international research that has found that children born with PAE and its associated conditions are more likely than their peers to be placed in foster care (Toutain & Lejeune, 2008), owing to unstable family
TABLE 3: Non-significant scores related to social playfulness PAE mean
Reference mean
t-test
P-value
Finesse with which players ask for what they need Proportion of time during which the player interacts with others Ease with which players support play of other Ease with which the player becomes a part of the group already engaged in an activity Ease with which players share
1.00
1.40
1.60
0.22
1.40
2.13
3.85
0.06
1.07
1.47
1.80
0.19
0.93
1.53
2.68
0.11
1.00
1.46
1.12
0.28
Proportion of time during which players give clear messages Skill with which the child acts in accord with others’ play cues
1.47
1.73
0.72
0.40
1.53
1.80
1.23
0.28
Item
Description
Negotiates with others to have needs met (Skill) Engages in social play (Extent) Supports the play of others (Skill) Enters a group already engaged in an activity (Skill) Shares (toys, equipment, friends, ideas) (Skill) Gives readily understandable cues (facial, verbal, body) (Extent) Responds to other’s cues (Skill)
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environments and continued alcohol abuse by their mothers (Streissguth et al., 1991). In addition, significantly more PAE participants were found to have repeated grade 1. The third of children in the PAE group who repeated grade one was higher than the national average of 7.2% (Department of Basic Education, 2011). In comparison, the reference group at 6.7% were only marginally lower than the national average. This finding is supported by reports that deficits in social and intellectual functioning in children exposed to alcohol prenatally often lead to difficulties in school (Pienaar & Molteno, 2010). More research is required to ascertain the exact relationship between early grade retention and PAE for this population. These results suggest that although all participants faced daily struggles with poverty, PAE participants were faced with additional family problems and learning difficulties. Research has demonstrated that playfulness scores correlate strongly with scores of adaptability and coping, as both constructs share a thread of flexibility (Hess & Bundy, 2003). Thus researchers have suggested that occupational therapists working with children who face adversity consider providing interventions tailored to improve their playfulness, in aid of helping them develop resilience. Occupational therapists are experts at assisting marginalised children with health conditions to play optimally (Skard & Bundy, 2008) and are skilled at creating or adapting environments that support alternative ways of playing. Occupational therapists have a responsibility to ensure occupational justice (Townsend & Wilcock, 2004) so that children with PAE who are found to have poorer playfulness scores, receive the opportunities to engage in play that is culturally appropriate and which promotes health and their overall physical, emotional, cognitive and social development. Although playfulness is a stable trait that remains constant over time, studies have revealed that occupational therapy interventions can significantly improve the playfulness scores of both children with disabilities as well as typically developing children (Bundy et al., 2008; O’Brien & Shirley, 2001; Okimoto et al., 2000). South Africa has a health-care service in crisis and although policies provide a mandate for occupational therapy services to be made available to all citizens, occupational therapy services still function as a luxury in many health, education and community settings. This begs the question of where to position occupational therapy services in order to improve the playfulness of children with PAE? Considering the shortage of occupational therapists in rural contexts, sustainable interventions, such as Bundy et al.’s (2008) proposal to use environmental adaptation to improve children’s playfulness, could be considered. Children growing up in low resource rural communities often lack playground facilities and equipment (de Villers et al., 2012), thus interventions should aim to
promote occupational justice by providing cost-effective and culturally relevant play opportunities on school playgrounds. Interventions could also focus on utilising the strengths of children born with PAE. For instance, as children with PAE equally sought out social interaction during play, ensuring regular typically developing peers are included in the intervention is likely to create a motivating environment. In turn, this will enhance their engagement in the intervention process in order to facilitate the development of resilience. However, given the shortage of occupational therapy services, school staff may require training to assist in implementing such interventions in the school environment.
Limitations A descriptive analytical study design was used, therefore causality could not be assumed. The small and non-randomised sample limits the generalisability of the findings to other PAE populations. Children were only filmed outdoors in their school playground. Although the ToP does not require that children be filmed in both their school and home contexts, it is preferred as it could potentially give a more thorough observation of children’s playfulness.
