Using Children Play as Therapy

Environment and Play

Research connects a poor environment with reduced cognitive and social functioning of a child. In order to realize an activity, a child needs playtime interaction with physical, social, cultural, economic and organizational aspects of the environment. Physical environment may be natural, such as a parcel, climate or man-made such as buildings or even toys. By analyzing the cultural environment it is crucial to be familiar with social norms such as beliefs, traditions, attitudes and expectations. In estimating economic environment it is necessary to gain insight into the availability of resources such as finances on an individual and social level. Organization environment is structural and as such it is connected with the government or police. The importance of environment in relation to play is availability of toys and materials [5]. According to numerous researches, children who come from poor environments in which the interaction with listed aspects is not realized show difficulty in performing play activities.

Theoretical Understanding of Playtime

Theory has always focused on research or understanding of the natural phenomenon. Just as there are many definitions of play, there are as many theories of play. There are three classic theories about play:

• Theory of Excess Energy
• Practice
• Recapitulation The theory of excess energy was created late in the 19th century and says that children are not responsible for their own survival they have excess energy which they put into playing. The practice theory is focused on papers by Gross who claims play activities enable a child to practice acting on instincts which is crucial for survival. The recapitulation theory is tightly connected with the phases of development; it exists as civilization itself and is an upgrade of the basic (primitive) human abilities [6]. Using Play as Therapy In the early years, “the spirit of play” was seen as an essence of a valuable life [7]. Playing was used in the early years for different purposes like attention diversion, developing kills and remediation [8]. Play becomes a key element in therapy in the final years of the 20th century. It is a primary activity in childhood and is viewed as a unique value above acquiring skills.

It is important to state that playing and activities of play don’t have the same meaning. Therapists use activities of play to enable an improvement of certain skills such as decision making or achieving a therapeutic effect in improving ability of fine motor skills. In a therapeutic context, playing can be seen through the child’s everyday life areas. The historical development of therapeutic intervention through play advocated the viewpoint of play being a key part of a child’s free time, neglecting the meaning of it in everyday life [9]. It is scientifically proven that children learn through playing and gain new skills and experience; they create the potential to build their self-confidence which is the basic part of mental health. Play can create the feeling of belonging to various social groups like family, peers and the wider community. If play is a wheel which individuals use to become masters of their environment, then it should be the most powerful therapeutic tool [1]. Some of the research has scientifically proven that play contains a possible protective factor in preventing depression at a child’s age. In situations when a child participates in selecting a media through intervention. Selecting play or free time activities defines beyond doubt what a child’s goal is and what the child aspires to [10].

Play and Free Time

Work therapists as members of therapy teams believe that participating in meaningful activities including play may better health and wellbeing (WFOT, 2012). Children see daily responsibilities as work which inhibits the possibility for realizing play [11]. Research shows that in Europe, the average time children spend sleeping is eight to nine hours, watching TV one to two hours a day, time spent on sports twenty to eighty minutes a day, other free time activities take up only ten to twenty minutes [12].

Play Theories

Health workers should value the benefits of play far more. Unfortunately, most health workers in pediatric departments in Croatia don’t see play as a dynamic interaction of the child, activities done daily and its environment. Among many theories, an important place is given to the theory of playfulness which is described as “movement” or “a tendency to play” [13]. In theory there four key concepts:

• Intrinsic motivation
• Inner control
• Freedom from reality limitations
• Framing All four key concepts are significant in understanding play theory. A significant importance can be added to intrinsic motivation of an individual. Children are not interested in external prizes as a source of motivation; the emphasis is on the individual participating in the activity for pleasure. For example, children who play with spider webs, sticks and stones, do not have a predetermined goal; the focus is on the feeling of joy and pleasure during the play.

Inner control is focused on control the players have over the game, during play a child decides on the rules. For example, children use boxes as cars or houses when playing with dolls and plush toys. During play, the child interprets available social clues providing insight into ability or limitations at the level of social interaction.

Process Transformation Model

Process transformation model of occupation (PTO) was suggested to understand the development of children’s interest with a slight focus on developmental abilities. Process transformation model refers to children’s occupation described as activities children find interesting and which they enjoy doing because to them, they have a meaning and purpose [14]. According to the Process transformation model, health workers gain insight into a child’s participation in occupation through play which may be seen as a:

• Construction of occupational opportunities: it defines the influence of the community, social and cultural environment.
• Social transaction on occupational advancement: determines involvement of more persons in the occupation, for example, two children add to the meaning of the occupation by presenting new or existing skills which may be recognized during play through the task of dressing a doll, which gives the occupation new meaning.
• Process of self-organization and transformation in occupation: deals with a dynamic system. Intrinsic abilities of the child enable an occupational performance for play. Abilities are reorganized as the occupation changes; repetition through occupation enables better performance.

Play and Chronological Age

Understanding play and the need to implement it into therapy calls for understanding play in relation to the chronological age of a child. The period of a small child (0-6 months): overcoming sensomotoric games, social play is focused on attachment and connection, repeating actions for fun and pleasure, smile, laughter, cooing, screaming.

• 6-12 Months Research: Sensomotoric play evolves into functional play. Functional: using players according to functional purpose.
• Social: attachment to parents, playing “take and give”, brief interaction with other children.
• 12-18 Months Research: researches all spaces in the room using crawling and rolling, Functional: simple pretending in the play focused on them (pretend to sleep, eat), imitating a model. Social: begins interacting with peers, parallel play, and shares toys with parents.
• 18-24 Months Functional: performs various connected actions together. Social: participates in parallel play, imitates parents and peers, group play, watches other children, starts waiting for their turn, enjoys individual games (e.g. coloring, building). Symbolic: animism (non-living objects are given characteristics of living creatures-a doll eats, dances). Connects pictures with actual objects.

