Running head: TEST OF PLAYFULNESS 1

Use of the Test of Playfulness within Occupational Therapy Practice:

Increasing Playfulness in Children with Developmental Disabilities

Jacquelyn Szczepkowski

Trinity Washington University

School of Nursing and Health Professionals

Department of Occupational Therapy

October 5, 2017
TEST OF PLAYFULNESS 2

Abstract

Enabling participation in occupation is the primary goal of occupational therapy

intervention and play is widely considered the primary occupation of childhood. Play is

fundamental to children’s mental, physical, social, and emotional development. The Test of

Playfulness (ToP) is an assessment designed to measure playfulness, or a child’s approach to

play. It measures four elements of play: intrinsic motivation, internal control, freedom to

suspend reality, and framing. This paper will review studies in which the ToP has been used to

study the playfulness of children with developmental disabilities, including developmental delay,

cerebral palsy, autism spectrum disorder, prenatal alcohol exposure, and attention deficit

hyperactivity disorder. Studies in which the ToP assessed the effectiveness of interventions on

playfulness were also reviewed, including environmental modifications, sensory integration,

caregiver support, and play-based interventions. Findings support the use of the ToP within

pediatric occupational therapy practice as an effective measure of playfulness. More research is

needed to develop and test interventions that help increase playfulness and enable participation

in play for children with developmental disabilities.

Keywords: play, playfulness, Test of Playfulness, ToP, play-based occupational therapy,

play assessments, developmental disabilities

TEST OF PLAYFULNESS 3

Table of Contents

Chapters Page

1. Introduction……………………………………………………………………………………4

Play as Occupation……………………………………………………………………….4

Value and Meaning of Play………………………………………………………………5

Assessment of Play……………………………………………………………………….6

Statement of the Problem…………………………………………………………………9

2. Review of the Literature……………………………………………………………………....10

Measuring Playfulness in Children with Disabilities……………………………………10

Measuring the Effectiveness of Interventions……………………………………………11

Benefits for Occupational Therapy Practice……………………………………………..13

Limitations……………………………………………………………………………….14

3. Method………………………………………………………………………………………...16

4. Results…………………………………………………………………………………………17

5. Discussion……………………………………………………………………………………..19

Conclusion……………………………………………………………………………….20

References………………………………………………………………………………………..22
TEST OF PLAYFULNESS 4

Use of the Test of Playfulness within Occupational Therapy Practice:

Increasing Playfulness in Children with Developmental Disabilities

Chapter 1

Introduction

Play as Occupation

The ultimate goal of occupational therapy intervention is to enable the client’s

participation in occupation (AOTA, 2014). Occupation refers to the client’s engagements in

daily life that consist of various activities (AOTA, 2014). Occupational therapists consider play

to be the primary occupation of childhood (Rodger & Ziviani, 1999). Due to the central role of

the occupation of play in the lives of children, and the central role of occupational therapists to

elicit participation in occupation, it is evident that an effective assessment of play and

playfulness is crucial for pediatric occupational therapists.

A holistic focus distinguishes occupational therapy from other professions (AOTA,

2014). Occupational therapists widely recognize the importance of multiple and interconnected

elements on occupational performance (Bundy, Waugh, & Brentall, 2008). Occupational

therapists look at body structures, performance skills, performance patterns, and various

contexts, as well as life occupations (AOTA, 2014). Looking at a child’s play takes a holistic

approach because within play children engage their body functions, develop and demonstrate

their motor, process, and social interaction skills, and interact with their environments. Yet,

despite play’s holistic nature, a reductionist view of play is perpetuated within occupational

therapy practice, which tends to focus on performance components rather than play’s value as

the primary occupation of childhood (Cameron, Leslie, Teplicky, Pollock, Stewart, Toal, &
TEST OF PLAYFULNESS 5

Giak, 2001). Assessment tools that evaluate play as an occupation may help bridge this gap

between theory and practice (Cameron, et al., 2001).

Value and Meaning of Play

A rights-based perspective highlights the need to have a clear understanding of what play

is to children (Davey & Lundy, 2011). Children’s right to play is deemed a fundamental human

right according to Article 31 of the United Nations Convention on the Rights of the Child

(UNCRC) (Davey & Lundy, 2011). The broad definition of play in the UNCRC treaty makes

ensuring the right to age-appropriate play difficult (Davey & Lundy, 2011). An understanding of

what play looks like is crucial to ensuring the basic rights of children, advocating on their behalf,

and developing interventions that maximize access and ability to play. The Test of Playfulness

seeks to give a structured framework to observing play that helps define what play truly looks

like.