Conclusions and implications for research This study described the playfulness of a small group of children with a positive history of PAE, who reside in a rural area in the Western Cape, South Africa. The results suggest that children with PAE are more likely to have a lowered disposition to play than children without PAE. Children who are prenatally exposed to alcohol can therefore be considered to be more likely to experience a lowered quality of play and are more likely to struggle with some elements of social play than children not exposed to alcohol in utero. Considering the shortage of occupational therapists in South Africa and the prevalence of PAE, occupational therapists are challenged to engage with creative and sustainable interventions that occur at the level of the environment and are best suited to help the majority of the individuals and communities living with PAE. This research has implications for future research. Firstly, the study could be replicated with a greater sample size spanning a variety of different communities in South Africa, to evaluate whether the children with PAE score poorly on the same items in different contexts. A larger sample size would also allow for between-group comparisons on how the amount of PAE relates with playfulness scores. Future research could also focus on using the ToP with PAE children in both indoor and outdoor environments at home and within the community, so as to determine whether differences in playfulness scores exist in different contexts. Research utilising comprehensive social skills assessments could be undertaken to further explore the social skills of children with PAE who reside in a rural © 2014 Occupational Therapy Australia
266 African context. The Test of Environmental Supportiveness (Skard & Bundy, 2008) could be used on the school playgrounds to investigate the impact of the environment on children’s playfulness in more depth. Research could also focus on exploring the link between playfulness levels and adversity in the South African context. Future research could explore the link between the playfulness and resilience of PAE children in South African communities.
Acknowledgements The authors would like to thank Professor Anita Bundy for her help in the use of the Test of Playfulness, as well as the Kidzpositive occupational therapists who assisted with the scoring of the tapes. Gratitude is also due to the Western Cape Education Department and especially to the research participants.
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Department of Basic Education. (2011). Report on dropout and learner retention strategy to portfolio committee on education. Department of Basic Education: South Africa. Greene, S. (1997). Playmates: Social interaction in early and middle childhood. In: B. Chandler (Ed.), The essence of play: A child’s occupation (pp. 131–157). Bethesda, MD: American Occupational Therapy Association. Hamm, E. (2006). Playfulness and the environmental support of play in children with and without developmental disabilities. The Occupational Therapy Journal of Research: Occupation, Participation and Health, 26, 88–96. Hess, L. & Bundy, A. (2003). The association between playfulness and coping in adolescents. Physical and Occupational Therapy in Paediatrics, 23, 5–17. Hicks, C. (2009). Research methods for clinical therapists: Applied project design and analysis. Edinburgh: Churchill Livingston Elsevier. Kelly, S., Day, N. & Streissguth, A. (2000). Effects of Prenatal Alcohol Exposure on social behaviour in humans and other species. Neurotoxicology and Teratology, 22, 143–149. May, P., Gossage, P., Kalberg, W., Robinson, L., Buckley, D., Manning, M. et al. (2009). Prevalence and epidemiologic characteristics of FASD from various research methods with an emphasis on recent in-school studies. Developmental Disabilities Research Reviews, 15, 176–192. McKinstry, J. (2005). Using the past to step forward: Fetal Alcohol Syndrome in the Western Cape Province of South Africa. American Journal of Public Health, 95, 1097–1099. Molteno, C., Jacobson, S., Carter, R. & Jacobson, J. (2010). Infant symbolic play as an early indicator of fetal alcohol-related deficit. The Official Journal of the International Society on Infant Studies, 15, 586–607. Murthy, P., Kudlur, S., George, S. & Mathew, G. (2009). A clinical overview of Fetal Alcohol Syndrome. Addictive Disorders and their Treatment, 8, 1–12. National Planning Commission. (2011). Diagnostic overview. Pretoria: Department of the Presidency. O’Brien, J. & Shirley, R. (2001). Does playfulness change over time? A preliminary look using the test of playfulness The Occupational Therapy Journal of Research, 21, 132– 140. Okimoto, A., Bundy, A. & Hanzik, J. (2000). Playfulness in children with and without disability: Measurement and intervention. American Journal of Occupational Therapy, 54, 73–82. Parham, L. (2008). Play and occupational therapy. In: L. Parham & L. Fazio (Eds.), Play in occupational therapy for children (2nd ed., pp. 3–39). St Louis, MO: Mosley Elsevier. Pelzer, K. & Ramlagan, S. (2009). Alcohol use trends in South Africa. Journal of Social Science, 18, 1–12. Pienaar, M. & Molteno, C. (2010). A self psychology perspective on the formulation and treatment of psychopathology in children with Foetal Alcohol Spectrum Disorders. Psychoanalytic Psychotherapy in South Africa, 18, 58–80. Rasmussen, C., Pei, J., Manji, S., Loomes, C. & Andrew, G. (2009). Memory strategy development in children with
