Rodger Play Based OT 1999

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Play-based Occupational Therapy

Sylvia Rodger & Jenny Ziviani
Available online: 21 Jul 2010
To cite this article: Sylvia Rodger & Jenny Ziviani (1999): Play-based Occupational
Therapy, International Journal of Disability, Development and Education, 46:3, 337-365
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International Journal of Disability, Development and Education, Vol. 46, No. 3, 1999
Play-based Occupational Therapy

S Y LVIA R OD GER & J EN NY Z IVIAN I
The Departm ent of Occupational Therapy, The U niversity of Q ueensland, Brisbane
QLD 4072, Australia
AB STRA CT In this paper, we will provide an overview of how occupational therapists view
play, illustrate how occupational therapists’ view of play has evolved, generating a shift in
focus for intervention, introduce a model of play as occupation to illustrate how children’ s
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ability to play m ay be in¯ uenced by developmental disabilities, outline occupational therapy

assessm ent and treatm ent using play as the basis for intervention, and ® nally, identify
aspects of best practice. The term developmental disabilities refers to a heterogeneous group
of disorders. It is not within the scope of this paper to provide detailed discussion of
play-based occupational therapy intervention for all the children who com prise this group.
Therefore, we have chosen to illustrate various points m ade with examples of different types
of children with various types of disability.
A major goal of occupational therapy is to enhance a person’ s ability to interact

com petently or effectively in his/her environm ent (R eilly, 1974 ; Schaaf & M ul-
rooney, 1989) . Involvem ent in purposeful activity is viewed by occupational thera-
pists as a means of enhancing com petence (Reilly). Occupational therapy aim s to
enable clients to engage in self-directed daily occupations in the areas of self-care/
self-maintenance, productivity (school, work), and play or leisure. Play is viewed by
occupational therapists as a need-ful® lling and im portant occupation in the life of
every person, as well as an arena for the developm ent of competence (Canadian
Association of O ccupational Therapists [C AO T], 1996 ; Schaaf, 1990) . For chil-
dren, play is the major m eans by which com petence is developed and is their
prim ary expression of purposeful activity. Through play children learn skills to
support their roles as players, and later their other occupational roles such as friend,
play group m ember, school student (Burke, 1993) .
Play and Occupational T herapy
Bundy, an occupational therapist, proposed the following de® nition of play: ª Play is
a transaction between an individual and the environm ent that is intrinsically m oti-
vated, internally controlled and free of m any of the constraints of objective realityº
(1991 , p. 59).
A nother occupational therapist, Burke (1993 ) described eight dim ensions of play
which incorporate key tenets from a range of theories about play. She regarded play
ISSN 1034-912X (print)/ISSN 1465-346X (online)/99/030337-29 Ó 1999 Taylor & Francis Ltd
338 S. Rodger & J. Ziviani
as: an opportunity for children to learn about physical, social, em otional abilities and
skills; a mechanism for exploring one’ s own m otivation and achievem ent; a non-se-
rious pressure-free opportunity to perform for the process of feeling rather than the
product; and an im aginary world for m astery over unmanageable aspects of reality.
In addition she suggested that play activates an individual’ s exploration and sense of
wonder, is a foundation and builder of interpersonal relationships, a way of learning
and developing interests and skills in concentration, problem -solving and judgement
and an arena for learning about adolescent and adult roles as well as role behaviours.
Play is regarded by occupational therapists to be the occupational or life role of
infants and young children. Occupational therapy provides a unique contribution to
the m ultidisciplinary approach to play. This unique perspective lies in the pro-
fession’ s views that occupations are activities or tasks which engage a person’ s
resources of tim e and energy, speci® cally self-care productivity and play/leisure.
Occupational therapists aim to assist the child to achieve a playful state where the
challenges of the activity are balanced with the skills of the individual (CAO T,
1996) . W hen play is viewed as an occupation, the transaction between person and
environm ent is acknowledged. Three elem ents of play are always considered by the
occupational therapist: the person, the environm ent, and the occupation (the pro-
cess as well as outcom e of play) itself. Occupation relates to different types of play
activities, which have been traditionally categorised as manipulative, im aginative,
constructional, and sensorim otor play. Since activity is occupational therapy’ s essen-
tial uniqueness, much can be offered in terms of activity-based assessm ent and
treatm ent. Activity analysis is used by occupational therapists to identify the
strengths and challenges in a person’ s skills and in¯ uences of the hum an (e.g.,
fam ily, teachers, therapists, peers) and non-hum an environment (e.g., toys, play
spaces) on play. Activity utilisation and adaptation are critical and fundam ental to
occupational therapy intervention (CA OT). Occupational therapists use play activi-
ties to facilitate the achievem ent of therapy goals, one of which may be the
prom otion of play development (Rast, 1986) . This requires an understanding of the
child’ s abilities, interests, and lim itations as well as the environm ental context in
which the child functions.
Sim ilar to occupational therapy, play has form ed the corner stone of quality early
childhood education, however, early childhood special educators have only recently
begun to recognise the value of play in program s (Copland, 1995) . T he im pact of
disability on children’ s ability to play has been a more recent area of enquiry
(CAOT, 19 96; Copland, 1995 ; R ast, 1986) .
Traditionally play was a highly visible aspect of occupational therapy program-
ming for children. Although the concept of play as occupation still appeared in the
profession’ s literature in the mid-twentieth century, play was eclipsed by m ore
scienti® cally and technically oriented concerns (Parham & Primeau, 1997) . R eilly
(1974 ) reintroduced the concept of occupation, which form ed the basis of the
occupational behaviour fram e of reference, further developed by Kielhofner and
Burke (1980 ) and Kielhofner (1985) . Occupational role is a central organising
concept of the occupational behaviour fram e of reference. Contemporary ap-
proaches based on this frame of reference include: (a) occupational science (Clark
Play-Based O ccupational Therapy 339
et al., 1991 ) which focuses on play as occupation and to what extent it is supported
by intrapersonal and environm ental factors, (b) the concept of valuing play for its
own sake, a legitim ate end in itself, a quality of life issue (Parham & Primeau, 1997) ,
and (c) Bundy’ s model of playfulness (Bundy, 1991) . Concepts of play are likely to
be relevant across the lifespan and play applications for adults are being increasingly
explored in the occupational therapy literature.
Play is utilised by occupational therapists to gain the child’ s attention, practice
speci® c m otor and functional skills, prom ote sensory processing and perceptual
abilitie s, as well as cognitive and language developm ent (Rast, 1986). In therapy
settings, play becomes a tool used to work towards a goal. Play activities are used to
facilitate the achievem ent of therapy goals, that is, the development of speci® c skills
or perform ance com ponents. In this case play is viewed as a means to an end, play
activities are goal-directed and externally controlled by the therapist. For exam ple,
puzzles may be used to enhance visual perceptual skills or rolling play dough with
a rolling pin to m ake biscuits for a tea party used to facilitate bilateral hand use. T he
choice of play activities is based on the therapist’ s knowledge of norm al play
developm ent and an awareness of an individual child’ s personality, interests, abili-
ties, and lim itations (CA OT, 1996) .
A t other times, a goal m ay be the prom otion of play development itself. In this
case, the therapist m ay attempt to teach the child play skills through, for exam ple,
modelling, prom pting, demonstration with appropriate play m aterials. T he therapist
may provide the child with free range of the playroom and become engaged in the
child’ s fantasy play, extending and elaborating on the child’ s play themes.
A m ajor shift in the occupational therapy literature has been to view play as a
need-ful® lling and appropriate occupation in the life of all individuals. Play is seen
as a legitim ate end in itself because it is a critical element of the human experience
(Parham & Prim eau, 1997) . W ith this shift the focus has been on how we can
support the child’ s play with appropriate intrapersonal and environmental factors.
The outcome of intervention becomes com petence or improved performance in play
itself. Occupational therapists draw on a theoretical knowledge of play to prom ote
a playful attitude during therapy, that taps a child’ s intrinsic motivation and
self-direction to master his/her environment (CA OT, 1996) . W e contend that both
views of play are im portant. Occupational therapists continue to use playful activities
(as a m eans to an end) to facilitate speci® c goal attainment, as well as prom oting
play as an occupation in and of itself.
M odel of Play
Prior to identifying the ways in which developmental disabilities can im pact upon
the play of children it is ® rst necessary to adopt a framework for this analysis. In an
attem pt to better understand the play behaviour of children who had been abused,
Cooper (1997 ) advanced a m odel of play which clearly encapsulates the occu-
pational therapy perspective (see Figure 1). This m odel serves as a useful base from
which occupational therapists can expand their understanding of play in children
with developm ental disabilitie s.
F IG . 1. M odel of Factors that Impact upon the Development of Play in C hildren. Reproduced with
perm ission from Cooper (1997).
Broadly speaking the m odel conceptualises play as an innate behaviour, univer-

