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'4’ fier-W LI..Y?RAP Y W‘\.£;gan 51"u,‘ University This is to certify that the thesis entitled THE EFFECT OF A THERAPEUTIC PLAY PROGRAM ON THE DEVELOPMENT OF PRESCHOOL NEUROLOGICALLY IMPAIRED CHILDREN presented by Joanne FitzGerald has been accepted towards fulfillment of the requirements for Masters degree in Health, Plysical Education and Recreation mm Major professor Date August 8. 1978 0-7 639 THE EFFECT OF A THERAPEUTIC PLAY PROGRAM ON THE DEVELOPMENT OF PRESCHOOL NEUROLOGICALLY IMPAIRED CHILDREN By Joanne FitzGerald A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF ARTS Department of Health, Physical Education and Recreation 1978 ABSTRACT THE EFFECT OF A THERAPEUTIC PLAY PROGRAM ON THE DEVELOPMENT OF PRESCHOOL NEUROLOGICALLY IMPAIRED CHILDREN By Joanne FitzGerald The purpose of this study is to determine the develop- mental effect of incorporating therapeutic play into the physical therapy program of neurologically impaired, preschool children. A quasi-experimental design was used for this study. Eighteen preschool, neurologically impaired children, selected from three physical therapy programs in southern Michigan were matched into pairs based on their child's pretests's overall developmental quotient. Pre— and posttests were administered to each subject with a comprehensive developmental exam. The experimental group was involved in a weekly therapeutic play program for eight weeks. Play activities were selected for each session based on the subjects' physical therapy goals. The results of this study,as determined by the Wilcoxon Sign Test for Matched Pairs, demonstrated a significant change in both overall and gross motor development. No significant changes were noted for the manipulative, re- flexive, expressive language and cognitive-social developmental areas. ACKNOWLEDGEMENTS The writer wishes to extend her appreciation to the many people who contributed to this thesis. This thesis was part of a joint studydone in conjunction with another physical therapist, Dawn Welch. It was designed to determine the developmental effects of a therapeutic play program and a parent education program on play for preschool, neurologically impaired children. Working with Ms. Welch was both enjoyable, educational and facilitated the ease of doing the total study. Thanks are extended to the committee members Dr. Marcia Carter, Dr. William Heusner and Sr. Barbara Cline. Without Dr. Heusner's enthusiasm and assistance with the statistical analysis, Dr. Carter's encouragement, and Sr. Barbara Cline's interest and knowledge in this area of play this thesis would have been much more difficult to complete. To the volunteers who assisted in the conduction of the therapeutic play program, the writer wishes to express her appreciation for their continued cooperation and assistance throughout the duration of the study. To the children, their parents and the staff of the Wayne-Westland and Durant-Tuuri-Mott school systems and Ingham Medical Center, special thanks are extended for their willingness to participate in the therapeutic play program. Many thanks are also extended to the Michigan Easter Seal Society, who donated funds for the implementa- tion of this study. Without this aid the thesis could not have been completed. CHAPTER I CHAPTER II TABLE OF LIST OF TABLES . . . . . LIST OF FIGURES. . THE PROBLEM Need for the Study. . Purpose of the Study. . . Research Hypothesis . . . Antecedent Problems . Research Plan Rationale . . . . . . Assumptions. . . . . Limitations. . . . . . . Definitions . . . . . . . . CONTENTS Origin and Approaches to Play Definition of Play. . . . . Benefits of Play. . . . . . Physical Effects . . . . Social Effects . . Cognitive Effects. . Emotional Effects. . . . Development of Play . Play and the Physically Impaired Child. Treatment Play in Physical Therapy Early Intervention . . . Program Design. . . . . . . Use of a Group Situation Systems Approach . . . Testing. . . . . . . . . Summary. . . . . . . . . . CHAPTER III RESEARCH PLAN Subjects and Sampling . . . Independent Variable . . . Pilot StUdyl O O O O O 0 Control of Extraneous Factors Test Procedures . . . . . . Conduct of Treatments . . . Dependent Variables . . . . Instrumentation . . . . Data Collection Procedures . Data Analysis . . . . . . . ii REVIEW OF THE LITERATURE Page iv H HOOubbJ-‘wn Hid H b 14 15 17 l8 19 20 21 23 27 31 32 33 33 34 35 35 37 37 40 41 42 43 44 44 45 48 49 ”QF‘ [r .Lf‘ W: ass 5.— i... n . . . .14 at. .2 vi. C. ~.. 11 . n‘» at...» Huh _. . l~u liuu Add \ nu Odu |Au In“ vlh “If. “D 0...; 9 ~ I .u . Page CHAPTER IV THE RESULTS 51 Statistical Analysis . . . . . . . . . . . . . . . 51 Data Collection . . . . . . . . . . . . . . . . 53 Data Analysis . . . . . . . . . . . . . . . . . 53 Play Assessment. . . . . . . . . . . . . . . . 62 Discussion of Anecdotal Data . . . . . . . . . . . 63 Demographic Data . . . . . . . . . . . . . . . . . 66 Discussion of Analysis . . . . . . . . . . . . . . 67 Summary . . . . . . . . . . . . . . . . . . . 70 CHAPTER V SUMMARY, CONCLUSIONS & RECOMMENDATIONS 71 Summary . . . . . . . . . . . . . . . . . . . 71 Conclusions . . . . . . . . . . . . . . . . . . 72 Recommendations . . . . . . . . . . . . . . . . . 74 Clinical Recommendations. . . . . . . . . . . . 74 Research Recommendations. . . . . . . . . . . . 76 APPENDICES 78 APPENDIX A Therapeutic Play and Parent Education Programs. . . . . . . . . 78 APPENDIX B Demographic Data. . . . . . . . . . . 89 APPENDIX C Volunteer Training Program . . . . . 90 APPENDIX D Program Schedules for Play and Parent Programs . . . . . . . 92 APPENDIX E Instrumentation - EPCDEC and DDST . . 95 APPENDIX F Pilot Project Evaluation. . . . . . . 101 APPENDIX G Anecdotal Data Forms. . . . . . . . . 