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Foetal Alcohol Spectrum Disorders. Developmental Neurorehabilitation, 12, 207–214. Rendall-Mkosi, K., London, L., Adnams, C., Morojele, N., McLoughlin, J.-A. & Goldstone, C. (2008). Fetal Alcohol Spectrum in South Africa: Situational and gap analysis. Pretoria: United Nations Children’s Fund South Africa, Medical Research Council, University of Cape Town, and University of Pretoria. Royeen, C. (1997). Play as occupation and as an indicator of health. In: B. Chandler (Ed.), the essence of play: A child’s occupation (pp. 1–16). Bethesda, MD: American Occupational Therapy Association. Skard, G. & Bundy, A. (2008). Test of playfulness. In: L. Parham & L. Fazio (Eds.), Play in occupational therapy for children (2nd ed., pp. 71–93). St. Louis, MO: Mosley Elsevier. Sood, B., Delaney-Black, V., Covington, C., Nordstrom-Klee, J., Ager, J., Templin, T. et al. (2001). Prenatal Alcohol Exposure and childhood behaviour at age 6 to 7 years: I dose-response effect. Pediatrics, 108, 33–42. Streissguth, A., Aase, J., Clarren, S., Randels, S., LaDue, R. & Smith, D. (1991). Fetal Alcohol Syndrome in
267 adolescents and adults. The Journal of the American Medical Association, 265, 1961–1967. Toutain, S. & Lejeune, C. (2008). Family management of infants with fetal alcohol syndrome or fetal alcohol spectrum disorders. An International Journal of Obstetrics and Gynaecology, 20, 425–436. Townsend, E. & Wilcock, A. (2004). Occupational justice and client-centred practice: A dialogue in progress. Canadian Journal of Occupational Therapy, 71, 75–87. Urban, M., Chersich, M., Fourie, L.-A., Chetty, C., Olivier, L. & Viljoen, D. (2008). Fetal Alcohol Syndrome among Grade 1 schoolchildren in Northern Cape Province: Prevalence and risk factors. South African Medical Journal, 98, 877–882. de Villers, A., Steyn, N., Draper, C., Fourie, J., Barkhulzen, G., Lombard, C. et al. (2012). “Healthkick”: Formative assessment of the health environment in low-resource primary schools in the Western Cape Province of South Africa. Biomedicalcentral Public Health, 12, 794–804. Woods, D. (2002). Birth defects manual. Cape Town: Perinatal Education Trust.
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doi: 10.1111/1440-1630.12118
Research Article
Playfulness and prenatal alcohol exposure: A comparative study Jordan Louise Pearton,1,2 Elelwani Ramugondo,1 Lizahn Cloete1 and Reinie Cordier3,4 1 Occupational Therapy Division, Department of Health and Rehabilitation Sciences, University of Cape Town, Cape Town, South Africa, 2Oxford University Hospitals NHS Trust, London, UK, 3School of Occupational Therapy and Social Work, Curtin University, Perth, Western Australia, Australia and 4School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, Queensland, Australia
Background/aim: South Africa carries a high burden of alcohol abuse. The effects of maternal alcohol consumption during pregnancy are most pronounced in poor, rural communities. Earlier research suggests that children with prenatal alcohol exposure have poor social behaviour; however, to date, no research has investigated their playfulness. This study investigated the differences in playfulness of children with and without prenatal alcohol exposure. Methods: Grade one learners with a positive history of prenatal alcohol exposure (n = 15) and a reference group without a positive history of prenatal alcohol exposure (n = 15) were filmed engaging in free play at their schools. The Test of Playfulness was used to measure playfulness from recordings. Data were subjected to Rasch analysis to calculate interval level measure scores for each participant. The overall measure scores and individual Test of Playfulness social items were subjected to paired samples t-tests to calculate if significant differences existed between the groups. Results: Children with prenatal alcohol exposure had a significantly lower mean overall playfulness score than the reference group (t = 2.51; d.f. = 28; P = 0.02). Children with prenatal alcohol exposure also scored significantly lower than the reference group on 5 of the 12 Test of Playfulness items related to social play.
Jordan Louise Pearton MSc (OccTher), BSc (OccTher); Masters Student. Elelwani Ramugondo PhD (OccTher), MSc (OccTher), BSc (OccTher); Head of Division. Lizahn Cloete PhD; Lecturer. Reinie Cordier PhD; Associate Professor. Correspondence: Associate Professor Reinie Cordier, School of Occupational Therapy and Social Work, Curtin University, Perth, WA 6845, Australia. Email: reinie.cordier@ curtin.edu.au Accepted for publication 21 January 2014. © 2014 Occupational Therapy Australia
Conclusions: This research suggests that children with prenatal alcohol exposure are more likely to experience poorer overall quality of play, with particular deficits in social play. Considering play is a child’s primary occupation, this finding becomes pertinent for occupational therapy practice, particularly in post-apartheid South Africa, where high prenatal alcohol exposure prevalence rates are couched within persistent socio-economic inequalities. KEY WORDS foetal alcohol syndrome, poverty, psychological, resilience, rural health, socio-economic status.