sally recognised as a primary occupation of childhood. W ithin this context play is
conceived as being com prised of developmental foundation skills (developm ental,
play, and social skills) and behaviour elem ents (internal control, freedom to suspend
reality, intrinsic m otivation). In turn these two factors in¯ uence and are in¯ uenced
by the child’ s physical and social play environm ent.
Developm ental Skills
Successful play engagem ent is in large part reliant upon sensorim otor, locom otion,
eye-hand coordination, cognitive, language, and personal-social com petence. Inad-
equate or dysfunctional developm ental attainm ent in any of these dom ains is likely
to challenge children in their physical and social play contexts (W illia ms & Lair,
1991) . Just as important, restrictions on play may lim it developm ental maturation.
For children with developm ental disabilities the developmental sequence itself m ay
be altered and m ilestones m ay be reached m ore slowly and in some cases not at all
(M unÄ oz, 1986) . The manifestation of the developm ental disabilities in any one child
can be quite unique, even though children with speci® c diagnoses can share som e
sym ptom s. It is, therefore, not possible to provide any de® nitive statem ent on
developm ental skill attainm ents. As part of the process of developing a pro® le of
abilitie s, however, the occupational therapist assesses and gathers inform ation which
will provide the basis for determ ining developmental status. This information is used
to create a developm entally appropriate play-based program , and then to m easure
change in performance over tim e.
Play Skills
Along with the attainm ent of sensorimotor, m otor, language and social m ilestones,
children develop speci® c play skills. W hile reliant on the form er, play skills are
re® ned on the basis of exploratory activity, practice, engaging with the environm ent,
and m odelling from others. As such, the am ount and quality of time spent in play
is an important consideration for children with developm ental disabilities. T he
literature is clear in this respect. Children with developmental disabilities in general
have greater restrictions placed on the nature and frequency of play opportunities
(M cConkey, 1983; Pollock et al., 1997) . These restrictions stem from the greater
percentage of time devoted to self-care, therapy, and educational remediation
(Howard, 1996 ) as well as the im pact of m obility, social, and environm ental barriers
(Nabors & Badawi, 1997) . As a result, the mechanisms by which play skills develop
(i.e., m odelling and practice) can be im peded.
Social Skills and Choices
Children’ s ability to manage the social dimension of play is dependent on their

language skills, self-concept, personality traits, and prior knowledge and experience
(Larson, 1995) . This social skill develops slowly and is m odi® ed in response to
environm ental feedback. W hile som e have proposed a linear progression from
solitary to social play (Parten, 1932) , it is now accepted that for children both
methods of play co-exist and are present throughout childhood (Barnes, 1981) .
Social skills can be dependent upon social opportunity and acceptance. Children
with behavioural and cognitive dif® culties have been shown to be m ore at risk of
social isolation than other children (Levy & Gottlieb, 1984) . W here this is com-
pounded by physical restrictions it becom es obvious that pro® ciency in social
com petence can becom e com prom ised.
In a qualitativ e investigation of adolescents with a range of developmental disabil-
ities (spina bi® da, cerebral palsy, juvenile rheum atoid arthritis), Pollock et al. (19 97)
found that for these young people found having friends during childhood was one of
their greatest supports. T he social environm ent appeared to be the most im portant
factor in enabling them to participate in play, especially at school or in the local
neighbourhood.
Freedom to Suspend Reality
Often referred to as symbolic or pretend play, the ability that children have to
represent actual or imagined experiences through the use of objects, motion, or

language is widely acknowledged as an im portant stage in the developm ent of
cognitive and language skills (M cCune-Nicolich & Fenson, 1984) . The delayed
em ergence of pretend play in children with D own syndrome (M cConkey, 1985) has
been hypothesised as being sym ptomatic of these children being less inclined in their
play to use affective reactions to signal pretence (e.g., smiling, adding noises). For
children with Autistic Spectrum D isorder (ASD ), evidence for the impact on
pretend play is m ore extensive and m ost agree that this group experiences dif® culty
in the spontaneous production of pretend play (Ungerer & Sigman, 1981). T he
pretend play which is present is further described as repetitive, stereotyped, and
lacking creativity (W ulff, 1985) . The nature of the play of children with autism has
been described as a fascination with the m ere presence of objects and their im medi-
ate sensory features rather than their cultural or symbolic m eaning (Trevarthan,
Aitken, Papoudi, & Robarts, 1996).
Intrinsic M otivation
A sense of pleasure and fun separates play from work (W est, 1990) . Children are
motivated to play and are able to obtain obvious pleasure from tasks which to others
may seem inherently unproductive (G arvey, 1991) . W hat is playful for one person,
however, may be work for another. The activity itself is not the key, but rather the
characteristics of the engagem ent in the activity. Factors such as the am ount of
choice (if I have to do it, it’ s work, if I choose, it’ s play), the self-direction versus
external control, and the spontaneity versus structure strongly in¯ uence the percep-
tion of the experience (Pollock et al., 199 7).
Physical and Social/Cultural Play Environment
Physical and/or social environm ents can either restrict or stim ulate play experiences
for children. A number of studies have now con® rmed that children with disabilitie s
are exposed to m ore sedentary activity and television than their non-disabled peers.
They also have less access to the raw m aterials of play and fewer opportunities to be
able to m odel on other children’ s play (Howard, 1991 ; Takata, 1971) . Equally
important in a child’ s environment is hum an involvem ent. M unÄ oz (1986 ) found that
parents of children with disabilities had inappropriate play expectations of their
children, with an overem phasis on m otor activity rather than the process of explo-
ration and interaction with a toy or the environm ent.
Play-Based Assessm ent
Occupational therapists assess play behaviour by way of general observations, as part