102 BIBLIOGRAPHY 103 iii LIST OF TABLES TABLE PAGE 4.1 Gross Motor Development 56 4.2 Manipulative Development 56 4.3 Reflexes 57 4.4 Expressive Language 57 4.5 Cognitive-Social Development 58 4.6 Overall Development 58 4.7 Gross Motor Development (Wilcoxon Sign Test) 59 4.8 Manipulative Development (Wilcoxon Sign Test) 59 4.9 Reflexive Development (Wilcoxon Sign Test) 60 4.10 Expressive Development (Wilcoxon Sign Test) 60 4.11 Cognitive-Social Development (Wilcoxon Sign Test) 61 4.12 Overall Development (Wilcoxon Sign Test) 61 iv LIST OF FIGURES FIGURE PAGE 3.1 Number of Subjects by Location and Group 39 3.2 Correlation Between Test Items 47 U! r CHAPTER I THE PROBLEM Play assumes an important role in the physical, social, intellectual and emotional development of children (Piaget 1969, Caplan and Caplan 1973, Herron and Sutton-Smith 1971, and Freeman 1967). Through play, the child learns to control his movements and his environment, to deal with life's stresses and strains, to adapt his feelings and emotions to society's demands and to develop satisfactory interpersonal relation- ships (Noble 1967). Fretz (1969) and Van Dalen (1947) have shown that play and physical activities do affect strength and motor performance. Social roles are first learned through play by playing at socialization. References have been made to play's major role as a medium for learning and acquiring other cognitive skills (Ellis 1971, Moffitt 1972, Piaget 1969, Herron and Sutton-Smith 1971). The neurologically impaired child, whose sensory input and motor output are abnormal, is not able to have the same experiences as a child with normal sensation and movement. Due to both sensory and motor impairments this child is unable to integrate these input-output processes. Free play with others or with items of his own choosing is not possible. His outlook on reality and his awareness of his own capabil- ities are limited (Lemkau 1967). As a result of this deprivation, as well as the need for decreasing abnormal tone and movement (all of which are major goals of a physical therapy program for the neurologically impaired child), he 1 2 needs an enhanced opportunity for playful interaction and stimulation as early as possible. The additional time that is needed for treatment services and basic home care activities (such as feeding and dressing), often decreases the time during which the neurologically impaired child is exposed to a play environment. Due to the longstanding idea that the younger the child the greater his ability to learn, profess- ionals in medical and educational fields advocate early inter- vention and treatment for a child with this type of impairment (Bobath 1967, Hartley and Frank 1952, Martin and Ovans 1972, and Caldwell 1967). Since these children are often involved in physical therapy programs and since play is an important adjunct in child growth and development, it may be beneficial to imple- ment play into such a treatment program. There is, therefore, a need to study the developmental progress of these children after their participation in a program which combines physical therapy treatment and play. NEED FOR THE STUDY Relatively little research has been done in the area of play and its role in the overall development of neurolog- ically impaired children. That which has been done has been of the observational variety. Since it has been documented that play assumes an important role in a child's developmental progress (Caplan and Caplan 1973, Piers 1972, Herron and SuttoneSmith 1971, Whiren 1976) more experimental study should be conducted to establish the importance and benefits of play V D “'i 3 for neurologically impaired children. It is also necessary to determine the beneficial types of play for these children and the various ways in which it can be effectively presented to them. No research data dealing with the effects of incorpora- ting play into a physical therapy treatment program has been found by this writer. Physical therapy is a service which is provided to most of these children, and could be an appropri- ate service to present to children in a playful manner in order to increase their exposure to play. Involving play in treatment may serve to make therapy a more enjoyable experi- ence. Many physical therapists do not include play in their treatment plans for their preschoolers. Physical therapy curriculums do not suggest play as a modality to be incor- porated into the treatment program for these children. Investigating the developmental effects of integrating play into a pediatric physical therapy program would demonstrate to both therapists and educators the effects on the children that play could have when included in their treatment program. PURPOSE OF THE STUDY The purpose of this study was to determine the effects of incorporating therapeutic play into the physical therapy treatment program of neurologically impaired preschool child- ren. Specifically, the study was designed to monitor changes in the physical, social and intellectual development of such children. pig] Stu. u'r-- .... ht. .1 \zbh RESEARCH HYPOTHESIS The hypothesis to be tested by this study is that a significant improvement in physical, social and/or intellec- tual development will be noted after the implementation of a therapeutic play program in the physical therapy treatment of the preschool neurologically impaired child. ANTECEDENT PROBLEMS Two antecedent problems were recognized and dealt with before the commencement of this study. 1. A scale was needed to evaluate developmental progress in children from one through four years of age in the areas of physical, social and cognitive development. 2. A determination was needed as to whether or not the group activities incorporated in the thera- peutic play program adequately met the program objectives. A pilot study, simulating the experimental play group, was conducted and evaluated by experts in order to resolve this problem. RESEARCH PLAN This investigation was conducted in conjunction with a companion study in order to afford an overall approach to the problem. Twenty—seven children were involved in the combined study, and the sample was selected from three pediatric physical therapy programs located in southern Michigan. 