Introduction South Africa is a country marked by extreme inequalities across livelihoods, access to public services and standards of living (National Planning Commission, 2011). These inequalities are exacerbated in some rural areas by high unemployment rates, a poor quality of education, inadequate infrastructure and an ailing public health system. Although the crippling impact of high HIV/AIDS prevalence rates on the public health-care system is well-documented, the devastating effect of alcohol abuse has yet to receive adequate attention (National Planning Commission). South Africa has high levels of risky drinking behaviour patterns (Pelzer & Ramlagan, 2009), including the highest recorded prevalence rates of foetal alcohol spectrum disorders (FASD) in the world, peaking at 68–89/ 1000 in some rural areas (Rendall-Mkosi et al., 2008). The legacy of prenatal alcohol exposure (PAE) in South Africa spans back to the 1700s when Europeans began wine farming in the Cape (McKinstry, 2005). To save costs, farmers paid their workers a portion of their wages in alcohol. This system became known as the ‘dop’ system, and resulted in local communities staying trapped in cycles of poverty and alcohol dependence. Although the system has long since been abolished, a
260 culture of alcoholism remains in some communities across the centuries (Cloete, 2012; McKinstry). In addition to the burden of alcohol abuse, a recent survey involving school principals from poor rural communities in the Western Cape highlighted their concerns regarding the impacts of high levels of poverty, unemployment and crime on learners’ development and educational outcomes (de Villers et al., 2012). The principals reported that poorly resourced rural schools struggled to engage parents and communities in school governance, particularly in addressing limited sports facilities and playground equipment with school playgrounds described as consisting mostly of sand and rocks. FASD is an umbrella term describing the range of a spectrum of physical, mental, behavioural and/or learning disabilities which are caused by maternal alcohol consumption during pregnancy (Murthy, Kudlur, George & Mathew, 2009). The term FASD is thus not intended for use as a clinical diagnosis, but rather a description of a spectrum of the consequences of PAE (Astley & Clarren, 2000). Alcohol is a known teratogen which easily crosses the placenta and can interfere with the normal growth and development of the foetus (Woods, 2002). PAE can lead to the development of FASD and a range of primary and secondary disabilities, and has profound socio-economic implications for the families and communities struggling with alcohol abuse (McKinstry, 2005; Rasmussen, Pei, Manji, Loomes & Andrew, 2009). Although PAE poses vast social, educational and health challenges to South Africa (Pienaar & Molteno, 2010), many professionals are not sufficiently trained to identify the conditions related to PAE (May et al., 2009). As such, many of the underlying occupational determinants associated with PAE are under-diagnosed in clinical settings (Cloete, 2012). Although some research is directed towards prevention, South Africa is faced with the reality of current generations of people with FASD who are not adequately afforded the opportunity to develop to their fullest potential (Pienaar & Molteno). Children affected by PAE have been shown to be at risk of a wide range of neurobehavioural problems (Carr, Agnihotri & Keightley, 2010; Urban et al., 2008). The majority of neurobehavioural problems relate to higher order cognitive functions, such as the ability to reason and problem-solve, as well as behavioural problems related to poor social skills. These neurobehavioural characteristics first become noticeable between the ages from six to seven years, the same age when children begin to construct concrete friendship circles and start to play ‘games with rules’. Thus far, research on the effects on play of the neurobehavioural problems associated with PAE has been limited to the assessment of play in infants and rats exposed to alcohol prenatally – both of which were found to be significantly less skilled in their ability to play than their matched
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counterparts (Kelly, Day & Streissguth, 2000; Molteno, Jacobson, Carter & Jacobson, 2010). Play is the primary occupation of children (Parham, 2008). Occupational therapists traditionally used play as a means to understand and improve the functional outcomes of children with a broad range of disabilities (Parham). Recent developments in occupational therapy have seen the profession move towards an occupational perspective of play, where play as an occupation is the outcome measured (Parham). Cognisant of the emerging occupational perspective of play, Skard and Bundy (2008) refined their concept of ‘playfulness’. They define playfulness as a child’s disposition to play, which remains constant over time and relates to a child’s ability to cope in later life (Skard & Bundy). The construct of playfulness comprises four fundamental elements: intrinsic motivation; internal control; the freedom to suspend reality; and framing (Skard & Bundy). These elements occur on a continuum and, when viewed in context, identify a child’s playfulness profile. Although play often seems to be referring to the ‘doing’ of play, playfulness points to the very ‘being’ of play (Royeen, 1997). Playfulness is a key aspect of play to explore in children with impairments, as it focuses on the quality of play and the adaptability and coping mechanisms of a child, regardless of ability (Hamm, 2006). Given the importance of play in childhood, the United Nations has recognised play as a basic human right. Participating in play is accepted to fundamentally protect children’s freedom to explore, discover, and interact with their physical and social environments (David, 2006). An occupational justice approach promotes the vision of an equitable society in which everyone has the opportunities and rights to participate in occupations of their choice to achieve their highest potential (Townsend & Wilcock, 2004). This should include play as the main occupation of childhood (Parham, 2008). Research has begun to explore how occupational therapists can promote occupational justice by creating and enhancing play opportunities for children. A study by Bundy et al. (2008) showed how broad environmental adaptations – such as positioning inexpensive play materials on a school playground – can significantly improve children’s playfulness. An inability to play well with others can lead to children developing a negative self-concept and becoming socially isolated (Greene, 1997). Furthermore, play in the social context of peer-to-peer interactions, hereafter termed social play, is the central medium through which children learn and practise the social skills and adaptive behaviours that support them throughout life (Greene). Studies have revealed that children who have been prenatally exposed to alcohol have poor social behaviour (Kelly et al., 2000). However, to date, no research has examined the playfulness of children who have been prenatally exposed to alcohol. In the present study, the
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Test of Playfulness (ToP) was used to test the following hypotheses: Hypothesis 1: The mean overall ToP measure score of children who have been prenatally exposed to alcohol will be significantly lower than that of children not prenatally exposed to alcohol.