of more generic assessments, and by m eans of speci® c play evaluations. D escribing
and docum enting play behaviour is as complex as trying to de® ne the phenom ena
itself. First, because it is an environm ental behaviour it is necessary to consider both
the individual activities of the player and the environm ental context. It has been
argued (Kielhofner & Barris, 1984 ) that the relationship between play and the
environm ent in which play is observed is intim ately linked and each can have a
signi® cant impact upon the other. Second, the view of play as both a naturalistic and
subjective behaviour m eans that no speci® c type of play can be predicted in any
particular situation. N o two children play exactly the sam e way in the sam e
environm ental context. T hird, the contextual nature of play means that therapists
remain critical of assessment procedures which unduly distort its natural occurrence
(Bryze, 1997) . Im plicit within the choice of an assessment of play is the inherent
de® nition and fram ework adopted by the assessm ent developers. Therefore, assess-
ments need to be carefully selected to m eet the speci® c needs and requirem ents of
the child being assessed.
W hile occupational therapists have viewed play as both a m eans of assessment and
treatm ent, it is only since the 1970 s that a range of formal assessments have been
developed (Knox, 1997) . Som e, but by no m eans all, of these have standardised
administrative procedures and norm ative data to support their clinical use. W hile
therapists draw on play assessments which have been developed within disciplines
such as psychology and education, it is prim arily those developed by occupational
therapists which will be addressed here as they provide insight into the approach to
play adopted by occupational therapists. Play assessments which have been, and are
being, developed by occupational therapists include the Preschool Play Scale (Bled-
soe & Shepherd, 1982 ; Knox, 1997) , Play H istory (Takata, 1974), Play Skills
Inventory (Hurff, 1980), Test of Playfulness (Bundy, M etzger, Brooks, & Binga-
man, in press; M etzger, 1993) , and Playform (Sturgess & Ziviani, 1996) . M ention
will also be made of the Transdisciplinary Play Scale (Linder, 1990 ) which, while
not developed by occupational therapists, has a m ultidisciplinary focus.
Preschool Play Scale
One of the m ost widely used play assessm ents by occupational therapists is the
Preschool Play Scale (Knox, 1974 , 1997) . D eveloped as an observational assessment
to be undertaken in a naturalistic environm ent, it aim s to provide a description of
play behaviour in children from birth to 6 years. The developers conceptualised play
behaviour around four dimensions: space managem ent, m aterial m anagem ent, im i-
tation, and participation. W hile no speci® c training is indicated, it is recom m ended
that those adm inistering the assessm ent are fam iliar with the literature on childhood
play and are experienced in observing children at play (Bledsoe & Shepherd, 1982) .
Ratings are based on a num ber of observations of free play ranging from 15 to
30 min units both indoors and outdoors.
Interrater reliability for the overall scale has been reported to be very high (.99).
These very high correlations may in part re¯ ect that the raters were also those
involved in revising the scale. Further, current recomm endations that reliability be
analysed using intraclass correlations and not Pearson’ s correlation m ay result in this
® nding being questioned in future research. There is already a suggestion that
independent ratings are around .75 (Cooper, 1997). Test-retest reliability has been
reported as ranging from .86 to .97 for the four dimensions over a one week period
(Bledsoe & Shepherd, 1982) .

Concurrent validity of the Preschool Play Scale has been undertaken with the
Lunzer Play Scale and the Parten Play Scale yielding correlations of .64 and .61
respectively. C orrelations between chronological age and the four dim ensions
ranged from .89 to .95 suggesting that the scale is assessing a developm ental
progression in play behaviour (Bledsoe & Shepherd, 1982) . T his scale has been the
most widely used by occupational therapists with children who have developm ental
disabilities. Speci® c ® ndings suggest that children with ASD dem onstrate statisti-
cally signi® cant differences in developm ental play age than nondisabled controls and
that most dif® culty, not surprisingly, is experienced in the dom ain of social partici-
pation (Restall & M agill- Evans, 19 94). Children identi® ed with sensory integrativ e
dif® culties were found to have the greatest problem in the area of space m anagement
(Bundy, 1989) . Children with juvenile rheum atoid arthritis were not found to differ
signi® cantly in play age from their nondisabled peers (M orrison, Bundy, & Fisher,
1991).
Play H istory
D eveloped in the late 1960 s and early 1970 s the play history takes the form of a
structured interview with children’ s parents or carers to determ ine their child’ s
developm ental play level and the adequacy of their play environm ent and experi-
ences (T akata, 1969 , 1974). Play is conceived as com prising ® ve major developm en-
tal epochsÐ sensorim otor, sym bolic and sim ple constructive, dram atic and com plex
constructive, gam es, and recreation. Inform ation is gathered on four aspects of these
epochs, nam ely materials, actions, people, and environm ental settings. In the early
versions data was analysed qualitativ ely (Rogers & Takata, 1981 cited in Kielhofner
& Barris, 1984) , though a later version provided a standardised adm inistration
procedure and attem pts to quantify the inform ation.
Validity for the play history is based prim arily on a thorough review of the
literature and the developm ent of a play taxonomy (content validity). Some attem pts
at construct validity have been undertaken (Behnke & M enarcheck-Fetkovick,
1984 ) with the play history being able to discrim inate between children with and
without developm ental disabilities. Concurrent validity has also been established
with the M innesota Child D evelopm ent Inventory by the sam e authors. Interrater
reliability has been reported to be as high as .91 for the total score and test-retest
reliability .77 (Behnke & M enarcheck-Fetkovick). This assessm ent is not widely
referenced in the current occupational therapy literature, however, it does have the
potential for being a useful descriptive guide of play and the play environment.
Play Skills Inventory
D eveloped by Hurff (1980 ) the Play Skills Inventory is a collection of 20 possible

play situation and activities representative of the skill of m iddle childhood. These
play situations and activities are proposed to be used as a basis for assessing the
com petence in sensation, m otor ability, perception, and intellect. This procedure
was not intended to be used in a standardised way but was produced more as a
model for therapists to exam ine the play of 8- to 12-year-old children. There is little
documentation on this inventory other than the original publication and, in its
present state, is of lim ited clinical application. However, the fact that it uses gam es
as a structure for observation is the reason why it has been included in this review.
This again points to the occupational therapy approach of using activity to re® ne
observations.
Test of Playfulness
D rawing on the work of Barnett (1990 ) and Lieberm an (1977 ) as well as the play
literature, Bundy (1997 ) developed a 60-item observation assessment known as the
Test of Playfulness. The key elements of playfulness were de® ned as intrinsic
motivation, internal control and freedom to suspend reality. It also incorporates a
fourth aspect of play described as framing. Fram ing here is described as the way
children give and read social cues when playing. The items on the Test of Playful-
ness were developed by observing children playing and creating item s to re¯ ect the
four elem ents previously described. The assessment was designed to be adm inis-
tered both indoors and outdoors and each item is scored on a 4-point scale
indicating the relative amount of tim e a child’ s behaviour is re¯ ected in the item
(0 5 rarely or never; 1 5 som e of the tim e; 2 5 most of the tim e; 3 5 alm ost always).
Scores on the scale are derived through observation of videotapes of children playing
for approxim ately 15 m in indoors and 15 min outdoors.
This assessm ent is more process (than outcom e) oriented and highlights what the
authors see as the individuality of play (i.e., what is playful for one person m ay not
be so for another). T he activity itself is not seen as the key but rather the
characteristics of the engagement in the activity. This test is still in the state of early
developm ent but initial studies look promising (Bundy, 1997) . Validity of the Test
of Playfulness has been addressed on the basis of content (which relies on the
availab le research and theoretical literature). Construct validity has also been con-
sidered and the item s in the assessm ent have been found to re¯ ect a unidim ensional
construct which the authors have labelled playfulness. Both children with and
without special needs were included in this study but more work is required to
exam ine the discriminative ability of the test. Reliability has also been addressed by
the test developers with interrater agreem ent being reported as 96% (Bundy et al.,
in press).
Playform
The playform was developed to aid in the understanding of how children perceived
them selves in different play situations (Sturgess & Ziviani, 1996) . This is a self-re-
port questionnaire for children aged 5 to 7 years. It requires children to indicate how
they think they would react to 20 play situation (i.e., very well, well, not very well).
Children respond by posting a card into an appropriately labelled box. D evelopment
of this assessment is still in its early stages but prelim inary reports suggest that this
assessm ent is obtaining unique inform ation about children’ s view of their own play
abilitie s. These views differ to those obtained from their teachers and parents
(Sturgess & Ziviani, 1995 , 1996) .
Transdisciplinary Play-Based Assessm ent
W hile not developed by occupational therapists, this assessment is included because