5 These included the Roosevelt-McGrath School in Wayne, Michigan, the Durant—Tuuri-Mott School in Flint, Michigan and Ingham Medical Center in Lansing, Michigan. Three comparison groups were established at all three centers: Group A: Group B: Group C: The control group for this study was com- posed of 9 Subjects — three from each of the 3 locales. The subjects in this group continued to attend their normally scheduled physical therapy treatment twice a week for 1 hour. This group was composed of 9 other children, 3 from each of the 3 locales. These subjects also continued with their therapy treatment once a week for an hour and participated in the experimental therapeutic play program once a week for an hour. This group was the experimental group for this study and the control group for the companion study. This group, the experimental group for the companion study, was composed of the re— maining 9 subjects, three from each of the 3 locales. These subjects received their therapy treatment once a week for an hour andparticipated in the experimental thera- peutic play group once a week for an hour. In addition to this, their parents were involved in a parent education program dealing 6 with play and its importance for the neuro- logically impaired child. The purpose of the companion study was to determine the developmental progress of the subjects after their parents' involvement in a parent education program focusing on play. This program's duration and time schedule followed that of this research study's therapeutic play program schedule. In this study an available sample of eighteen preschool, neurologically impaired children were selected from the three designated physical therapy programs. All subjects were be- tween one through four years of age. Only two of the three comparison groups were included in this study: the control group A and the play group B. The eight week therapeutic play program was designated as the independent variable. Three children in each of the three locales were involved in the play group. Three other children in each locale were placed in the control group. Subjects involved in the study were matched into pairs according to their overall deve10pmental quotient. The therapeutic play program included chosen activities intended to enable the achievement of selected program ob— jectives and sub-objectives. These objectives and those of the companion study may be found in Appendix A. The program was developed and implemented using a modified systems approach. This approach is a systematic method of program planning allowing the designer to select a course of action based on the assessment of the problem. Systems analysis 7 includes defining objectives, analyzing alternatives and possible outcomes, and evaluating the total program plan in its building stages and its finished product (Peterson 1976). A pre-test was administered one week prior to the start of the eight-week program and a post-test was admini- stered one week following the termination of the program. The dependent variables measured in this study were the reflexive, gross motor, manipulation, expressive language and cognitive—social developmental progressions as described by the developmental scales used in this study. The gain scores in each developmental category were determined for each sub- ject and compared to their matched partner. The Wilcoxon Sign Test for Matched Pairs was used to determine if a significant difference between the comparison groups existed. Rationale for Research Plan. Although many children with various problems and disabilities are involved in physical therapy programs, defining and limiting the popula- tion to preschool children with neurological impairments facilitated the selection of a more representative sample and helped assist in the control of the confounding variables. These children are often involved in physical therapy programs and comprise a large percentage of the physically impaired preschool population. Preschool children, between the ages of one to four years, were chosen because it has been documented repeatedly that the greatest amount of developmental change can take place during this period of time, and that early intervention is important. (Bobath 1967, Caldwell 1967, Hartley and Frank 1952). Five and six year olds were not selected because many of them by this time are now in kindergarten settings. Those under one year old were not chosen because many of these child- ren have not been diagnosed and thus are not in programs. Their inclusion would decrease the possibility of obtaining a representative sample. An eight week program was of a realistic duration for this study in order to maintain the parents' and childrens' interest and cooperation. A longer period of time for the study, though, most likely would have shown a more acceptable picture of the differences in devel— opment between the two comparison groups. The research design facilitates evaluation of the de- uflopmental progress of each child in five areas. Research on this study's topic is usually done by observational methods, but can be adapted to an experimental-control research design, even though significant limitations do exist. In this design the differences between the pre—and post-test scores were evalu- ated and a comparison of gain scores within each matched pair was noted. The data was then analyzed to determine if signi- ficant differences existed between the control and experimental subjects. Nonparametric statistics were used because of the small sample size. The El Paso Comprehensive Developmental Evaluation Chart (EPCDEC) was chosen as the primary evaluation tool for this study because it could be used to evaluate those areas of development that are of interest to this investigator. 9 Normative values are provided at two-week intervals for the first year of life. Many preschool, neurologically impaired children do not progress much further than the normal one year old child in some developmental areas. Therefore, a scale with small gradations in normative values within the first year was needed to determine developmental progress over such a short period of time. The Denver Developmental Screening Test (DDST) was used to extend the developmental scale for those subjects who developmentally tested above three years of age. Developmental items in each area for both tests were correlated. For those children whose devel- opment extended beyond that measured by the EPCDEC,administra- tion of both tests was performed. In addition, the Vulpe Play Assessment was used to supplement the data in the cognitive- social developmental area. No statistical analysis was done on this test's results. Assumptions. The assumptions underlying the conduct of this study are as follows: *1. A representative group of children with neurolog- ical impairments was available to the researcher. 