Early Childhood (2-5 years)

For many children, early childhood is a time when their social contacts grow. 2-3 years: social meaning of play: mainly asocial parallel play, waiting for turn in play, interest in peers, beginning of shared play and playing in small groups, being shy around strangers especially adults, making a mess, connecting red and yellow (3 years). Symbolic: uses toys to represent animals or people, plays with animals or imaginary friends. Constructive: drawing and puzzles, imitating adults using toys.

• 3-4 years: social meaning: participates in playing parts in a game of dress up, tells stories, play that includes imaginary characters, sings whole songs, roleplaying based on roles of parents. Constructive: enjoying produce, showing interest in artistic activity goals, constructs complex structures. Games with rules: group play with simple rules, participates in an organized, roughly motoric play.
• 4-5 years: social meaning of play: understands what it means to wait for their turn, plays with two or three children for about 20 minutes. Pretend: dress up games, games with fictional characters. Constructive: enjoying produce, interest in activity goal, complex structure. Games with rules: group play with simple rules. Sports: riding a tricycle, climbing a climber at the park swinging their legs or hands (hanging from the climber holding on with hands or legs)
• 5-6 Years: social meaning: playing with four to five children without constant advisory. Pretend: using marionettes. Constructive: complex structures, builds using simple tools (slopes, bars). Play with rules: explaining the game to others, social games. Sports: swinging, riding a bicycle, skipping rope, sliding forward three meters, hitting a ball with a stick or bat, walks or plays in water up to the waist.

Mid-Childhood (6-10 Years)

Playing includes construction, hobbies and using various technologies (e.g. CDs, DVDs). Social: playing includes conversation and joking, mostly with peers, they have a best friend; they have their “gang”. Trying to please others, less impulse, regulate their attitude, has competitive relationship. Play with rules: games with cards, computer games, has collections, may have a hobby. Sports: competitive play in groups, teams. Emphasizing victories and skills [15, 16]

Play Assessment

Literature lists various patterns a therapist may use as an initial measure in assessing the meaning of play. Among many, practice uses: The Symbolic and Imaginative Play Developmental Checklist [17] Play Skills Self Report Questionnaire [18] Test of Playfulness [1] Revised Knox Preschool Play Scale [8] Kids play profile [19] Preteen play profile [19] Adolescent leisure interest profile [19 Children’s Assessment of Participation and Enjoyment [20] The Preferences for Activities of Children [20]

Play Skills Self Report Questionnaire

Sturgess recognized the need to assess play in mid- childhood. Play Skills Self- Report Questionnaire (PSSRQ) was developed for 5-10 year olds who have troubles with playing or social skills; or they have other issues, such as an illness or disability which may have an effect on playing and/or social skills. Sturgess bases the grade on the assumption that playing and playfulness are useful for children; it happens in various life areas of the child; they happen independently or with others; they ease physical, cognitive, linguistic and social skills. The purpose of the PSSRQ is to gather the child’s ability self-awareness in 29 game skills in different contexts-home, school, community. A parental/guardian version of the PSSRQ is being used. It was designed to enable self-assessment over time and therefore it doesn’t have meaningful conclusions. PSSRQ takes 15 minutes and is appropriate for a set of health and education experts who swish to have a better understanding of a child’s development. Earlier research has confirmed the validity and reliability of the testing and retesting [22]. PSSRQ is a useful tool for assessment, focused on the child and family, can be used with children who have numerous mental health issues, including ADD caused by hyperactivity.

Therapeutic Intervention Through Play

Play therapy uses play to help the child express feelings, problems and growth of experience [16]. Play therapy uses eight basic principles: developing a friendly relationship; accepting the child; tolerance; recognizing feelings; respect; no guidance; allowing a natural process and boundaries. More and more therapists are using play intervention. Play is used as therapy and outcome. In this type of intervention, the therapist’s goal is to see an improvement in play as the outcome of the play intervention. The number of interventions that fulfill the criteria is limited but Learn to play and Cognitive Orientation to Daily Occupational Performance are two good examples of therapeutic guided intervention.

Learn to Play Program

According to Stagnitti, Learn to Play Program is a special play intervention which uses play as a therapeutic media and an outcome. This practical program develops imagination of play skills in 6 year old children and makes it easier for the therapist by focusing on family. Learn to Play refers to subject areas of the games, the sequence of game themes, switching subjects, social interactions, roleplaying, playing with dolls/ plush bears. It is appropriate and useful in practice or in a home environment. The Learn to play program may be used with children with disabilities, including autism disabilities and attachment disorders.

Cognitive Orientation to Daily Occupational Performance

Cognitive Orientation to Daily Occupational Performance (CO-OP) is an intervention based on a dynamic system or a cognitive neuroscience approach where the emphasis is on interaction between a person and the environment. CO-OP can be applied to playing; it can be used with older children in setting their mental health with issues like ADHD. Cognitive Orientation to Daily Occupational Performance (CO-OP) is focused on the person, based on performance with problem solving approach in which the therapist guides the child to discovering and following guidance to achieving a desired outcome [23, 24].

Therapists who work with children often come across a range of conditions including hyperactivity: autistic disorders, mental disorders, difficulty in behavior and eating disorders. All the above listed, and many other conditions, can effect play and free time activities in childhood which causes a decrease in the child’s quality of life.