of its transdisciplinary perspective and its use in developing intervention strategies.
It aims to assess a child’ s function using play as the medium (Linder, 1990). T he
approach is initiated by gathering inform ation from parents concerning the develop-
mental status of their child which is then used to plan a play session which, in turn,
is used to obtain observational data on the child’ s perform ance. T he procedure is
well structured and detailed and can be used across disciplines.
M odels of Service Delivery
Occupational therapy intervention can take several forms such as direct intervention
(individual and/or group treatm ent) and indirect intervention such as m onitoring
and consultation. D irect intervention refers to ª hands onº therapy conducted by the
occupational therapist with a child or group of children. O ngoing clinical judgments
are needed to adjust activities to best m eet the children’ s needs. D irect intervention
is both tim e consum ing and costly (D unn, 1991) . T his form of intervention usually
focuses on the developm ent of performance components needed for effective occu-
pational perform ance (e.g., hand skills needed to pour from a teapot when having a
tea party with teddies, developing the sitting posture needed to play a com puter
gam e, teaching turn-taking needed to play a gam e with others). Em phasis is placed
on the internal factors of the child including elem ents of playfulness, which facilitate
problem -solving and adaptation by the child (Bundy, 1991) . As well, having oppor-
tunities and the ability to socialise with peers, including the ability to give and
receive social cues, are external factors which are needed (CAO T, 1996) . Individual
and group intervention strategies m ay be used to prom ote these com ponents of
occupational performance in hom e, preschool, school, and com m unity environ-

ments.
O ccupational therapists draw from a range of treatm ent strategies to prom ote the
ª just right challengeº between a play activity and the child’ s ability . This requires a
thorough understanding of the child’ s developm ental and play abilities, as well as a
good knowledge of the dem ands of play m aterials, activities, and m edia. O ccu-
pational therapists use both task analysis and activity analysis skills to determ ine the
steps or components of the task/activity, as well as the qualities and dem ands of the
play activity itself. By being aware of the child’ s interests, the therapist can choose
play activities which will be intrinsically interesting to and m otivating for the child.
Indirect intervention involves collaboration with others and includes m onitoring
or consultation. M onitoring requires the therapist to identify the child’ s needs, plan
a program , and design an appropriate intervention, as well as teach others to assist
in carrying out the intervention with the child. T he therapist then supervises others
in the conduct of this intervention (D unn, 1991) . The therapist needs to m aintain
some regular contact with the child to evaluate whether the program needs further
adjustment. M ediator training is one way in which a program is planned and
monitored by an occupational therapist but administered by another person, such as
parent, carer, teacher, educational assistant. The therapist’ s role m ay include m od-
elling playful interactions with a child and/or dem onstrating ways to develop playful
environm ents in a child’ s home, school, or com munity.
Consultation m ay be delivered at the level of the system , colleagues, or individual
cases. The therapist is not regularly directly involved with the child, but m ay assist
others in m eeting the child’ s needs. The therapist aim s to advise, educate, coordi-
nate, and collaborate with others involved in the child’ s life (CAO T, 1996) . T he
occupational therapist m ay identify environm ental barriers and supports to play,
provide advice on how to elim inate these barriers, and facilitate play by adapting
toys, m odifying the child’ s play space, playground, using technology such as
switches to enable the child to engage in play. Caregivers m ay be educated about the
importance of play in the child’ s life and the provision of age appropriate activities.
Social networks of friends m ay be developed to encourage peer interaction in the
playground. C onsultation about cultural expectations and beliefs about play m ay
also be needed (CAOT, 1996) . M odi® cation of the environment and provision of
appropriate m aterials and playful adults or peers can create the ª just right challengeº
between the demands of the activity and the child’ s skills to enable the child with a
developm ental disability to achieve a sense of m astery and com petence.
A ssisting parents to see them selves as having an im portant role as ª playersº as well
as caregivers and nurturers within the fam ily context is an important consultative
role for occupational therapists (Burke, 1993) . Som e parents require assistance in
being playful with their children, especially when children have developm ental
disabilities. For exam ple, norm al playful interactions such as playing peek-a-boo
may not be as m uch fun for parents of children with ASD , who may not be able to
anticipate the reappearance of the parents’ face after it has been hidden, and fail to
show any excited anticipation when the game is repeated. The lack of responsiveness
of a child with ASD to this gam e may negatively affect the parent’ s concept of
him /herself as player, provider of fun for the child, and challenge his/her feelings of
parental adequacy. Parents need support in m odifying gam es to m eet the ª just right
challengeº for their children and explanations to help them understand why the
child with ASD does not initially respond. It is not their lack of parenting skills per
se, but rather the child’ s lack of object perm anence, inability to read facial expres-
sions, inability to sustain eye contact by looking at the parents’ face, and their
impaired affective responses and cooperation or reciprocal interaction, which are
relevant (Trevarthen et al., 1996).
Children with ASD rarely initiate activities with their parents or others which
require joint or shared attention, rarely point to objects, or bring objects to their
parents. It is, therefore, dif® cult to engage in shared play experiences with these
children (Trevarthen et al., 1996). Treatm ent focusing on using playful and im itative
behaviours to encourage these children with autism to be m ore responsive and
cooperative is indicated. W olfberg (1995) dem onstrated that integrated play groups
could be used to support and im prove the skills of children with autism in playing
with their typical peers. In this approach adults set up environm ents conducive to
social and im aginative play, and guide participation in peer group play through
direction, modelling play, and verbal guidance. Peer m ediation was also used when
adult support was withdrawn. T he gains made were generalised to other peers,
settings, and activity contexts. There are a num ber of factors which can be con-
sidered when designing a play experience. These include that toys match a child’ s
capabilities, toys/play m aterials are based on a child’ s response, toys arouse and
stim ulate curiosity (see Figure 2), age/stage appropriate play m aterials are availab le,
there are opportunities for success, there are opportunities to see and learn from
others, places are safe and playful, individual child’ s preferences/styles are accom-
modated, unfam iliar, novel objects are availab le (Burke, 1993) .
Play and Fram eworks for Intervention
Occupational therapists draw from a range of fram es of reference for intervention