2. The scales used adequately measured developmental changes in the five stated areas. *It is now mandated (PL 94-142) that all children below the age of twenty-six must be provided a free, comprehensive education and health service program. Therefore, all diagnosed children with neurologic impairments should be involved; in some therapy program. **4. 10 Physical therapy treatment has a beneficial effect on the developmental progress of a neurologically impaired child. There was no pre-test effect on the post-test scores. The play activities chosen for the physical therapy program appropriately and adequately met the purpose, objectives and subobjectives of this investigation, The program activities in the therapeutic play ses- sions afforded a "fun" atmosphere, incorporating a playful approach by the volunteers and group leader. Limitations. The limitations to be concerned within this study are as follows: 1. The cooperation of the parents, subjects and vol- unteers may not have been consistent. The philosophy, cooperation and truthfulness of the administration and personnel may have varied in the three facilities. Socio-economic and racial factors could not be controlled. The physical therapy treatment programs for the subjects may have varied due to the differences in the subjects themselves, their therapists' treat- ment approaches and/or the facilities' treatment rationale. **The items in the developmental examination are nonspecific and can be evaluated in different ways through observation. 11 5. The possibility of illness, inclement weather or other unanticipated factors, such as a change in work schedule, may have prevented continuation in the pro- gram of one or more subjects. 6. The philosophy and attitudes of the researcher and volunteers may have biased the study's results, though the variables and evaluation measures were selected because of their objective nature. 7. The attitude of the primary investigator may have differed from that of other group leaders' attitudes. 8. The short duration of the program may not have been sufficient to produce measurable changes. 9. Test reliability and validity of the developmental exam to be used has not yet been completely researched, though work in this area has begun. 10. The inability to randomly assign subjects to treat— ment groups could have affected the study's results. 11. The amount of play and playfulness in the home environment and during therapy could not be regulated. 12. The small sample size was utilized because it enabled the researcher to perform all pre- and post—tests, and to conduct all therapeutic play groups. An attempt was made to control these factors as much as possible. DE F I N‘I frogs, Neurologically Impaired. Any central nervous system defect manifesting a motor disability such as hypertonicity, can be classified as a neurologic impairment. Examples of 12 specific conditions which were included in this study under the definition of neurologically impaired are: cerebral palsy, post encephalitis, post meningitis, hydrocephalus, post traumatic head injuries and cerebral tumors. Conditions not dealt with in this study were: Downs Syndrome, peripheral nerve injuries, myelodysplasia and benign congenital hypotonias. Parent Education Program. An eight week program for parents focused on attitudes about play, knowledge about the value of play for neurologically impaired children, and adapta- tions and modifications of play activities and equipment for parents of preschool, neurologically impaired children. Physical Therapy for the Neurologically Impaired Chilg, An individualized, goal-oriented session was conducted twice a week, emphasizing inhibition of abnormal reflexes and muscle tone, facilitation of normal muscle tone, motor patterns and developmental sequence, maintenance of range of motion, increase of strength and endurance, improvement of balance and coordination, and improvement of ambulation and gait pattern. Play (for the neurologically impaired child). Behavioral characteristics which are self-initiated, pleasurable and internally motivated experiences and which are both receptive and/or expressive, constituted the entity of play. Playfulness. Lieberman defined playfulness as a: "personality trait characterized by the quantity and quality of physical, social and cognitive spontaneity, manifest joy and sense of humor" (Lieberman 1966). 13 Preschool. Children between the ages of one year zero months to four years eleven months were designated as preschool for purposes of this study. Therapeutic Play. Play activities for neurologically impaired children emphasizing self-initiated,pleasurable experiences (fun), which are oriented towards therapeutic goals i.e. optimal positioning, use of involved extremities, normal- ization of muscle tone and motor patterns and facilitation of mobility, constituted therapeutic play. Therapeutic Play Program. An eight week planned program of group play activities, which was designed to meet previously determined therapeutic goals. ‘‘‘‘‘‘ CHAPTER II REVIEW OF THE LITERATURE In this chapter the writer will cover several areas involving literature dealing with play. These include the definition of play, the importance of play to the preschool child, the therapeutic values of play in physical, social, cognitive and emotional areas, the application of play to the child's developmental progression, the need the physically impaired child has for play, the effect that a neurological impairment has on one's play ability and the inclusion of play in educational and therapeutic programs for preschool, handicapped children . ORIGIN AND APPROACHES TO PLAY Play has been an integral part of life since before unankind (Suomi and Harlow 1970). Although recognition and twesearch of this phenomena did not commence until the end of ttie eighteenth century, play has been considered important in life and development since the times of Plato and Aristotle (Sapora and. Mitchell 1961, Rogers 1932). Many theories have been presented since the beginning of tflae century, but none seem to define completely what play is, tlor have any of them been thoroughly researched or Valixiated. Gilmore has classified