In order to utilize play within intervention, occupational therapists must have an

understanding of the value of play as a means of acquiring diverse skills, and as a worthwhile

goal within itself. Play is fundamental to children’s mental, physical, social, and emotional

development. Though defining and measuring play has proven to be challenging (Howard &

McInnes, 2012), one needs clear definitions of the elements of play in order to assess a child’s

occupational performance and use play appropriately within intervention.

If the critical elements of play are not present, an adult may believe an activity has all the

benefits and characteristics of play, when in fact it does not. For example, the factor of choice is

so important to play that it’s presence or absence can determine if a child views an activity as

play or not-play (Howard & McInnes, 2012). Howard & McInnes (2012) found that children

demonstrated increased emotional well-being, problem solving, and improved performance when
TEST OF PLAYFULNESS 6

they perceived an activity as play. In their study, three elements differed between the “like play”

group and the “not like play” group (Howard & McInnes, 2012, p. 739). In the condition that

was experienced as play, the children performed the activity on the floor, had the choice to

participate or not, and the adult was situated proximal to the children. The identical activity was

not experienced as play when it was performed on a table, without the option to not participate,

and with an adult present (Howard & McInnes, 2012). Knowing such qualities of play is

important for occupational therapists attempting to provide play-based interventions and value

the occupation of play within their practice. The benefits of play, such as improved self-

regulation, confidence, autonomy, motivation, meta-cognition, and skill acquisition, will not be

optimally acquired if intervention planning does not consider the true nature of a playful activity

(Howard & McInnes, 2012). The occupation of play cannot be separated from the child’s

subjective experience of playfulness and still retain its benefits (Howard & McInnes, 2012).

Assessment of Play

Anita Bundy’s model of playfulness addresses these components that distinguish play

from not play, including intrinsic motivation, internal control, and freedom to suspend reality

(Parham, 2008). The Test of Playfulness was developed based on Bundy’s model, in order to

measure playfulness and promote play as a goal of occupational therapy practice (Parham, 2008).

Play is regarded as intrinsically motivated and engaged in for the process of doing it, more than

for the product or outcome (Skard & Bundy, 2008). Internal control is another characteristic of

play, in which players make decisions about who to play with, what to play, and when and how

to play it (Skard & Bundy, 2008). Freedom to suspend reality is the third element of play,

described by Skard & Bundy as the freedom to choose how close to objective reality the play

will be (2008). Each quality of play exists on a continuum; it is not necessarily desirable or
TEST OF PLAYFULNESS 7

possible for play to be entirely “intrinsically motivated, internally controlled, or free of the

constraints of reality” (Skard & Bundy, 2008, p. 73). However, the greater the presence of these

qualities within an activity, the more that activity resembles play (Skard & Bundy, 2008). An

additional element of playfulness included in the ToP is called framing, and refers to the child’s

ability to give and read social cues within a play transaction (Skard & Bundy, 2008).

Common assessments of play focus on the developmental skills used in play, the

activities that the child participates in, or whether or not skills fit the demands of the activity.

These include the Revised Knox Preschool Play Scale, which focuses on developmental aspects

of play (Knox, 2008), interest profiles and assessments of play and leisure, which focus on the

activities (Henry, 2008), and play history interviews and narratives (Bryze, 2008). These

assessments have strengths and limitations. One limitation is that they do not consider a child’s

disposition toward play, or playfulness (Skard & Bundy, 2008).

Anita Bundy developed the Test of Playfulness because she believed the crucial element

of playfulness was missing from other play assessments (Skard & Bundy, 2008). Playfulness, or

the way a child approaches a task, may be more important than any play activity itself, due to the

high correlation of playfulness with coping skills or adaptability (Skard & Bundy, 2008). It is

thus, in addition to play skills and play activities, an important area to evaluate in occupational

therapy practice.

