Peds: Chap 11 Assessment and Treatment of Play

What Is Play?

• Hard to define, but recognized by its core characteristics:

  • Spontaneous, fun, or joyful

  • Intrinsically motivated – done for its own sake, not for external reward

  • Internally controlled – child chooses how and what to play

  • Process-focused – enjoyment comes from the experience, not the outcome

  • Pretend or “as-if” elements – includes imagination and symbolic actions

  • Active engagement – involves thinking, problem-solving, and movement

  • Often social – includes interaction with peers, siblings, or adults

Play Theories

Older Play Theories

• Surplus Energy Theory

  • Play uses up excess energy not needed for survival tasks.

• Recreation or Relaxation Theory

  • Play restores energy and relaxes the body after work or stress.

• Practice (Pre-Exercise) Theory

  • Play allows children to practice adult skills (e.g., hunting, nurturing).

• Recapitulation Theory

  • Play reflects stages of evolutionary development (e.g., climbing = ancestral traits).

Modern Play Theories

• Psychoanalytic Theory (Freud)

  • Play helps children express and resolve unconscious conflicts and emotions.

• Arousal Modulation Theory

  • Play helps regulate sensory input and maintain optimal arousal levels.

• Metacommunicative Theory

  • Children use play to explore communication rules and social roles (e.g., pretend play with cues like “Let’s pretend…”).

• Cognitive Theories (Piaget, Vygotsky)

  • Play promotes problem-solving, learning, and development of thinking skills

  • Piaget: Play reflects cognitive stages

  • Vygotsky: Play supports social learning and self-regulation

Historical Foundations of Play in OT

• Adolf Meyer

  • Emphasized the balance of work, play, rest, and sleep as essential to health and well-being.

• Hull House (Jane Addams & Eleanor Clarke Slagle)

  • Early OT roots; provided structured play and activity programs to support immigrants and children in need.

• Mary Reilly

  • Advocated for the importance of play and work in development.

  • Introduced the concept of the "drive of curiosity" leading to:

    • Exploration

    • Competency

    • Achievement

• Takata, Florey, and Knox

  • Developed some of the first formal play assessments in OT (e.g., Knox Preschool Play Scale, Takata Play History).

• Emergence of Play as an Occupation

  • Recognized as a legitimate, purposeful, and therapeutic activity.

  • Supports development in motor, cognitive, emotional, and social domains.

  • Play is now considered a central occupation of childhood.

Examining Play in Natural Environments

• Form

  • What the play looks like (e.g., object play, pretend play, physical play)

  • Observable actions and types of activities

• Function

  • Why the child is playing

  • Purpose of the play (e.g., exploration, social bonding, skill building)

• Meaning

  • What play means to the child

  • Emotional experience, personal value, motivation behind the play

• Context

  • Where, when, and with whom the play occurs

  • Includes physical setting, social partners, cultural influences, and family routines

Examining Playfulness

• Playfulness is the child’s approach or attitude toward play

• Includes:

  • Intrinsic motivation

  • Internal control

  • Suspension of reality (pretend play)

  • Framing (social cues and communication during play)

Physical, Social, and Cultural Context

Physical Context

• Playgrounds & Play Spaces: Affect accessibility, safety, and creativity

• Toys & Materials: Influence type, complexity, and diversity of play opportunities

Social Context

• Parent & Peer Interactions: Shape social skills, imagination, and cooperation

• Parenting Style & Playfulness: Supportive vs. controlling styles impact child’s engagement

• Sibling Play: Promotes shared routines, imitation, and negotiation

• Adult Presence: Can either facilitate or limit spontaneous, independent play

• Gender Influences: Social expectations may shape types of play (e.g., rough-and-tumble vs. nurturing)

Cultural Context

• Perceptions of Play: Some cultures value play as learning; others may emphasize structured tasks

• Time Use: Varies by culture—some prioritize academics or chores over free play

• Play Forms: Cultural norms shape games, toys, and role-play scenarios

Temporal and Virtual Context

Temporal Context

• Historical Changes: Play has evolved (e.g., from outdoor free play to more digital play)

• Daily/Seasonal Rhythms: Time of day or season can influence energy levels and play type

Virtual Context

• Digital Play Spaces: Includes video games, virtual worlds, and apps

• Pros & Cons: Can support learning and socialization but may reduce physical and imaginative play

Intersection of Contexts

• Multiple contexts interact (e.g., a child’s play may be shaped by cultural expectations, parent behavior, and digital tools all at once)

• Context affects access, meaning, and engagement in play

Play Deprivation

• Can result in:

  • Delayed development (motor, cognitive, language)

  • Self-stimulation behaviors (e.g., rocking, hand-flapping) due to lack of sensory input

  • Difficulties with social interaction (limited play skills, poor communication)