these theories into three Categories: 1) classical (traditional) theories - concerned with tile purposes of play and the elements in man's nature that leaad him to play; 2) recent theories - concerned with 14 15 the actual form of play behavior; 3) modern theories - concerned with explaining play behavior in terms of a drive to maintain optimum arousal (Ellis 1972). The relevant points presented in each theory will be included as needed to support the content covered in this review. DEFINITION OF PLAY No one definition has been assigned to the entity 'play', but many qualities and characteristics have been attributed to play. Various attempts at defining play have been: 1) "an aimless expenditure of energy" (Schiller); 2) "a natural exercise of mind and body" (Gutmuth); 3) "the unfolding of the germinal leaves of childhood. makes use of recently acquired skills or involves changes of touch, sound and sight and is amusing" (Froebal); 4) "a free, aimless, amusing, diverting activity" (Lazarus); 5) "motor habits and spirit of the past persisting in the present" (Hall); 7) "instinctive practice that is prepa- ration for but not important in later life" (Groos); and 8) "A do what we want attitude" (Gulick) (Sapora and Mitchell 1961, Millar 1968). Traditionally, play has been defined as natural, voluntary, free, novel, self-rewarding, diverse, spontaneous and intrinsically motivating. It allows for mastery over anticipated outcomes and for a free choice of play instruments, play behavior and play time involved (Caplan and Caplan 1973, Herron and Sutton—Smith 1971, Sutton Smith and Sutton Smith 1974). 16 Play is an activity performed for its own sake with no serious consequences intended (Sapora and Mitchell 1961) that usually occurs in a relaxed atmosphere (Herron and Sutton-Smith 1971). Freud states that The child distinguishes play from reality, but uses objects and situations from the real world to create a world of his own in which he can repeat pleasant experiences at will, and can order and alter events in the way that pleases him best. The child wants to be grown-up and to do what adults do. In play this is possible (Millar 1968). Piaget says that play occurs when the effort in adapting to an object, action or person relaxes. Play involves the maintenance or repetitive exercise of an activity for the mere pleasure derived from mastering it, thereby acquiring a feeling of power (Piaget 1969). Play can make reality more meaningful by distorting reality and associating it to something more familiar to the individual (Herron and Sutton—Smith 1971). Berlyne in his Ludic Theory claims that play is something engaged in for its own sake and for pleasure, in order to seek a particular kind of external stimulation, imagery and thought (Reilly 1974). A most important element of play is the quality of fun that accompanies this phenomena. "Play is most fun and most playful when it is spontaneous, evolving from an in- tegration of impulses and ideas and providing expression, release, sometimes climax, often mastery, with a degree of exhilaration and refreshment." (Erikson 1972). Huizinga (l949)proposes that fun, resisting all analysis, is the essence of play. 17 Another entity derived from play is playfulness. In defining this term Erikson states that, "maybe such phenomena as playfulness or youthfulness or aliveness are defined by the very fact that they cannot be wholly defined." (Erikson 1972). Moran states that one's attitude and one's degree of involvement in an activity determine playfulness (Moran 1974). Lieberman proposes a scale for the measurement of playfulness: 1) amount of time engaged in spontaneous physical movement and activity during one's play; 2) amount of joy portrayed during play activities demonstrated by facial expression, singing, repetition of activity; 3) amount of time a sense of humor is portrayed during play, i.e. rhyming and gentle teasing, glint in the eye and seeing situations as funny; 4) amount of flexibility shown in one's interaction with surroundings (Herron and Sutton-Smith 1971). Play, along with fun and playfulness are three entities for which there is no standard definition or meaning. The careful reader is therefore left with descriptions and attempted interpretations of play and playful behaviors as the results of early efforts to define the concept "play". THE BENEFITS OF PLAY Play allows growth in mind and body and provides the impulse to create and achieve (Harvey and Hales-Tooke 1972). It "allows access to a multiplicity of groups which promote a diversity of experiences and interests" (Reilly 1974). Opportunities for voluntary repetition and competition, encouragement and a safe atmosphere to experiment and plan 18 model situations to cope with risky operations within reality are provided through play (Reilly 1974, Herron and Sutton-Smith 1971). Play facilitiates the development and expression of neuromuscular, perceptual-motor, sensorimotor, social, language and cognitive skills (Moran 1974, Wheman and Abramson 1976). Much documentation and research has been proposed concerning these specific aspects and benefits of play. Effects on Physical Development and Condition. Through active play circulation, respiration, excretion, skeletal and muscular growth and cardiac function are all advantageously affected (VanDalen 1947). Play involves fundamental movements of the body that are naturally and progressively performed. Large muscle activities, especially when using the trunk musculature, stimulate growth, improve posture and maintain good function of the body organs. With movement neural activity increases and neuromuscular control improves. This leads to an improvement in skill, accuracy, endurance, agility, strength and coordination (Sapora and Mitchell 1961, Rogers 1932). Changes have also been noted in motor reflexes and reactions through an improvement in neuromuscular skill after involvement in gross motor activities (Sapora and Mitchell 1961). Through play the child is able to test various motor skills such as somersaults, rolling, etc.