with children. Some of these include developmental, occupational behaviour, per-
ceptual motor, neurodevelopm ental, sensory integrative, and perceptual motor
frames of reference (Kram er & Hinojosa, 1993) . Som e of the literature on play in
occupational therapy can be understood from viewing several of the key fram es of
reference used by paediatric occupational therapists.
Perceptual Motor Approaches
Perceptual m otor approaches are based on using a series of perceptual and motor
experiences such as exercises and activities in a developm ental sequence which
reinforce the development of children’ s m ovement skills. These include activities
such as obstacle courses, ball catching, balance beam s, and games which are
adult-directed. The effectiveness of this approach in rem ediating gross m otor,
physical perform ance, and academ ic achievem ent has been questioned (Cum m ins,
1991 ; Kaplan, Polatajko, W ilson, & Faris, 1993; Kavale & M attson, 1983) . Re-
F IG . 2. Young boy playing with toy lion using switch activation to operate the toy. Photograph by
Sharon M ickan, taken at Xavier Special School, Education Queensland, Brisbane.
cently, some authors (Corrie & Barratt-Pugh, 1997 ) have suggested that if percep-
tual m otor programs do not facilitate developm ent, then why not play instead?
Kostelnik, Soderm an and W hiren (1993 ) described a continuum of four cate-
gories of playÐ free play, guided play, directed play, and work disguised as play.
Free play is child-centred, with the child electing to play and m ake all the decisions
about play. The child invents, creates, discovers, discusses, and im provises. This
may be solitary or involve others. In guided play the teacher or therapist can guide
the play by placing particular m aterials and equipm ent in the environm ent. Often
there are some rules to be followed. Directed play occurs when the teacher/therapist
organises activities such as group gam es. Cooperation and direction-following are
required. W ork disguised as play involves task oriented activities that include
practice and repetition. T his category lacks child-centred exploration and discovery.
From this continuum , it is obvious that free play and guided play can be used to
support the development of perceptual m otor skills in children with mild develop-
mental disabilitie s. In early childhood intervention indoor and outdoor equipment
can be set up in the playground or indoor environm ent of special and regular school
settings to facilitate developm ent of these skills (see Figure 3). Perceptual and ® ne
motor developm ent can also be enhanced through free and guided play during table
top activities.
For children with m ore signi® cant or multiple developm ental disabilities the
developm ent of perceptual, ® ne m otor, and sym bolic or pretend play frequently has
F IG . 3. Playing on outdoor equipment such as swings can provide many therapeutic bene® ts (sitting
balance, coordination, vestibular stim ulation) and m ost of all fun and a sense of mastery. Photograph
courtesy Down Syndrome Research Program , Schonell Special Education Research C entre,
University of Queensland, Brisbane.
to be facilitated by m ore directed m eans, as these activities may be avoided by the

child in free play. Often these children lack the spontaneous language skills to
engage in authentic conversation during play activities. Pretend play is often lacking.
Leister, Langenbrunner, and W alker (1995 ) identi® ed some strategies to assist
adults in promoting pretend play. These include: describing what the child is doing,
verbally or physically reinforcing the child’ s play, and physical participation or
modelling such as sitting down and pretending to bathe the doll. O ther factors
identi® ed as helpful in encouraging pretend play include: the size of the availab le
play space, decreasing the num ber of toys available for play, and allowing a suf® cient
amount of tim e for the behaviour to occur (R ubin & Howe, 1985) . A cting out
fam iliar stories of involvem ent in naturally occurring play situations such as dressing
a doll, cooking dinner, playing shops, are also useful starting points for children with
developm ental disabilities. G owen (1995 ) suggested that children do not participate
in pretend play without the help of a ª travel guide.º
Neurodevelopmental Treatment Approaches
The neurodevelopm ental therapy frame of reference involves the use of speci® c
handling techniques to inhibit abnorm al patterns of m ovement, facilitate norm al
muscle tone, patterns of m ovement and autom atic responses, and teach handling
techniques to parents. It is one treatment approach which is always delivered as
direct intervention by the therapist with the child. Integrating play activities with
neurodevelopmental treatment (N DT) is a com plex task, requiring the therapist to
elicit speci® c responses through handling while sim ultaneously engaging the child in
purposeful play activities (A nderson, Hinojosa, & Strauch, 1987) . It is considered
that children with neurodevelopm ental disabilities follow a developmental play
sequence similar to the sequence followed by normal children, but at a delayed rate
(Field, Rosem an, De-Stefano, & Knoewler, 1982) . Because of their m otor im pair-
ment, m ost children with cerebral palsy experience dif® culty participating in play
activities without assistance. Incorporating play within ND T has many bene® ts for
these children: to develop speci® c cognitive and perceptual skills, to provide appro-
priate activity experiences as stim uli for norm al m ovement patterns, and to m otivate
the children for intervention that supports norm al developmental needs (Anderson
et al.). Using play activities while handling a child involves ongoing analysis and
adaptation of activity. A ctivity adaptation during play activities involves: adapting
the size, shape, or consistency of equipm ent and m aterials, m odifying the rules and
procedures, adjusting the position of the child and m aterials, and controlling the
nature and degree of interpersonal interaction. Occupational therapists’ knowledge
of activity analysis and grading enable them to adapt activities. To successfully
integrate activities in ND T therapy requires an appropriately structured physical
environm ent with the activity and equipm ent at the correct height and distance.
Activity choices are in¯ uenced by the neurodevelopm ental goals (techniques and
sequences used) and the therapists’ own body mechanics and coordination. During
dynam ic m ovem ent sequences less com plicated play activities are often indicated
(Anderson et al.). Therapists must judge the child’ s ability to participate concur-
rently in m ovement sequences and play activities.
Fostering play in the child with cerebral palsy involves: understanding the child’ s
lim itations in m ovement, sensation-perception, and cognition; being aware of the
lim itations imposed on the child by the physical environm ent (accessibility to
materials, toys, recreational environm ents) and the adult’ s predisposition to play
(social barriers such as am ount of adult direction, overprotectiveness, free time in
therapy schedule, involvem ent in passive activities); and understanding the charac-
teristics of play experiences and activities (Blanche, 1997). Therapists need to be