The Test of Playfulness was designed to evaluate the child’s disposition toward play, or

playfulness (Skard & Bundy, 2008). The ToP is a process-oriented observational assessment

that is administered for 15 minutes indoors and 15 minutes outdoors while the child is engaged in

free play (Skard & Bundy, 2008). The view of play as an occupation considers the interaction

between the child, the environment, the process of play, and the outcome of play (Rodger &
TEST OF PLAYFULNESS 8

Ziviani, 1999). The Person-Environment-Occupation (PEO) model is helpful for considering the

influences of various factors on a child’s play behaviors (Rodger & Ziviani, 1999). However,

assessments of play are often conducted in clinical environments that remove the child from

natural contexts for play (Bundy, Waugh, & Brentnall, 2008). If an assessment of play does not

consider the influence of physical and social environments, it will not capture all the strengths

and limitations of the child’s participation in play in his or her daily life. The Test of Playfulness

is conducted in natural settings, both indoors and outdoors, so that it may capture environmental

influences on the playfulness of the child (Skard & Bundy, 2008).

The ToP may be used to assess children from six months of age to 18 years (Pearton et

al., 2014). The play is videotaped and scored by a trained professional (Skard & Bundy, 2008).

In version four of the ToP, 30 items are rated on a four-point Likert scale with respect to extent,

intensity, and skillfulness (Pearton, Ramugondo, Cloete, & Cordier, 2014). Extent refers to the

proportion of time engaged in the behavior, intensity refers to the degree of engagement, and

skill refers to the adeptness, ease, or ability demonstrated (Skard & Bundy, 2008). The concepts

described previously that clarify what to look for when assessing the playfulness of a child,

including intrinsic motivation, internal control, freedom to suspend reality, and framing, are

further broken down and operationalized in order to be measurable for the ToP assessment

(Skard & Bundy, 2008). Examples of the items assessed in the ToP include pretending, which

demonstrates freedom to suspend reality, and initiates interaction, which shows internal control

(Skard & Bundy, 2008). The ability to break down an occupation as vast as play into measurable

components is a huge step toward understanding the experience of play within the lives of

children with disabilities.

TEST OF PLAYFULNESS 9

The ToP is found to have high inter-rater reliability, moderate test-retest reliability,

strong construct validity, is valid across cultures and sexes, and for children with and without

disability (Pearton et al., 2014). It is not a norm-referenced test, and is designed as an

individualistic measure of a child’s play characteristics (Cameron et al., 2001).

Statement of the Problem

In order for pediatric occupational therapy practice to reflect the overarching aim of the

profession, to enable participation in occupation (AOTA, 2014), it must view participation in

play as an end goal of intervention. Occupational therapy practice commonly views play as a

means to skill acquisition, but less often as a goal within itself (Parham, 2008). Children with

developmental disabilities have been shown to have deficits in play behaviors (Okimoto, Bundy,

& Hanzlik, 2000). This literature review seeks to discover if the Test of Playfulness is an

effective assessment tool for measuring playfulness in children with developmental disabilities.

Additionally, is the ToP helpful in measuring the effectiveness of interventions designed to

increase playfulness in these populations? Most importantly and overall, this review seeks to

establish the usefulness of the Test of Playfulness in occupational therapy practice.

TEST OF PLAYFULNESS 10

Chapter 2

Review of the Literature

Measuring Playfulness in Children with Disabilities

Children with disabilities often experience barriers to their participation in play (Graham,

Truman, & Holgate, 2015). The Test of Playfulness has been used to assess the approach to play

of children with and without disabilities (Okimoto et al., 2000). Using the Rasch measurement

model, reliability and validity have been established for various populations, including children

with cognitive impairments, infants, and children with physical disabilities (Okimoto et al.,

2000). This high reliability may be partially due to the inclusion of children with disabilities in

the development of the assessment tool (Muys, Rodger, & Bundy, 2006). Once test reliability

and validity is established for a population, the ToP may be used to learn about the playfulness

profiles of various populations, assess the individual play style of a particular child, and evaluate

the effectiveness of interventions designed to increase playfulness.