  • Difficulties with mental health (e.g., anxiety, depression, attachment disorders)

• Highlights the critical role of play, interaction, and stimulation in early development

Leisure

• Definition:
  Nonobligatory activity that is intrinsically motivated and done during discretionary time—not during required tasks like work, self-care, or sleep

• Importance:

  • Supports development, identity, and quality of life

  • Enhances mental health, social skills, and life satisfaction

• Key Factors:

  • Driven by preference, desire, and internal motivation

  • Not “assigned” or required—chosen freely by the individual

• Barriers for Youth with Disabilities:

  • Physical, cognitive, or social limitations

  • Lack of access, support, or inclusive opportunities

  • May require adapted activities, environments, or social facilitation

Play and Leisure Assessment

• Considerations:

  • What the child is doing (type of play/leisure)

  • Why they are engaging (motivation, purpose)

  • How they engage (socially, independently, skillfully)

• Assessment Methods:

  • Observation in natural environments

  • Interviews with child and caregivers

  • Standardized tools (e.g., Knox Preschool Play Scale, CAPE/PAC)

• Focus Areas:

  • Attitudes & preferences (likes, dislikes, motivations)

  • Playfulness (intrinsic motivation, creativity, spontaneity)

  • Developmental competencies (motor, cognitive, social skills expressed through play)

Play Intervention

1. Play as a Tool

   • Play is used to develop a specific skill

   • Requires activity analysis to match the toy or activity to the child’s needs

   • Example: Using a puzzle to improve fine motor or problem-solving skills

2. Play as a Reward

   • Used as positive reinforcement after completing non-preferred tasks

   • Motivates participation in other therapy activities

   • Example: Earning 5 minutes of free play after finishing handwriting exercises

3. Play as an Occupation

   • Play is the goal itself

   • Focus on developing play skills, play performance, or playfulness

   • Encourages intrinsic motivation and exploration of preferences

   • Example: Supporting imaginative play or social play development

Facilitating Playfulness

• Attitude:

  • Warm, curious, enthusiastic, and open to the child’s ideas

• Body Language:

  • Animated expressions, inviting gestures, relaxed posture

• Speech:

  • Expressive tone, varied pitch, playful language, sound effects when appropriate

• Modeling Playfulness:

  • Demonstrate how to be silly, creative, or imaginative during activities

• Use of Novelty:

  • Introduce new or unexpected elements to spark interest and engagement

• Imaginary Play:

  • Willingness to participate in pretend or symbolic play with the child

• Having Fun:

  • Show genuine enjoyment—children notice and respond to authenticity

• Shared Control & Decision-Making:

  • Allow the child to make choices and negotiate the flow of play

  • Encourages collaboration and builds trust

Importance of Modifying, Adapting, and Assistive Technology

• "Just Right" Challenge:

  • Activity is not too easy or too hard—matches the child’s skill level and promotes growth.

• Fun Over Frustration:

  • Activities should be enjoyable to maintain engagement and motivation; avoid boredom or overwhelm.

• Promote Access & Choice:

  • Adapt tasks and environments to ensure the child can fully participate and explore a variety of options.

• Safety is Critical:

  • Always consider physical, emotional, and environmental safety to support risk-taking within a secure framework.

Additional Roles of the OT in Pediatric Practice

• Education of Others

  • Teach parents, teachers, and caregivers about development, strategies, and the value of play and occupation

  • Promote understanding of adaptive behaviors and support needs

• Coaching

  • Collaborate with families and staff to set goals, model strategies, and reflect on progress

  • Empower others to support the child’s participation in daily routines

• Advocacy

  • Promote inclusion, access, and participation in all settings (school, community, home)

  • Advocate for policies and programs that support children with disabilities

• Focus Areas:

  • Physical wellness – Encourage activity, motor skill development, and healthy routines

  • Quality of life – Enhance engagement in meaningful, enjoyable activities

  • Mental health – Address emotional regulation, social participation, and resilience

Rules in Play – Key Concepts

• Self-Imposed Rules:

  • In pretend play or imaginative games, children create and follow their own rules (e.g., "You’re the dragon, and I’m the knight").

  • Supports cognitive flexibility and social negotiation.

• Social Rules:

  • In group play, especially games with peers, children must follow agreed-upon rules (e.g., taking turns, no cheating).

  • Builds social understanding, fairness, and cooperation.

• Physical/Environmental Rules:

  • Unspoken rules from physical space or materials (e.g., only using certain toys, playing on safe surfaces).

  • Helps children learn boundaries and safety.

• Adult-Guided Rules:

  • In structured or therapeutic play, adults may introduce rules to promote learning, safety, or goal achievement.

  • Common in school settings or therapy sessions.

Why Rules Matter in Play:

• Develop executive functioning (planning, impulse control)

• Teach social norms and problem-solving

• Encourage self-regulation and group participation