(Cap1an and Caplan, 1973). Sensation and perceptual-motor skills have been shown to be affected through play (Marx 1973). Because 19 children with neurological impairments are unable to experience normal motor patterns on their own, exposure to gross and fine motor play activities is important. Language especially through group experiences is also facilitated through play (Leyland 1976). "By playing with his lips and tongue he (the child) prepares for vocalizing and speech" (Pearson 1972). Play is a base for language building. Words evolve from a foundation of play experiences, from encounters with people, objects and wordly events. The young child delights in experimenting with different word shapes and discovering the meaning of words. Repetitive, rhythmic vocalizations signify playful states (Garvey 1977). Since play is an adjunct in facilitating language deve10p- ment, children with speech and hearing problems, which many neurologically impaired children have, often suffer mentally, emotionally and socially due to a diminished exposure to language developmental processes. Thus, they may benefit from play experiences (Caplan and Caplan 1973). Effects on Social Skills. "Other skills which are necessary for successful development and growth are those which might be called 'social skills',such as cooperation with others, self-discipline and self-relevance." (McClellan 1970). Play provides opportunities for character growth and discovery. Cultivation of tastes through personal integration, social adaptation and cooperation is provided through play (Martin and Ovans 1972), Play is adjunctive in developing interpersonal relationships. Developing the ability to be 20 willing, to follow directions, to obey rules and regulations and to accept decisions and disciplinary actions are attributes of play. Increasing self-help skills, improving self- direction and establishing one's identity can also be nurtured through play (Moran 1974). Imitation of peers helps to shape development (Reilly 1974). Children are susceptible to suggestion,and they imitate mores, attitudes and personal experiences (Sapora and Mitchell 1961). Suomi and Harlow (1970) in their animal studies have found that play is important in social development because through play social function can be integrated, initiated and perfected. Early social development approximates the manner in which children deal with play materials and with each other. Social interaction starts with the parent (Cratty 1970). The toddler is egotistical and asocial in his play, but he is interested enough in other peOple and objects to explore them (Harvey and Hales-Tooke 1972). Leadership starts to appear between the ages of two and three. It manifests itself either as the "diplomat" who acts through artful and indirect suggestions or the "bully" who with brute force bosses a small group. Between the ages of three and four cooperation starts to manifest itself through imitation and approval seeking (Cratty 1970). Effects on Cognition. Play has been asknowledged for centuries as an important medium for learning. Plato in 380 B.C. said, ". . . in teaching children, train them by a kind 21 of game and you will be able to see more clearly the natural bend of each." (Moran 1974). Much has been written concern- ing the benefits of play on intellectual development. Moffitt has broken down percepto-cognitive skills and suggested some play activities that could be used to improve these skills. She emphasizes that play is a medium for learning (Moffitt 1972). Through play definitions of words and concepts, listening techniques, performance of mental tasks and an understanding of the environment increase (Moran 1974). Piaget (1969) examined the relationship of play and learning. He said, Intellectual adaptation occurs when the two pro- cesses balance each other, or are in "equilibrium'. When they are not, accommodation or adjustment to the object may predominate over assimilation. This results in imitation. Alternatively, assimilation in fitting the impression in with previous experience and adapting it to the individual's needs may predominate. This is play. It is the pure assimilation which changes incoming information to suit the individual's requirements. Play and imitation are an integral part of the development of intelligence, and, consequently go through the same stages. Piaget also says play integrates concepts from social and objective worlds, reproduces what he has encountered and evokes what pleases him (Piaget 1969). Several other authors have written about the importance of incorporating play into learning situations (Caldwell 1964, Ellis 1973, Martinello 1973, Marzello and Lloyd 1972 and Wolfgang 1974). Emotional Aspects. "It is through play that the young child learns to master his environment, to deal with the strains and stresses of daily living,to adapt himself and his emotions 22 to the demands which society makes upon him and to make satisfactory relations with the people around him." (Noble 1967). Moran stated that it is through play that one develops a concept of self and that play is the medium for personality development. As success is experienced through play, an increase in confidence, desire, drive and motivation is noted (Moran 1974). Psychological needs and drives are expressed through play. It redirects and channels aggression and regression, and achieves a state of emotional balance. Clarapede in the Psychology of the Child states that "The function of play is to allow the child to express his ego, to display his personality, to pursue momentarily the line of his greatest interest in cases when he cannot do so through serious activity." (Piaget 1969). Play therapy is a technique incorporated into the therapy for children with emotional impairments. Through play, a "natural medium for self-expression, the child is given the opportunity to play out his accumulated feelings of tension, frustration, insecurity, aggression, fear, be- wilderment and confusion." By playing out these feelings he brings them to the surface, gets them out in the Open, faces them, learns to control or abandon them (Axline 1969). Freud and Klein have found that through play therapy children are encouraged to free themselves of negative feelings through processes identified as purging, transferring or assimilating (Ellis 1973). 