The Test of Playfulness reveals useful information regarding play for children with

disabilities. Using the ToP, children with cerebral palsy were shown to have physical and social

barriers to play, but showed inherent playfulness when barriers were decreased (Okimoto et al.,

2000). For children with sensory processing disorder, playfulness scores were higher during

sedentary play than active play (Bundy, Shia, Qi, Miller, 2007), revealing both strengths and

limitations that can inform intervention planning. Children with autism spectrum disorder

(ASD) showed deficits in reading social cues (Muys, Rodger, & Bundy, 2006), whereas a study

of children with prenatal alcohol exposure (PAE) showed that an area of relative strength for

children with PAE was in framing, or giving and responding to social cues (Pearton et al., 2014).
TEST OF PLAYFULNESS 11

Pearton et al. (2014) thus suggested that a strengths-based approach could possibly improve

overall playfulness scores for children with PAE.

Measuring the Effectiveness of Interventions

The Test of Playfulness has also been shown to be a reliable and valid measure for use

with children with ASD (Muys et al., 2006), cerebral palsy (CP), and developmental delays

(Okimoto et al., 2000). The ToP has been subsequently used to determine the effectiveness of

specific interventions for populations of children with developmental disabilities, leading to

interesting findings that can inform further efforts to design appropriate occupation-enabling

interventions.

For example, a play-based intervention to increase empathy in children with attention

deficit hyperactivity disorder (ADHD) was found to effectively raise ToP scores for items

reflecting interpersonal empathy, including the skill of sharing ideas or objects, and the skill of

responding to play cues (Wilkes, Corider, Bundy, Docking, and Munro, 2011). The ToP has also

been used to show when an intervention is ineffective. Studies have demonstrated that scores of

playfulness in children with ASD were resistant to improving with intervention (Bundy, Luckett,

Naughton, Tranter, Wyvery, Ragen, Singleton, & Spies, 2008), showing that more research is

needed in order to increase playfulness in this population, though certain skills such as social

communication have elsewhere been shown to improve through play-based interventions for

children with ASD (Fabrizi, Ito, & Winston, 2016). A study by Fabrizi et al. (2016) tested the

effects of a community playgroup and caregiver support on the playfulness of children from an

early intervention program. The significant improvements in ToP scores post-intervention

indicated the benefits of community playgroups on young children with disabilities (Fabrizi et
TEST OF PLAYFULNESS 12

al., 2016). It also indicated that playfulness increased when caregiver responsiveness increased,

suggesting the benefit of interventions that support caregivers (Fabrizi et al., 2016).

One study investigated the effectiveness of using an adapted Lego robot during free play

on the playfulness of children with CP, and found that ToP scores increased (Rincon, Adams,

Magill-Evans, & Cook, 2016), thus showing a way to enhance participation in the occupation of

play for children with CP. This approach supports the finding that interventions to change

behavior are more effective than interventions to change impairments in children with motor

deficits (Kolehmainen, Frnacis, Ramsay, Owen, McKee, Ketelaar, & Rosenbaum, 2011). When

interventions are designed to reduce physical barriers to play and enhance parental

communication, children with CP show increased playfulness (Bundy, et al., 2008). A top-down

assessment approach that values occupational participation, by using an instrument such as the

ToP, lends itself to the development of an intervention to enhance playfulness and the many

benefits associated with playfulness, such as coping (Saunders, Sayer, & Goodale, 1999) and

empathy (Wilkes et al., 2011); whereas an assessment that focuses on identifying impairments

may not.

The Test of Playfulness can also be instrumental in research that helps practitioners

advocate for play for children with and without disabilities. Researchers in Sydney, Australia

used the ToP to assess children’s playfulness before and after environmental modifications to

their mainstream school playground (Bundy et al., 2008). The asphalt playground with gross

motor equipment, including balls and jump ropes, was enhanced by adding “loose parts”, or

materials without a fixed play purpose, such as cardboard boxes, wooden planks, and tires

(Bundy et al., 2008, p. 524). This environmental modification was shown to improve

playfulness scores in the children (Bundy et al., 2008). Teacher observations of increased
TEST OF PLAYFULNESS 13

creativity, focus, coping skills, resilience, and social play, and decreased aggression, confirmed

the benefit of adding loose parts to the playground environment (Bundy et al., 2008). Although

the children in the study were children without disabilities, the results have positive implications

for children with disabilities. By changing the physical environment, the social environment

changed as well (Bundy et al., 2008). Prior to the modifications, children most skilled in sports

led the play on the playground (Bundy et al., 2008). Adding materials that favored skills of

imagination, rather than physical prowess, shifted the social play dynamic so that children who

were previously “sidelined in sports activities” became leaders in the new creative play activities

(Bundy, et al., 2008, p. 526). This demonstrates the significance of the environment in enabling

participation in play, and suggests ways that occupational therapists, educators, families, and

caregivers can support play participation for children with disabilities by adapting the

environment.

