The Importance of Pretend Play in Child Development – Occupational Therapy Notes

Introduction

• Play acknowledged within occupational therapy (OT) as complex yet central to child development, despite appearing simple (Knox 1974; Reilly 1974).
• Bracegirdle (1992a) – study of play critical for understanding development & treating impairment.
• Paper’s aim: Show how pretend play functions as a “window” into a child’s broader play abilities and how OT knowledge of pretend play helps identify impairments → activity limitations → participation restrictions (using WHO’s ICIDH-2 model).
• Core contention: Limited pretend play activity = restricted participation (social, emotional, cognitive consequences).

WHO ICIDH-2 Framework

• Transition from ICIDH (1980) to ICIDH-2 (WHO 1999) to be finalized in 2001.
• Renaming to remove negative connotations:
  • “Disability” → “Activity limitation.”
  • “Handicap” → “Participation restriction.”
• Three key dimensions:
  • Body functions & structures (impairments).
  • Activities (activity limitations).
  • Participation (participation restrictions).
• Environment, personal factors, culture act as contextual modifiers.

Definition & Key Characteristics of Play

• Consolidated characteristics (Bundy 1997; Stewart et al. 1991):
  • Internally motivated > externally motivated.
  • Reflects & transcends reality.
  • Player controlled; process focused.
  • Safe, fun, pleasurable, spontaneous.
  • Unpredictable & involves non-obligatory active engagement.
  • Exploratory; involves movement & manipulation of environment (Sutton-Smith 1967).
• OT views play as the primary occupation of childhood (CAOT 1996) drawing on motor, sensory, cognitive/perceptual skills.

Pretend Play: Definitions & Forms

• Age window: $18\text{ months} \rightarrow 6\text{ years}$ (peak in preschool years; Piaget 1962; Vygotsky 1976).
• Two inter-related forms encompassed by “pretend play”:
  • Symbolic play – object/action/absent-object substitution (Lewis et al. 1992). Example: shoe → car; stick → horse.
  • Conventional imaginative play – using conventional toys (doll, bed) in make-believe ways (reflecting reality).
• Pretend play merges freedom from reality with capacity to represent/decouple meanings (representational thought, decentration).

Cognitive Capacities Required

• Representational thought evidenced by:
  • Object substitution.
  • Attributing properties to objects/actions.
  • Referring to absent objects/actions.
• Additional cognitive skills influencing pretend play (Schrader 1990; Pelligrini 1993):
  • Narrative competence, sequencing, organisation of thinking.
  • Decontextualised language; emergent literacy links.
  • Attention, concentration, memory, visualisation.
  • Divergent & convergent problem solving.
• Theory of Mind connection – transforming objects relates to perspective-taking deficits in autism (Baron-Cohen 1996).

Social & Emotional Capacities

• Social awareness, role experimentation → understanding norms/rules (Vygotsky 1976).
• Decentration fosters empathy, perspective taking (Rubin et al. 1983).
• Emotion regulation: acting out scenarios with alternative outcomes.

Motor & Sensorimotor Supports

• Fine/gross motor & sensory skills enable manipulation/exploration; foundational during sensorimotor period $0\text{–}18\text{ months}$ (Piaget 1962).
• Pretend play is rooted in earlier sensorimotor mastery (manipulation, object permanence, imitation).

Model 1 – Pretend Play within ICIDH-2 (Fig. 1)

• Impairments (functions/structures) → Activity limitation (pretend play difficulties) → Participation restriction (social, learning, communication).
• Pretend play itself promotes further skill development, closing a positive developmental loop.

Model 2 – Piagetian Timeline (Fig. 2)

Sensorimotor Stage  (0–18 mo)  →  Pretend Play Period (19 mo–6 yr 11 mo)  →  Games-with-Rules Stage (≈7–9 yr)

• Pretend play stage hallmarks: representational thought, language acquisition, flexible thinking, etc.