able to distinguish between play as a m otivator, play as the context for acquisition
of adaptive skills, and play as an intrinsically m otivated, process-oriented activity
(Blanche). Play m aterials, free play tim e, and different form s of play, such as fantasy
play can be used as motivators.
The adult has a pivotal role in encouraging spontaneity in children with cerebral
palsy by being less directive and providing activities that are ¯ exible, with rules
which can be m odi® ed (Blanche, 1997) . Because of cerebral palsy these children
may not have much freedom to choose and carry out tasks. By providing choice of
activities children are likely to be m ore m otivated to perform the task, which has
been shown to enhance m otor control (Giuliani, 1991) . Fantasy play can be used to
encourage the child to suspend reality and use creative thinking skills. The use of
costumes and props which help a child to pretend and the use of alternate story
telling can enhance the child’ s active participation in treatm ent (Blanche). Fun and
enjoym ent are different for different children, with som e gaining enjoym ent from the
process and others from the product, while others enjoy both. T herapists tend to
provide play activities for children with cerebral palsy which address their m ovement
lim itations and may not be considered fun by the children them selves. Striking a
balance between therapeutic activities and free fun activities that also have m ove-
ment outcom es is a challenge to therapists who need to consider their readiness and
willingness to play (Blanche). Jones and Reynolds (1992 ) identi® ed roles that can be
assum ed by adults such as stage m anager, m ediator, director, observer, and player.
The ultim ate goal of encouraging play during treatm ent and preschool/school
activities is to enhance the child’ s motivation to play independently. Children with
cerebral palsy and other m otor im pairm ents often require m odi® cation of external
factors such as the physical environm ent and their structured routines in order for
play to be fostered. These children need the opportunity to have appropriate play
materials, play space, play tim e, and playm ates (Pugm ire-Stoy, 1992) . W hen consid-
ering play m aterials the type of toys, variety of toys, need for adaptive toys, and
access to toy lending libraries needs to be considered. M issuana and Pollock (1991)
recomm ended that toys of interm ediate novelty are optim al. A toy should have an
elem ent of familiarity but be suf® ciently novel to induce exploration. Adaptations to
the size, shape, weight, and consistency of m aterials m ay be needed. Technology
and com puter adaptations also assist children with physical disabilities to access toys
and play (Langley, 1990 ; M issuana & Pollock, 1991 ; Pugm ire-Stoy, 1992) . Play
space requires considering distractions, seating and positioning, adapted play-
grounds, and back yard activities. Play tim e needs attention to tim e with others at
hom e and school and in the comm unity. W hen considering playmates, Blanche
suggested considering both physically challenged and non-physically challenged
children, for exam ple siblings, neighbours, friends, classm ates with or without
disabilities. N on-physically challenged children can provide excellent role m odels of
spontaneous play behaviour and are likely to be better than adults in ful® lling this
role.
Creative and innovative use of play materials, the environment, and the self as
play agent are all aspects in the effective integration of motivational play with N DT .
Sensory Integration Fram e of Reference
Sensory integration has been de® ned as the process of organising sensory infor-
mation in order to make an adaptive response (i.e., when a child successfully m eets
an environm ental challenge) (Kim ball, 1993) . W hen A yres (1973) described the
ª art of therapyº in the context of sensory integrativ e therapy, she deliberately did not
use the term play, for fear that it was unscienti® c. Today play is accepted as an
important lifelong occupation and respectable goal in therapy (Bundy, 1991) . Ayres
claimed that therapy had to be fun, tapping into the child’ s intrinsic m otivation.
Bundy (1991 ) highlig hted how sensory integration therapy and play characteristics
are intertwined. Bundy (1991 , 1997 ) suggested that play transactions represented a
continuum of behaviours that are m ore or less playful, depending on the degree to
which the criteria (perception of control, source of motivation, and suspension of
reality) are present. Perception of control can be placed on a continuum between
internal and external, source of m otivation between intrinsic and extrinsic, and
suspension of reality between free and not free. By proposing that playfulness
referred to an individual’ s style or approach, these three continua refer to play
transactions as well as describing traits of people. The sum contribution between
these three elements tips the balance between play or nonplay and playfulness or
nonplayfulness.
N ot all kinds of play are appropriate in sensory integration therapy. In sensory
integration, treatm ent is thought to be m ost successful when the activities are
intrinsically m otivating, when the individual is actively involved, in control, and
directing the ¯ ow of the therapy session (Bundy, 1991 , 1997) . Bundy (1991)
proposed that sensory integration treatm ent described a special subset of play
transactions in which all activities aim to enhance sensory stim ulation. W hile not all
occupational therapy is play, play is what therapists using sensory integrativ e
principles strive to achieve. Coster, Tickle-Degnen, and Armenta (1995) suggested
that play m ay give both meaning and structure to treatm ent utilising a sensory
integration approach. M ailloux and Burke (1997 ) suggested therapy sessions offer
the opportunity for merging play with sensory integrativ e goals by using play them es
in treatment. Play them es (e.g., pretending to be pirates swinging from the pirate
ship, walking the plank, hunting for treasure) can m ake challenging activities m ore
enticing and encourage longer duration of involvement. Therapists aim to m eet
therapeutic objectives within as playful a fram ework as possible. Activities are
provided that closely m atch the child’ s skills and are intrinsically motivating for the
child, such that the child feels that he/she is playing. T his playful interaction
prom otes com petence in the child.
Bundy (1989 ) and Clifford and Bundy (1989 ) investigated whether preschool
aged boys with sensory integrativ e dysfunction also had resulting impaired play
skills. They found that this type of dysfunction does not always result in play de® cits.
They also found that boys with sensory integrativ e dysfunction altered their play
preferences to m atch their abilities. Schaaf (1990) presented a case study, in which
she dem onstrated improved play skills in a boy aged 5 years 8 m onths as a result of
sensory integrativ e therapy. Increases in tactile based play activities and imaginative
F IG . 4. Children playing together on a slide. Other children can provide support enabling children
with developmental disabilities to engage in new and challenging play experiences. Photograph
courtesy Down Syndrome Research Program , Schonell Special Education Research C entre,
University of Queensland, Brisbane.
play were seen over a 10 month treatm ent period. She proposed that im proved
sensory integrative abilities in¯ uenced the boy’ s occupational behaviour. As he
becam e m ore organised and better able to process sensory inform ation, he becam e
a more competent player. In contrast, Bundy (1991 ) proposed that if children have
both sensory integrativ e and play de® cits, therapists need to play with children, as
playful role m odels and to teach them to play, as well as treat any underlying sensory
integrativ e dif® culties. The involvem ent of friends, siblings, or peers as play
tutors or role m odels has also been suggested (M ailloux & Burke, 1997) , especially
as a m eans of supporting follow-up therapy during home and school activities
(see Figure 4).
Play Training
Play training involves direct teaching or training of speci® c play skills using behav-
iour modi® cation techniques. For children with developm ental disabilities due to
intellectual im pairm ent, the acquisition of play skills is frequently delayed. Com m on
misperceptions such as that these children do not play and that their play serves a
different function in their developm ent to the play of norm al children, have been
challenged (M ahoney, 1992) . For som e children with intellectual im pairm ent, play
skills develop in the sam e sequence as for children without dif® culties, but the rate
of progress is delayed. For others, the process of acquisition (i.e., the way in which
they develop play skills) is different. For example, they may not develop these skills
merely by observing others or by being in a playful environm ent with lots of
attractive play m edia. A pproaches which merely focus on the environm ent or
providing appropriate peers is generally not suf® cient to develop the play skills of
these children. Speci® c training strategies are required, usually based on behavioural
strategies and the adoption of a structured skill training approach.
M alone and Langone (1994 ) reviewed single subject design research on the object
related play of individuals (aged 2 to 20 years) with intellectual disabilities, pub-
lished between 1966 and 1993 . T ypes of techniques used in these studies included:
provision of reactive or non-reactive toys or training based on techniques such as
reinforcement, prom pting, adult m odelling, adult direction, and demonstration. In
each of the 11 published studies reviewed, the reinforcement of play resulted in an
increase in appropriate play behaviour and a corresponding decrease in targeted

inappropriate play behaviour. O ne of the shortcomings of direct training approaches
is that there is little or no generalisation of the skills gained during training sessions
to other situations or limited maintenance of skills once intervention ceases. M any
interventions have focussed on teaching constructive or object-related toy play,
rather than sym bolic or imaginative play skills to children with intellectual im pair-
ment (M alone & Langone). This type of intervention has therapeutic potential due
to the relationship between sym bolic or representational function and language
developm ent.
Play is ideal as a focus for the developm ent of home-based intervention programs,
since successful playful interaction is critical to the developm ent of quality parent-
child relationships. It is important for therapists and educators who are devising
such program s as part of Individual Fam ily Service Plans (IFSPs), to target well-
de® ned play behaviours, using intervention strategies which can be documented,
evaluated using sim ple data collection m ethods, and which are valid across hom e
and school environm ents.
The Environm ent as a Focus for Intervention
The environm ent is an important focus for intervention as occupational therapists