Benefits for Occupational Therapy Practice

Using the Test of Playfulness in clinical practice benefits occupational therapists beyond

the usefulness of the tool for assessment. In a study by Cameron et al. (2001), pediatric

occupational therapists gave feedback on the clinical utility of the ToP. Therapists reported that

the ToP gave them a structured framework for observing play, increased their awareness of the

importance of environmental fit, and enhanced their recognition of the importance of free play in

the lives of children (Cameron et al., 2001). The ToP helped broaden their views of individual

children by revealing strengths and deficits that were not observed through other means of

assessment (Cameron et al., 2001).

The ToP also helped facilitate sharing information about play with caregivers (Cameron

et al., 2001). Parents of children with disabilities can feel a burden of guilt when they do not
TEST OF PLAYFULNESS 14

direct play toward therapeutic goals (Graham, Truman, & Holgate, 2015). It is therefore

important for them to learn of the benefits of free play, even without a therapeutic focus (Graham

et al., 2015). Occupational therapists familiar with assessing playfulness in children may also

help families learn new ways to facilitate their children’s play, and may indirectly help relieve

the family’s burden by teaching children independent play skills within intervention (Graham et

al., 2015).

The Test of Playfulness can also help remove practitioners’ erroneous assumptions

regarding a child’s play behaviors (Cameron et al., 2001). For example, children with severe

motor impairments may receive high playfulness scores because internal locus of control,

intrinsic motivation, and suspension of reality are present (Cameron et al., 2001). On the other

hand, a physically active child may unexpectedly receive low scores (Cameron et al., 2001).

“The ToP’s occupation based focus helps to move the emphasis in occupational therapy

assessment away from the child’s performance component deficits” (Cameron et al., 2001, p.

109). Occupational therapists who become familiar with using this tool may be able to shift to a

more occupation-based and holistic perspective in their practice.

Limitations

Occupational therapists who gave feedback on the utility of the ToP reported some

limitations with using the evaluation tool (Cameron et al., 2001). They reported that it was

challenging to interpret the results without concrete interpretation guidelines, though they found

it easy to administer and score (Cameron et al., 2001). The ToP also lacked normative data to

determine the age appropriateness of play behaviors (Cameron et al., 2001). The therapists also

raised questions regarding the practicality of using the ToP in practice, feeling that competing

priorities make it difficult to allot time for the observation of free play (Cameron et al., 2001).
TEST OF PLAYFULNESS 15

While certain skills may be assessed in a short amount of time, the occupational therapists did

not feel that the ToP observation time of 15 minutes was enough to gain a realistic picture of a

child’s playfulness (Cameron et al., 2001).

Another limitation to the ToP is that it focuses assessment on the child, without detailed

attention to the influence of the environment (Muys et al., 2006). Although the Test of

Environmental Supportiveness (TOES) was designed to be used in conjunction with the ToP, in

order to account for environmental influences on play, (Bundy, Waugh, & Brentnall, 2008),

using the ToP alone does not provide a framework for understanding these influences.

Therefore, occupational therapists who use the ToP as a stand-alone assessment will have to rely

upon their own skill set to interpret the environmental factors that contribute to the person-

environment-occupation interaction. The ToP does encourage observation in natural play

environments that are both indoors and outdoors (Skard & Bundy, 2008). Though the focus of

assessment is on the child and not the environment, the inclusion of natural contexts is an

improvement over observations that occur in clinical settings. However, as playfulness and play

are too complex to rely solely upon unstructured observation skills, dynamic environmental

influences on play could also use a structured evaluation tool in order to be properly understood.