Hypothesis 2: The mean scores of children who have been prenatally exposed to alcohol will be significantly lower than those of children not prenatally exposed to alcohol on items that reflect the social dimensions of play.
Autism or Cerebral Palsy. Previous studies have shown that these other disabilities or illnesses can affect children’s playfulness (Hamm, 2006; Okimoto, Bundy & Hanzik, 2000).
Group 2: Reference group This group included 15 children who did not have a history of PAE. No history of PAE was confirmed by parents or guardians during a semi-structured interview discussing the children’s developmental history. The same exclusion criteria were used for this group as were used for the group with PAE. The demographic information of the participants can be found in Table 1.
Instruments
Method
ToP
Participants
The ToP (version four) was used to measure the children’s playfulness. The ToP is designed to assess the playfulness of children and adolescents between the ages of six months and 18 years (Skard & Bundy, 2008). Scores are recorded on the ToP protocol sheet after 15 minutes of free play is observed. The ToP comprises of 30 items that are rated on a four-point scale and which can be scored directly or through the use of video-recording (Skard & Bundy, 2008). Each score reflects the extent (0 = rarely/never, 3 = almost always), intensity (0 = not, 3 = highly) or skilfulness (0 = unskilled, 3 = highly) of play behaviours outlined by the ToP (O’Brien & Shirley, 2001; Skard & Bundy). Space is provided alongside each item on the scoring sheet for the raters to comment on any behaviours or observations made. The ToP has been found to have high inter-rater reliability (96% of raters have met the assumptions of the Rasch model) and moderate test–retest reliability (interclass correlation of 0.67 at P < 0.01) (Brentnall, Bundy & Kay, 2008). Bundy, Nelson, Metzger and Bingaman (2001) report that the ToP has strong construct validity (98% of respondents and 93% of the items conform to the Rasch expectations). Furthermore, the ToP has been found to be valid across cultural groups and sexes, as well as among children with disabilities (Okimoto et al., 2000; Skard & Bundy, 2008).
Thirty grade one children aged between six and seven years participated in the study. The children were divided into two groups: group 1 consisted of children who had positive histories of PAE whereas group 2 consisted of typically developing children with no history of PAE. This age group was deemed most appropriate to explore how children with PAE approach social play, as it is the age in which this aspect of play comes to the fore, as well as the age that the neurobehavioural problems associated with PAE can be more easily observed (Greene, 1997; Sood et al., 2001). Afrikaans was the first language of all participants. Participants attended four schools located within a rural municipality in the Western Cape of South Africa; a geographical area that has been identified as having high PAE prevalence rates. The local education department assisted with identifying schools that were be matched on socio-economic status and play contexts.
Group 1: Children with PAE This group included 15 children who had positive histories of PAE. A history of PAE was obtained from one of their parents or guardians during a semi-structured interview discussing their child’s developmental history. To be included in the PAE group, participants needed to have a history of minimal to heavy PAE, as research has indicated that any amount of PAE can increase the chance of disruptive behaviour (Sood et al., 2001). Children were excluded from the study if they had histories of exposure to other drugs in utero, except nicotine, because previous research has indicated that the majority of South African mothers who consume alcohol when pregnant have been shown to smoke prenatally (Urban et al., 2008). Children were also excluded from the study if they currently or previously received treatment for play or socio-behavioural problems. Furthermore, children were excluded if they had known major neurodevelopmental or psychiatric disorders, such as
Background information questionnaire A questionnaire was used to determine which children met the inclusion and exclusion criteria as well as for inter-group comparisons on demographic information. The questionnaire was modelled on a history-taking questionnaire the primary researcher had developed previously while working with children at risk for PAE. It was tested and refined during the pilot study, prior to being administered for the main study. Questions were designed to elicit participants’ demographic information, birth history, medical history, early childhood development and social situation. © 2014 Occupational Therapy Australia
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TABLE 1: Comparison of the prenatal alcohol-exposed group and the reference group biographical information PAE group (n = 15) Gender n (%) Men Women Age Mean (SD) Custodian n (%) Parent Guardian Years in grade 1 n (%) 1st year Repeat Alcohol intake n (%)† Non Minimal Moderate Heavy Exposure to nicotine n (%) Smoking Non-smoking Unknown
Reference group (n = 15)
Statistic
P-value
Pearson v2 = 0
1.00
t = 1.19
0.24
8 (53.3) 7 (46.7)
7 (46.7) 8 (53.3)
7.05 (0.50)
6.81 (0.58)
11 (73.3) 4 (26.7)
15 (100) 0 (0)
Pearson v2 = 4.62
0.03*
10 (66.7) 5 (33.3)
14 (93.3) 1 (6.7)
Pearson v2 = 3.33
0.07*
15 0 0 0
–‡
0 5 5 5
(0) (33.3) (33.3) (33.3)
9 (60.0) 5 (33.3) 1 (6.7)
(100) (0) (0) (0)
Pearson v2 = 10.64
1 (6.7) 14 (93.3) 0 (0)
–‡
0.00*
*Significant at P < 0.05. †Alcohol intake is classified in units of alcohol equal to 10 mL of absolute alcohol (AA): minimal (< 5 units AA/week); moderate (5–10 units AA/week or binges 5–10 units AA/episode); heavy (> 10 units AA/week or binges > 10 units AA/episode) (Croxford & Viljoen, 1999). ‡Unable to calculate statistics for alcohol intake due to lack of cell density.