structure or m odel the physical and social environm ent around the child to facilitate
playfulness (CA OT, 1996 ; Law, 1991) . Play-based environm ents have always been
used by early childhood educators, whereas special educators have tended to use
more teacher-directed activities, which focus on speci® c skill developm ent (Hanline
& Fox, 1993) . Hanline and Fox argued cogently for using play activities to form the
basis for effective instruction and classroom organisation in early childhood special
education settings. In these settings therapists can complem ent the work of teachers.
By sharing a comm on understanding that instruction or therapy can occur through
play enables teachers and therapists to work together in developing program s which
meet individual children’ s goals. Systematic instruction m ay still be required for
children with signi® cant disabilitie s, however, this can be embedded in play activities
of the child’ s choice.
O ccupational therapists de® ne environm ents as those contexts (situations) which
occur outside individuals and elicit responses from them . Environm ents can both
help or hinder satisfactory occupation (Law, 1991) . Environm ental opportunities
include adequate and safe play spaces, a com bination of fam iliar and novel play
materials, familiar playm ates with sim ilar interests and the support of, or lack of
interference from , adults and peers. A sim ple environmental adaptation such as an
adaptive switch can enable the child with developm ental disabilities and the parent
or another child to play together. By facilitating play with the toy via the switch, the
child engages in the occupational role of independent player, interacts with the
environm ent, and develops social and cognitive skills (Burke, 1993) . The parent
experiences positive feedback from the child, leading to feelings of success and
satisfaction with their role as parent. A peer experiencing a playful interaction is
more likely to seek out that child again to play.

A n effective play-based curriculum involves structuring the environm ent to en-
courage children’ s engagement in self-initiated, self-directed and adult supported
play activities. Attention must be directed at the physical arrangem ent of the setting,
the play activities (which allow for construction, sym bolic, and sensorim otor play),
and the use of indoor and outdoor settings (Hanline & Fox, 1993) . The environ-
ment also needs to allow for solitary play and quiet activities and privacy as well as
for group activities and social interaction. Attention to the external scheduling needs
to be structured to prom ote children’ s learning through play.
A well designed play space takes into consideration spatial density and size, spatial
arrangem ents, and the organisation of m aterials. Play spaces need to include clearly
de® ned boundaries and have play materials explicitly organised, visible, clear,
accessible, and logically arranged around activities and them es (W olfberg, 1995) .
Occupational therapists can recom m end strategies such as appropriate placement
and accessibility/availability of toys, which can increase the likelihood that toys will
be used by the child. O bservation of the ways in which the child can access toys
(e.g., rolling across the ¯ oor to a toy, knocking toys over to get them within reach,
or requiring adult assistance) enables the therapist to determ ine best placement
strategies.
Play environm ents can provide children with developm ental disabilities with
opportunities to take risks and experience failure within a supportive context. Play
itself can provide a non-threatening environm ent in which a child can fail and learn
without any serious consequences (Bundy, 1993) . Children with developm ental
disabilities are often protected from taking risks and experiencing failure by well-
meaning parents and caregivers. Experiencing failure and disappointm ent are uni-
versal human experiences which can be experienced in a supportive play
environm ent.
Infants and toddlers as well as children with developmental disabilities are
stim ulated in their play when there is novelty in the arrangement of the environment
(Burke, 1993) . The use of novel objects as well as novel arrangem ents in the
environm ent are potent ways to in¯ uence play. Play spaces that have easy to move
F IG . 5. Snoezellen room s exemplify sensory rich environm ents which encourage curiosity and
exploration. Photograph courtesy of Toowoomba W est Special School, Education Queensland.
objects such as tables, chairs, boxes, shelves, bean bags, and assorted containers, are
able to be rearranged regularly , in an attem pt to keep the environm ent interesting
and continue to arouse curiosity. Novelty brings spontaneity which taps a child’ s
inner drive or his intrinsic m otivation. Snoezellen room s are an exam ple of play
spaces which prom ote exploration and curiosity (see Figure 5). As well as novelty,
variety has an im portant relationship to play (Burke). Placing fam iliar objects in
unpredictable places and rotating toys into storage and play space at regular intervals
can m aintain interest. W hile this m ay be useful for many children with developm en-
tal disabilities, for children with A SD , continual changes to the environm ent can be
distressing due to their insistence on sameness and routine. These changes need to
be considered carefully in term s of the disequilibriu m likely to be caused by the
change in the environment.
R esearchers have attem pted to classify and evaluate the effectiveness of toys used
with children with disabilities. Toys need to be novel, diverse, im m ediately reinforc-
ing, and com mensurate with the child’ s developm ental level, chronological age, and
functional level (W ehm an, 1976, 1983) . The purpose and function of a toy should
allow establishm ent of rapport, stimulation of senses, dem onstration of the child’ s
skills, and developm ent of skills and concepts (Tebo, 1986) . Tebo investigated toys
used by 30 teachers in early childhood special education settings. She found a major
distinction between toys used for free play and those used for structured learning.
Those used for free play were ones which stim ulated the child’ s interaction, while
those used for structured learning required an adult to initiate the interaction. W hile
this m ay be needed to teach play skills to children with severe intellectual disabilities,
Tebo raised concerns as to the effect of the repeated need for adult initiation in
term s of the interest value of the toy to the child. A ssistive technology has opened
up a range of opportunities for toy play for children with developm ental disabilities,
in that switch activated toys are able to elicit non-directed and appropriate interac-
tion (see Figure 2).
Therapists need to be aware of the child and fam ily’ s hom e routines, in order to
be able to facilitate playfulness in everyday interactions. Som e research (Johnson &
D eitz, 1985 ) has suggested that when com pared to their peers, m others of children
with physical disabilities spent less tim e in play and social interaction with their
children. This has implications for ® nding ways to encourage playful interaction
within daily routines to enhance the child’ s role as player and the parents’ enjoyment
of play with their child.
Assistive Technology to Enable Play
Children with physical, sensory, and com municative disabilities appear to have less
control over and participation in play and learning experiences (M istrett & Lane,
1995) . Lack of sensory awareness and limitations in exploratory behaviour drasti-
cally reduce the emergence of typical play activity. C hildren with disabilities often
lack sustained interaction during activity. External supports are needed to prom ote
play because the child may not pursue play for intrinsic pleasure resulting in
decreased exploratory curiosity. D iminished m otivation can result in passivity and
learned helplessness (Mistrett & Lane). Use of assistive technology has the potential
to increase independence, decrease passivity, and prom ote participation. Assistive
technology can help create play environm ents that are increasingly com plex, yet
accessible, and enhance the child’ s overall developm ent. Research has dem onstrated
that assistive technology can extend the play repertoires and interaction of young
children with disabilities (Behrm an, Jones, & W ilds, 1997 ; Behrman & Lahm ,
1984) . For som e children with signi® cant disabilities, assistive technology may be
the only means by which they can engage in play in a physically and socially
responsive environm ent.
A ssistive technology can provide these children with m ore success in directly
controlling their environm ent. This can reduce the risk of potential secondary
social-em otional and intellectual handicaps (Butler, 1997) . Care is needed to select
appropriate technology and identify strategies to prom ote independence, training,
and generalisation of technology use in play situations. Both high and low assistive
technology options should be considered (D eitz & Swinth, 1997 ; M istrett & Lane,
1995) . A num ber of factors need to be considered before selecting any assistive
technology for a child. Evaluation of the child is the ® rst step in identifying the
child’ s functional skills, physical and cognitive abilities, reliability of m ovement
patterns, and then the child’ s assistive technology needs. In addition, positioning,
method of access, availa bility of personnel, environm ental supports, selection of toys
or access to toys are other important considerations. In selecting a switch toy, the
toy’ s characteristics are m atched with the abilities and preferences of the child
(M istrett & Lane).
Increasingly technology is becoming availa ble for children as young as 18 m onths