If the goal of using the ToP is to increase holistic and occupation-focused practice, detailed

attention to environmental influences, and guidance on interpreting ToP results, would be

helpful.
TEST OF PLAYFULNESS 16

Chapter 3

Method

To gather literature relevant to the topic, WRLC Library Services for Trinity Washington

University was the primary search engine used. Google scholar was also searched. Databases

searched included CINAHL, Nursing and Allied Health Database, psychINFO, and Academic

OneFile. Terms searched were “playfulness”, “Test of Playfulness”, “occupational therapy”,

“play assessments”, “Anita Bundy”, “children with disabilities”, “developmental disabilities”,

and “play-based occupational therapy”. Only peer-reviewed, scholarly, and full-text articles

available in the library collection were selected. Initial searches were limited to the past ten

years, but were then expanded to include articles as far back as the 1990s, for background theory

and evidence on the assessment and topic of this review. A textbook central to the subject was

also used, Play in Occupational Therapy for Children.

TEST OF PLAYFULNESS 17

Chapter 4

Results

Various uses for the Test of Playfulness were gathered from the literature. Studies that

tested the playfulness profiles of specific disabilities yielded information that can benefit

occupational therapists working with these populations. Disabilities measured for playfulness

included sensory processing disorder (SPD) (Bundy, Shia, Qi, & Miller, 2007), autism spectrum

disorder (Muys et al., 2006), cerebral palsy and developmental disabilities (Okimoto et al., 2000;

Hamm, 2006), and prenatal alcohol exposure (Pearton et al., 2014). These studies all

demonstrated playfulness deficits in the populations studied. Some studies led to results that

indicated play preferences and strengths that could inform intervention plans, such as the relative

strength of framing in children with prenatal alcohol exposure (Pearton et al., 2014) and the play

preference for sedentary activities in children with SPD (Bundy et al., 2007). Some studies first

tested and confirmed the reliability and validity of the ToP for the populations studied (Hamm,

2006; Okimoto et al., 2000), while other studies were conducted on the knowledge that reliability

and validity had already been established (Pearton et al., 2014; Muys et al., 2006).

A handful of studies tested the effectiveness of interventions designed to improve ToP

scores for children with and without disabilities, including a sensory integration intervention for

children with sensory processing disorder (Bundy et al., 2007), a robotic intervention for children

with cerebral palsy (Rincon et al., 2016), environmental modifications for a diverse group of

typically developing 5-7 year olds (Bundy et al., 2008), a play-based intervention for 5-11 year

olds with attention deficit hyperactivity disorder (Wilkes et al., 2011), and a playgroup

intervention for children with various disabilities in early intervention (Fabrizi et al., 2016).
TEST OF PLAYFULNESS 18

Playfulness increased in all of the interventions reviewed, with the exception of the sensory

integration intervention for children with SPD, which was found to be ineffective for improving

ToP scores (Bundy et al., 2007). One study was reviewed that utilized ToP results to create

measurable goals to increase playfulness for a ten-year-old with special needs (Hindmarsh-Hook,

2005). This model of an individualized intervention plan (Hindmarsh-Hook, 2005), along with

the results of research on play-enabling interventions, may help practitioners formulate

intervention plans that aim to increase participation in the occupation of play.

In addition to looking at the ToP profiles of various developmental disabilities and the

effectiveness of interventions for raising ToP scores, literature was also reviewed to enhance

understanding of the Test of Playfulness, play in children with disabilities, and the need for an

assessment that measures playfulness within occupational therapy practice (AOTA, 2014;

Cameron et al., 2001; Bundy, 1993; Bundy et al., 2008; Howard & McInnes, 2012; Rodger &

Zivianni, 1999; Davey & Lundy, 2011; Skard & Bundy, 2008; & Graham et al., 2015). These

studies all supported the importance of play in the lives of all children, and the need for

occupational therapists to use an effective assessment tool for measuring playfulness.

Aside from the above uses of the ToP, the measure may also be used in research that can

help advocate for the significance and benefits of play. One study further proved play’s benefits

by investigating the relationship between playfulness and coping in preschool children (Saunders

et al., 1999). Saunders et al. (1999) added support to the goal of enabling playfulness in

occupational therapy practice in order to improve children’s adaptability for all life skills.

The underlying consensus of the literature reviewed, from studies that show benefits or

deficits of play to studies that show the effectiveness of intervention, is that the Test of

Playfulness is a beneficial tool to be used in occupational therapy practice.