Procedure Ethics approval was granted by the University of Cape Town’s Human Research Ethics Committee. Permission was granted by the Western Cape Education Department to approach the schools involved in the study and thereafter school principals granted permission for their schools to take part in the study. Participant information letters and consent forms were sent to the parents/ guardians of all the grade one learners. Interviews were conducted (in person or telephonically) with the parents/guardians who gave consent and were contactable (n = 77; 11.9%). Of those contacted, 13.0% (n = 10) were unable to participate due to exclusion criteria. Of the remaining participants, 15 children met the inclusion criteria for PAE; parents/guardians were asked for permission for their child to be included in the study. Learner assent was obtained before commencing with data collection. Data were collected by video-recording 15 minute observations of each of the participants engaging in free play on their school playground during break time. Approximately 14 hours were required to complete © 2014 Occupational Therapy Australia
filming. A research assistant who was familiar with the context and use of recording equipment was hired to assist with the filming. Some degree of responder bias was expected due to the novelty of being exposed to film equipment in the lower socio-economic areas in which the schools were located. However, most of the responder bias was observed to wear off approximately five minutes after filming began. It was noted that the grade one learners scarcely seemed to notice that they were being filmed, whereas the older children on the playground appeared to be more interested in the filming that took place. All the video tapes were mixed and divided into three groups of 10, before being given to three trained and calibrated raters of the ToP for scoring. The raters were blinded to the identification of which child had a history of PAE, but not to the purpose of the study.
Data analysis To attain interval level scores for each participant, raw ToP scores were subjected to Rasch analysis using the Facets program (version 3.62.0; http://www.winsteps.com). Prior to further calculations, however, the goodness-of-fit
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statistics for people and items were examined to ensure that they were within an acceptable range set a priori (MnSq < 1.4; standardised value < 2; Bond & Fox, 2007); this ensured that the measure scores were true interval level measures. The resulting ToP measure scores and participants’ biographical information was then entered into SAS/JMP (version 10; SAS Institute, Cary, NC, USA). The data were verified by performing a frequency analysis upon nominal/ordinal variables and measures of location and dispersion, as well as the distributions of continuous data. Erroneous/anomalous data were identified by inspection and corrected. No validation was performed because the ToP is a standardised and calibrated instrument. Descriptive analysis was performed on the PAE group and the reference group to determine similarities and differences between them. Chi-squared tests were performed on categorical variables and t-tests were performed on the continuous variables. To investigate whether or not there was a difference in the overall playfulness scores between the PAE group and reference group, the ToP measure scores were subjected to a paired samples t-test. To investigate differences in scores on the individual ToP items, data were analysed and either subjected to parametric or non-parametric tests. In cases where the data were normally distributed, the scores were analysed using the one-way ANOVA test (Hicks, 2009). Non-parametric statistics were used when the data were not normally distributed (i.e. Pearson v2). All significance levels were set at P < .05.
Results Before the data could be analysed, person response validity and item validity were investigated. Unexpected ratings on individual items occurred on 30 of the 930 (3.23%) items scored in the study. Unexpected scores occurred when the participants scored low on
easy items and/or when they scored high on more difficult items. Most of the higher-than-expected scores were recorded on the items ‘clowns/jokes’ and ‘mischief/ teasing’, whereas the majority of the lower-thanexpected scores were recorded on the items ‘interacts with objects’ and ‘safety’. The biographical profiles of the groups were then analysed to determine how well matched the groups were. Results can be found in Table 1. The PAE group and the reference group were found to be similar with regard to their ages and gender. However, significantly more PAE participants lived with guardians (rather than their biological parents) compared with the reference group. Significantly more PAE participants were also found to be repeating grade 1. Mothers of the PAE group reported drinking varying amounts of alcohol during their pregnancies. Almost one-third of all participants were exposed to nicotine prenatally and the majority of these participants belonged to the PAE group.