of age. Early intervention is focusing on teaching switch use and scanning tech-
niques, for control of powered m obility, com munication, independent learning,
play, and environm ental interaction. Increased independence with m obility using
electric carts has allowed children with physical disabilities to be m ore independent
in indoor and outdoor play. This increased independence results in decreased need
for parental assistance and supervision, and increased interaction with peers (Butler,
1997) . Play involving exploration of space, objects, and com m unication with peers
and caregivers results from m ore independent mobility. The age of introducing
powered mobility is decreasing with some authors suggesting it can be trialed for
children as young as 20 months of age (Butler, 1997 ; D eitz & Swinth, 1997) . A s the
child becom es older, the types of play and leisure activities in which he or she wants
to engage should be taken into consideration when selecting manual or powered
wheelchairs (D eitz & Swinth).
Com puters and com munication devices such as vocal output com munication aids
(VO CAs) can be used to meet the com munication needs of children with disabili-
ties, therefore enhancing play. Children as young as 3 years of age can be assisted
to interact with peers in play situations, as well as in structured learning settings
through the use of augm entative and alternative comm unication system s (D eitz &
Swinth, 1997) . Teaching peers and play partners how to com municate with a
VOCA user is im portant in early intervention settings, if two way comm unication is
to be part of play.
M icrocomputers which can be accessed through a switch/es are being used with
children under three years. O ne use of com puters has been to stim ulate children
who could not m anipulate objects in their environm ent or play together with other
children, or who displayed lim ited interest in their surroundings (Butler, 1997) .
M icrocom puters are also providing new tools for recreation, which im plies the
concept of play. Single switch controls allow children to turn on a television, a tape
recorder to play favourite music or stories, listen to songs, control battery operated
toys and engage in play activities. Battery operated toys can provide a range of
sensory inputs for children with developmental disabilitie s and play with these toys
FIG. 6. Four-year-old boy playing using Touch Window Ô to make a picture with geometric shapes.
Photograph by Sharon M ickan, taken at Xavier Special School, Education Queensland, Brisbane.
is an im portant aspect of early intervention curriculums (Goossens & Crain, 1986) .

M ost battery operated toys can be adapted through the use of a switch. A t the
sim plest level cause and effect relationships can be enhanced and developed in play.
Activation of a toy through a switch can be tied to representational or sym bolic play,
involving com munication skills (Behrmann et al., 1997) . Socialisation activities can
be built in, having children take turns activating the toy and playing together or in
parallel. Following on, two switches can be introduced which activate different toys
producing opportunities for further discrim ination and choice-m aking. Com puter
software allows children to draw, paint, do art and craft, and listen to music.
M ovement of a cursor or use of touch windows allow a child unable to hold a crayon
to draw a line, press a switch and ® ll in colour or paint by num bers (Behrm ann
et al., 1997) (see Figure 6).
In sum mary, assistive technology can enhance the play of children with develop-
mental disabilities through the use of m obility devices, sim ple toy and environm ental
adaptations, the use of com puters, through augmentative and alternative com m uni-
cation systems, and through environm ental control system s. Assistive technology
itself is not a panacea, it m ust be applied appropriately so that children actively
participate in play as part of daily routines, both on their own and with play partners.
Assistive technology can also be used to com pensate for the physical limitations of
children with developmental disabilities.
Best Practices
Program s which implem ent best practices, that is, those which are developm entally
appropriate, are ones in which the prim ary vehicle for prom oting learning is
child-initiated, child directed, therapist and/or teacher supported play (Hanline &
Fox, 1993) . A range of strategies can be used from non-directive to directive based
on the focus of instruction and the needs of the individual child. Best practices
involve: use of age-appropriate m aterials and methods (i.e., toys and play equip-
ment), accom modating for individual development, learning through interacting
with peers, teaching within natural environm ents and meaningful routines, attention
to the developm ent of autonomy, choice-making, provision of opportunities for
self-initiation and use of the environment as a m ethod of facilitating play and
learning (Hanline & Fox).
H anline and Fox (1993 ) hypothesised four features of best practice: (a) instruc-
tion in play-based approaches should be conducted within reciprocal, horizontal
interactions with peers; (b) play-based approaches enhance motivation by em bed-

ding skill acquisition within child-directed activities that are relevant to and reinforc-
ing for the child; (c) instruction should maxim ise the use of natural cues and
reinforcers within natural activity routines and play; and (d) play-based instruction
should occur within a chain of behaviour that the child initiates. Play is clearly being
supported as an im portant avenue for enhancing skill developm ent in children with
developm ental disabilities. It is also the only m eans of facilitating children’ s speci® c
play skills as well.
W hile best practice guidelines have been identi® ed, the effectiveness of these
guidelines still have to be evaluated. Further research on the play development of
young children with disabilities is required if we are to re® ne our methods of
intervention appropriately.
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Play-based Occupational Therapy

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Play-based Occupational Therapy

ability to play m ay be in¯ uenced by developmental disabilities, outline occupational therapy

A major goal of occupational therapy is to enhance a person’ s ability to interact

Play and Occupational T herapy

Broadly speaking the m odel conceptualises play as an innate behaviour, univer-

Developm ental Skills

Social Skills and Choices

Children’ s ability to manage the social dimension of play is dependent on their

Freedom to Suspend Reality

represent actual or imagined experiences through the use of objects, motion, or

Physical and Social/Cultural Play Environment

Play-Based Assessm ent

Occupational therapists assess play behaviour by way of general observations, as part

Preschool Play Scale

(Bledsoe & Shepherd, 1982) .

Play Skills Inventory

D eveloped by Hurff (1980 ) the Play Skills Inventory is a collection of 20 possible

Transdisciplinary Play-Based Assessm ent

W hile not developed by occupational therapists, this assessment is included because

M odels of Service Delivery

occupational performance in hom e, preschool, school, and com m unity environ-

Play and Fram eworks for Intervention

Occupational therapists draw from a range of fram es of reference for intervention

Perceptual Motor Approaches

to be facilitated by m ore directed m eans, as these activities may be avoided by the

Neurodevelopmental Treatment Approaches

teristics of play experiences and activities (Blanche, 1997). Therapists need to be

Sensory Integration Fram e of Reference

increase in appropriate play behaviour and a corresponding decrease in targeted

The Environm ent as a Focus for Intervention

The environm ent is an important focus for intervention as occupational therapists

more likely to seek out that child again to play.

Assistive Technology to Enable Play

Increasingly technology is becoming availa ble for children as young as 18 m onths

is an im portant aspect of early intervention curriculums (Goossens & Crain, 1986) .

interactions with peers; (b) play-based approaches enhance motivation by em bed-

T AK ATA , N. (1974). Play as a prescription. In M . R EILLY (Ed.), Play as exploratory learning

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