TEST OF PLAYFULNESS 19

Chapter 5

Discussion

Anita Bundy designed the Test of Playfulness in order to help promote play as a distinct

goal of occupational therapy practice (Parham, 2008). Despite the influence Bundy’s research

had in the 1990s on reorienting the profession back to valuing play, occupational therapy

practice continued to have a strong functionalist perspective, viewing play more as a means to

functional goals than an outcome of treatment (Parham, 2008). Pressures of academic goals in

school settings, and reimbursement issues in other settings, make it challenging to translate

evidence on play into practice (Parham, 2008). Yet Bundy has developed this “ingenious

assessment tool” to help bridge the gap between theory and practice (Parham, 2008, p. 25).

The Occupational Therapy Practice Framework (OTPF), published by the American

Occupational Therapy Association (AOTA) for the purpose of guiding and structuring

occupational therapy practice, regards play as one of eight areas of occupation addressed by

practitioners (AOTA, 2014). The OTPF declares that “achieving health, well-being, and

participation in life through engagement in occupation is the overarching statement that

describes the domain and process of occupational therapy in its fullest sense” (AOTA, 2014, p.

S4). This confirms the critical need to regard participation in play, widely acknowledged as the

primary occupation of childhood, as a central goal within pediatric occupational therapy practice.

Despite the barriers to bridging this gap between play theory and clinical practice, the ToP offers

support to the goal of participation, both as a tool used in research to support evidence-based

practice, and as an assessment tool to be used by practitioners.

TEST OF PLAYFULNESS 20

Due to high reliability and validity in testing the playfulness of children with and without

disabilities (Skard & Bundy, 2008), the ToP has been used in studies to prove whether or not

certain interventions increase playfulness in various populations (Bundy et al., 2007; Rincon et

al., 2016; Bundy et al., 2008; Wilkes et al., 2011; & Fabrizi et al., 2016). The findings from

these studies can inform evidence-based occupational therapy practice. Playfulness strengths

and deficits common to various developmental disabilities have also been uncovered through use

of the ToP in research (Okimoto et al., 2000; Hamm, 2006; Pearton et al., 2014; Muys et al.,

2006; & Bundy et al., 2007). This knowledge also promotes the inclusion of play as an end goal

of occupational therapy practice. The demonstration of play’s correlation with emotional well-

being (Howard & McInnes, 2012) and adaptive behavior (Saunders et al., 1999) adds to the

knowledge base that supports play as an outcome of intervention.

Though barriers to interpreting and applying ToP results exist, occupational therapists

who utilized this measure reported an expanded awareness of the significance of play, and an

increased understanding of their clients’ abilities (Cameron et al., 2001). The increased

awareness of the value of play is an important outcome of research. Though there are external

obstacles to applying play research to practice, such as institutional expectations, the internal

barrier of a lack of understanding is one that can be removed through knowledge. A shift in

perceptions about play among practitioners will help elevate play’s role in occupational therapy

practice. The Test of Playfulness, by giving a structured framework to the observational

evaluation of play, is one instrument that can help bridge evidence to practice.

Conclusion

More research is needed to test interventions that increase playfulness in children with

disabilities. The Test of Playfulness may be used as a reliable and valid measure to assess play
TEST OF PLAYFULNESS 21

deficits, develop intervention plans, and test the effectiveness of those interventions in increasing

participation in the occupation of play. Though the Test of Playfulness can be used in

occupational therapy practice to assess the disposition toward play of individual children,

without more research into interventions that improve playfulness scores, practitioners may not

know how to apply the results of the assessment. Another important use for the Test of

Playfulness within research is to continue to build the evidence base that demonstrates strong

correlations between playfulness and skill development in various areas. Since play participation

as a goal within itself continues to be undervalued in occupational therapy practice, more

research into play’s value would clearly be helpful. More knowledge on play promotes

advocacy into areas beyond occupational therapy practice, and can empower parents and

educators to advocate for children’s right and need to play. The goal of occupational therapy

practice is to enable participation in life occupations (AOTA, 2014). Regarding play

participation as a central role of occupational therapy practice requires educating communities,

families, and educators about the significance of play in children’s development. Use of the Test

of Playfulness within research and practice will help move the profession more toward the goal

of increasing playfulness in children with disabilities, and enhancing participation in play.

TEST OF PLAYFULNESS 22

References

American Occupational Therapy Association. (2014). Occupational therapy practice framework:

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