Hypothesis 1 The PAE group were found to have significantly lower overall mean playfulness scores than the reference group (t = 2.51; d.f. = 28; P = 0.02). The research hypothesis was therefore accepted.
Hypothesis 2 Items related to social play in the ToP are defined as those that require two or more children to interact in order for the item to be scored (Cordier, Bundy, Hocking & Einfeld, 2009). The PAE group was found to have scored significantly lower on 5 of the 12 ToP items related to social play than their reference group counterparts. These items were the extent to which participants clowned or joked with others; the skill with which participants clowned or joked with others; the intensity of the participants’ social play; the skill with which
TABLE 2: Significant scores related to social playfulness
Item
Description
Engages in Social Play (Intensity)
The depth of the player’s interactions with playmates The skill with which the player interacts with playmates Ease with which the player initiates a new activity Proportion of time when players engage clowning and joking The ease or cleverness with which a player clowns or jokes
Engages in Social Play (Skill) Initiates play with others (Skill) Clowns or jokes (Extent) Clowns or jokes (Skill)
PAE mean
Reference mean
t-test
P-value
1.47
2.20
7.00
0.01*
1.40
2.00
4.85
0.04*
0.77 0.33
1.80 1.00
8.47 7.00
0.01* 0.01*
0.62
1.14
5.33
0.03*
*Significant at P < 0.05. © 2014 Occupational Therapy Australia
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participants engaged in social play; and the skill with which participants initiated play (see Table 2 for item descriptions). There was no significant difference in the following 7 of the 12 ToP items related to social play: the skill with which participants negotiated with others to have their needs met; the extent to which participants engaged in social play; the skill with which participants supported the play of others; the skill with which participants entered a group already engaged in an activity; the skill with which participants shared; the extent to which participants gave readily understandable cues; and the skill with which participants responded to other’s cues (see Table 3 for item descriptions). In addition, children with PAE were found to score significantly lower than the reference group on two other items not exclusively related to social play, namely ‘Transitions’ from one play activity to another (t = 7.74; d.f. = 1; P = 0.01), and ‘Modifies’ activity to maintain challenge or make the activity more fun (t = 5.60; d.f. = 1; P = 0.03).
Discussion PAE is rife in South Africa’s impoverished rural areas. It is known to cause a multitude of neurobehavioural problems, which could negatively affect a child’s ability to engage in the occupation of play. This study presents research on the implications of PAE on children’s disposition to play: their playfulness. The primary research hypothesis was supported as results indicated that the PAE group performed significantly worse on their overall playfulness scores than the
reference group. Although causality cannot be determined, the result recognises a link between PAE and lower levels of playfulness. This is a new finding in research regarding PAE and suggests that children with PAE are more likely to experience a lowered disposition to play than their non-PAE counterparts. This research is of particular relevance when play is recognised as a child’s primary occupation and in light of persistently high levels of PAE in South Africa. Interestingly, children with PAE were found to score similar to children with no history of PAE on more than half of the ToP items related to social play. These items mainly relate to the fourth element of playfulness: framing (i.e. giving and responding to cues). Framing requires an understanding of social rules and gives players the possibility to support their playmates. These findings suggest that children with PAE have the potential to navigate social play contexts for inclusion, as well as an ability to support the play of others. Although these children may lack in many other areas, such as the ability to alter objective reality by stretching the rules through clowning or joking with others, they clearly demonstrate play skills that could inform a strengths-based approach when designing interventions that aim to improve the social play skills of children with PAE. Analysis of the participants’ biographical data identified that significantly more PAE participants lived with guardians (rather than their biological parents) compared to the reference group. This result echoes local and international research that has found that children born with PAE and its associated conditions are more likely than their peers to be placed in foster care (Toutain & Lejeune, 2008), owing to unstable family
TABLE 3: Non-significant scores related to social playfulness PAE mean
Reference mean
t-test
P-value
Finesse with which players ask for what they need Proportion of time during which the player interacts with others Ease with which players support play of other Ease with which the player becomes a part of the group already engaged in an activity Ease with which players share
1.00
1.40
1.60
0.22
1.40
2.13
3.85
0.06
1.07
1.47
1.80
0.19
0.93
1.53
2.68
0.11
1.00
1.46
1.12
0.28
Proportion of time during which players give clear messages Skill with which the child acts in accord with others’ play cues
1.47
1.73
0.72
0.40
1.53
1.80
1.23
0.28
Item
Description
Negotiates with others to have needs met (Skill) Engages in social play (Extent) Supports the play of others (Skill) Enters a group already engaged in an activity (Skill) Shares (toys, equipment, friends, ideas) (Skill) Gives readily understandable cues (facial, verbal, body) (Extent) Responds to other’s cues (Skill)