Documented Benefits of Pretend Play

• Facilitates:
  • Flexibility & adaptability of thought; problem solving (Florey 1971; Howard 1986).
  • Social, intellectual, emotional & physical skills.
  • Language & literacy (Westby 1991).
  • Social perceptiveness / theory of mind (Baron-Cohen 1996).
• Thematic pretend play predicts divergent problem-solving ability (Wyver & Spence 1995).
• Elaborate, purposeful play may forecast later school performance (Power & Radcliffe 1991).

Pretend Play Assessment & Observation in OT

• Historic OT focus broad; pretend play only recently emphasised.
• Knox Preschool Play Scale (Revised) – now includes “Pretence/Symbolic.”
• Other tools: Warwick Symbolic Play Test; Westby Scale; Symbolic Play Test.
• Key observational foci:
  • Ability with conventional toys vs. inanimate object transformation.
  • Level of spontaneity / self-initiation vs. adult-prompted play.

Conventional vs. Symbolic Play Differences

• Autism, language disorders, sensory-integration dysfunction, aggressive behaviour show distinctive profiles:
  • Children with sensory integration dysfunction: symbolic play limited to miniatures; fail to transform large objects (Clifford & Bundy 1989).
  • Autism spectrum: poor symbolic play ↔ symbol use deficits; conventional play may be relatively spared (Lewis et al. 1992).
  • Socially aggressive children: competent with conventional toys, poor with inanimate object transformation (Stagnitti 1998).

Self-Initiated (Spontaneous) Play

• Typical development: spontaneous, self-steered pretend play.
• Developmental difficulties: rely on imitation or adult prompting (Westby 1991; Lewis et al. 1992).
• Self-steering correlated with mental activity, flexibility, intrinsic motivation, internal locus of control (van der Kooij 1989).

Activity Limitations → Participation Restrictions

• If pretend-play deficit persists beyond $18\text{ months}$:
  • Likely restrictions in fulfilling “player” role.
  • Social interaction & peer relationships hindered.
  • Learning & cognitive development compromised.

Implications for Occupational Therapy Practice

• OT role:
  • Identify impairments (cognitive, social-emotional, motor) hindering pretend play.
  • Design interventions to enhance pretend play → reduce participation restrictions.
  • Facilitate environments rich in pretend-play opportunities (materials, peer play, cultural sensitivity).
• Example intervention: “Learn to Play” programme (Stagnitti 1998) – practical curriculum to develop imaginative play (awaits empirical validation).
• Interdisciplinary relevance – speech therapy, psychology, education exploit symbolic play parallels with language.

Ethical, Philosophical & Practical Considerations

• Play as intrinsic right & occupation of childhood – deprivation regarded as secondary disability risk (Missiuna & Pollock 1991).
• Terminology shifts (ICIDH-2) reflect philosophy of empowerment over deficit labelling.
• Culturally variable play forms necessitate contextualised assessment.

Numerical / Statistical Highlights

• Core age brackets:
  • Sensorimotor: $0–18\text{ months}$.
  • Pretend play period: $19\text{ months}–6\text{ years }11\text{ months}$.
  • Games with rules emergence: $7–9\text{ years}$.
• Research findings (examples):
  • Wyver & Spence (1995): children with thematic pretend play scored higher on divergent problem-solving tasks (exact statistics not provided in transcript).

Key Literature Connections

• Piaget, Vygotsky & Fein provide theoretical underpinning.
• Theory of Mind research bridges pretend play & autism.
• OT pioneers (Reilly, Knox, Michelman) integrated pretend play into practice scales & creative interventions.

Conclusion

• Pretend play is both an indicator and facilitator of cognitive, social, emotional, and motor development.
• Deficits create identifiable activity limitations and participation restrictions which OTs can target.
• Applying ICIDH-2 framework guides holistic assessment & intervention, ensuring children over $18\text{ months}$ receive support to fulfill their primary occupational role: player.