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environments and continued alcohol abuse by their mothers (Streissguth et al., 1991). In addition, significantly more PAE participants were found to have repeated grade 1. The third of children in the PAE group who repeated grade one was higher than the national average of 7.2% (Department of Basic Education, 2011). In comparison, the reference group at 6.7% were only marginally lower than the national average. This finding is supported by reports that deficits in social and intellectual functioning in children exposed to alcohol prenatally often lead to difficulties in school (Pienaar & Molteno, 2010). More research is required to ascertain the exact relationship between early grade retention and PAE for this population. These results suggest that although all participants faced daily struggles with poverty, PAE participants were faced with additional family problems and learning difficulties. Research has demonstrated that playfulness scores correlate strongly with scores of adaptability and coping, as both constructs share a thread of flexibility (Hess & Bundy, 2003). Thus researchers have suggested that occupational therapists working with children who face adversity consider providing interventions tailored to improve their playfulness, in aid of helping them develop resilience. Occupational therapists are experts at assisting marginalised children with health conditions to play optimally (Skard & Bundy, 2008) and are skilled at creating or adapting environments that support alternative ways of playing. Occupational therapists have a responsibility to ensure occupational justice (Townsend & Wilcock, 2004) so that children with PAE who are found to have poorer playfulness scores, receive the opportunities to engage in play that is culturally appropriate and which promotes health and their overall physical, emotional, cognitive and social development. Although playfulness is a stable trait that remains constant over time, studies have revealed that occupational therapy interventions can significantly improve the playfulness scores of both children with disabilities as well as typically developing children (Bundy et al., 2008; O’Brien & Shirley, 2001; Okimoto et al., 2000). South Africa has a health-care service in crisis and although policies provide a mandate for occupational therapy services to be made available to all citizens, occupational therapy services still function as a luxury in many health, education and community settings. This begs the question of where to position occupational therapy services in order to improve the playfulness of children with PAE? Considering the shortage of occupational therapists in rural contexts, sustainable interventions, such as Bundy et al.’s (2008) proposal to use environmental adaptation to improve children’s playfulness, could be considered. Children growing up in low resource rural communities often lack playground facilities and equipment (de Villers et al., 2012), thus interventions should aim to
promote occupational justice by providing cost-effective and culturally relevant play opportunities on school playgrounds. Interventions could also focus on utilising the strengths of children born with PAE. For instance, as children with PAE equally sought out social interaction during play, ensuring regular typically developing peers are included in the intervention is likely to create a motivating environment. In turn, this will enhance their engagement in the intervention process in order to facilitate the development of resilience. However, given the shortage of occupational therapy services, school staff may require training to assist in implementing such interventions in the school environment.
Limitations A descriptive analytical study design was used, therefore causality could not be assumed. The small and non-randomised sample limits the generalisability of the findings to other PAE populations. Children were only filmed outdoors in their school playground. Although the ToP does not require that children be filmed in both their school and home contexts, it is preferred as it could potentially give a more thorough observation of children’s playfulness.
Conclusions and implications for research This study described the playfulness of a small group of children with a positive history of PAE, who reside in a rural area in the Western Cape, South Africa. The results suggest that children with PAE are more likely to have a lowered disposition to play than children without PAE. Children who are prenatally exposed to alcohol can therefore be considered to be more likely to experience a lowered quality of play and are more likely to struggle with some elements of social play than children not exposed to alcohol in utero. Considering the shortage of occupational therapists in South Africa and the prevalence of PAE, occupational therapists are challenged to engage with creative and sustainable interventions that occur at the level of the environment and are best suited to help the majority of the individuals and communities living with PAE. This research has implications for future research. Firstly, the study could be replicated with a greater sample size spanning a variety of different communities in South Africa, to evaluate whether the children with PAE score poorly on the same items in different contexts. A larger sample size would also allow for between-group comparisons on how the amount of PAE relates with playfulness scores. Future research could also focus on using the ToP with PAE children in both indoor and outdoor environments at home and within the community, so as to determine whether differences in playfulness scores exist in different contexts. Research utilising comprehensive social skills assessments could be undertaken to further explore the social skills of children with PAE who reside in a rural © 2014 Occupational Therapy Australia
266 African context. The Test of Environmental Supportiveness (Skard & Bundy, 2008) could be used on the school playgrounds to investigate the impact of the environment on children’s playfulness in more depth. Research could also focus on exploring the link between playfulness levels and adversity in the South African context. Future research could explore the link between the playfulness and resilience of PAE children in South African communities.
Acknowledgements The authors would like to thank Professor Anita Bundy for her help in the use of the Test of Playfulness, as well as the Kidzpositive occupational therapists who assisted with the scoring of the tapes. Gratitude is also due to the Western Cape Education Department and especially to the research participants.
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