23 Play, normally, assists the child to master fear, anxiety and passivity; the handicapped child may be denied this assistance. Physical handicaps may lead to "emotional immaturity", dependency, poor reality-testing, poor impulse control and stereotyped activities. Lack of play experiences may lead to excess daydreaming, an inability to form strong emotional ties and an inability to individualize and redirect fantasies (Freeman 1967). DEVELOPMENT OF PLAY Man, known as the highest functioning member of the animal kingdom due to his adaptability and intellectual facilities, maintains the longest period of protective childhood during which time practice through play and imitation is experienced (Groos)(Reilly 1974). Play contributes to the total deve10pment of the child, integrating within his natural tendencies to explore the people and artifacts of his culture, his abilities to observe, do, learn and feel. Most play activities use all aspects of development. The children do not recognize the potentials for motor coordination for concept development, for practicing the social skills so necessary for a full and wholesome life. They are just 'playing' (Wolfgang, 1974). Exploratory, play the first type seen, is initiated by novel stimuli in the environment (Wolfgang 1974). While playing with an object the infant acts upon it to produce interesting visual, auditory or kinesthetic effects which are intrinsically rewarding and lead the child to repeat these actions. The more one is exposed to play, the more patterns of exploration and play he exhibits. An increase 24 in gross motor coordination and manipulation serves to generate cognizance of the general properties of various objects. This leads to concept formation (Collard 1972). A sociodramatic play stage follows. Imaginative play, Smilansky says, is important in the development of abstract logical thinking and information usage (Collard 1972). This play is a precursor of creativity along with promoting effective interaction. Fantasy play provides a concrete method of expressing hope, fears, needs, wishes and desires (Moran 1974). Piaget has evolved a developmental schema of play, which he defines as a "distorting continuation of assimila- tion." Sensorimotor play connotes the first stage; an object is assimilated to an earlier known schema without new accommodation or anticipation of later causal sequences (Piaget 1969). Here the child, when confronted with novel objects, explores them and tries out motor patterns he previously applied to other objects (like pushing a hanging toy). This is tested and repeated over and over, making small adaptations with each trial. At twelve to eighteen months he is an active, systematic experimenter, learning to move towards behavioral actions without objects and initiating symbolization, pretense and make-believe. The next stage, symbolic or make-believe play which lasusfrom two to seven years is characterized by actions which are appropriate to one object and are substituted for another object. Spontaneous talk and answers to questions begins. 25 He starts to assimilate and consolidate emotional experi- ences. With the growing experiences of his physical and social environment, a transition to a more accurate picture of reality begins (Miller 1968). These activities lead to more representational thinking. Ages three through five involve an egocentric stage. Imitation of older children who do follow rules is present (Knox 1974). The pre- operational (eleven and twelve year olds) and operational (teen years) stages then follow (Moran 1974). Using as her reference developmental progression, Takata has also defined play levels. She begins with solitary play, which is self-initiated with no acknowledge- ment of others. Next parallel play (one to three years of age) entails playing in a room with others with no mani- fested physical interaction. Pretend and make-believe play follow next. These finally progress to cooperative play (Takata 1974). The development of play originates in the child's oral area and is associated with his needs at that time i.e. feeding. He plays at each new motor skill he acquires. By three to four months he kicks vigorously, coordinates eye-hand motion, responds to his mother, reacts to smiles, explores more with moving toward, touching and handling, and takes swipes at things for no apparent reason (Caplan and Caplan 1973). By six months he laughs, uses single syllables, holds objects, shakes rattles to make noise, and likes toys. By ntuato twelve months he is reaching out 26 while sitting, playing 'peek-a-boo', searching for lost toys, imitating simple sounds, throwing toys and wanting them back (Millar 1968, Sutton-Smith and Sutton-Smith 1971 and Caplan and Caplan 1973). A toddler's world expands as he learns to walk (Harvey and Hales-Tooke 1972). He begins to experiment and seek new ways to solve problems (Caplan and Caplan 1973). He uses large balls and other toys to accompany him by pushing or pulling when he moves (Wolfgang 1974). He scribbles and his vocabulary broadens during this time. He enjoys other children around and plays at building his self-image. A two year old likes to run, pull toys, build towers, talk to himself, listen to stories, copy adults and maintain constant movement. He clings tightly with affection, defends his possessions, distracts easily, and acts selfishly. At three he turns corners while running, rides a tricycle, cuts with scissors, knows nursery rhymes, demands favorite stories, starts to share, and shows affection to younger siblings (Reilly 1974, Harvey and Hales-Tooke 1972). Brown (1972) has found an increase in dramatic play concentrating mainly on family situations after the age of three. Real and pre- tend are still not completely separate. Activities with collecting and gathering are abundant. Curry and Tittnich (1972) have found that the four year old is more independent. He manages aggressive impulses by incorporating super heroes. Safe hideaways are common, and dress-up is fun for him. Body competence is tested. Dramatic play now includes society 27 and there is an apparent distinction between real and fantasy. He is more persistent in striving to achieve results and shows preference for different activities. He begins to H ask "why and "how". Cooperative play is starting. He demonstrates this by being more patient when taking turns and also sympathizing for those in distress (Harvey and Hales-Tooke 1972). This brief review includes documented support for the effects of play on development, the approaches to play development, and the observed actions and movements during play which are seen during the first four years of life. There appears to be a lack of controlled experimentation dealing with developmental aspects of play. Any research that has been undertaken has been implemented via observa- tional methods. PLAY AND THE PHYSICALLY IMPAIRED CHILD The major premise of this thesis is that play is important for the neurologically impaired preschool child. Many of these children, who need more sensory input and stimulation via play than "normal" children, actually re- ceive less. This is primarily due to their physical impair- ment (Gralewicz 1973). Even though certain motor responses are prohibited, the need these children have for arousal and stimulation is not less (Rogers 1932). The United Nation General Assembly in 1959 proposed a bill concerning Children's Rights, which stated that, "The child who is physically, mentally or socially handicapped shall be given the equal 28 treatment, education and care required by his particular condition." (Michelman 1974). A more recent law (PL 94—142) requires that all handicapped children be provided with appropriate public education emphasizing special education and ancillary services, both designed to meet each child's needs (Education for All Handicapped Children Act of 1975). (Goodman 1976) When speaking of play and the handicapped, it has been stated, "in human capacities for play lie the developmental roots of competence, and therefore a major resource for endeavors to remedy human deficits" (Michelman 1974). A handicap is a "double blow" to development for two reasons. First, it limits the potential of the individ- ual and, secondly, it handicaps the processes whereby the individual can achieve his potential (Rogers 1932). Another statement regarding this problem is, "The retarded infant is at twice a disadvantage. First, although he needs more assistance in progressing through the stages of development than the nonhandicapped infant, he receives less and that less too late. Second, like all babies, his emotional health depends on the emotional health of his parents' but because he is a handicapped child, his parents suffer fear, anguish, bewilderment and far too often shame." (Diamond 1971). Disturbances in organic or environmental pathology will result not only in quantitative shifts but qualitative distortion of the development of intelligence which Peter Wolff called "actual stage reversals". If the developmental path is blocked, alternative growth patterns are usually 29 found (Piers 1972). If one's environment does not provide the necessary conditions for integrating physical, emotional, mental and social development, an unruly, antisocial, with— drawn behavior character pattern can deve10p (Freeman 1967). ". . . the social contacts of the handicapped often tend to be inordinately limited by the handicapping condition." (Moran 1974). These children also have problems with attention span, for it is hard for them to filter the irrelevant stimulation. Play actiivites seem to draw their interest and attention. Play affords the needed opportunities for increasing self- confidence, independence and satisfaction (Caplan and Caplan 1973). "Like nothing else, play gives every child a chance to lay plans, to judge what is best in each play situation, to create and control the sequence of events." (Caplan and Caplan 1973). Once he appreciates his actions on different materials, trying out new experiences will quickly evolve. Limitations will arise only within his skills and/or the nature of the material to be used. This will all increase the child's view of reality (Lemkau 1967). Finnie (1975) said of the cerebral palsied child, "If the slightest move- ment this child makes accidently moves the object or even makes a noise, he will have made something happen himself. This will most likely stimulate him to try again, thus experi- menting on his own and not being directed to do so. This is an initial step in learning." When attempting an action, if he does not succeed by the second or third try, he will give 30 up because the frustration tolerance of the neurologically impaired child is often low. This is why careful evaluation and forethought is important in planning playful, learning situations for this child. Neurological impairments affect in varying degrees the muscle tone and motor patterns of the extremities and trunk. Sensory (audition and vision included), perceptual- motor and cognitive abilities can also be affected. Extra appropriate stimulation is needed. An important part of early education for these children conskts of gross motor activities for motoric and perceptual training (Gralewicz 1973). Uncontrolled, irregular movement characteristic of these children inhibit normal sensori-motor input. These movements impair symbolic function, which will inhibit normal sensory and kinesthetic experience necessary for learning (Reilly 1974). Through play, trial and error sessions can allow for the development of motor patterns (Pearson 1972). Finnie said that play is equally important for the cerebral palsied child because he too must have-a chance to develop his self-image, explore his body, learn about himself in relation to others and understand the world around him. Because of his slow developmental progress and physical impairments, he needs much help. ". . . his handicap prevents him from learning through play in a natural way, so . . . he will not be able to learn as he plays or to reach his potential" (Finnie 1975). 31 Few researchers have documented the role of play in the growth and development of neurologically impaired children such as those with Cerebral Palsy. These children are delayed in most developmental areas. Since play appears to be valuable in all areas of child growth and development as noted earlier, play may be important in the early care of the neurologically impaired child. However there is need to test this hypothesis. Play in Physical Therapy Treatment. Gralewicz (1973) in a study on the play deprivation in multiple handicapped children found that the handicapped child has fewer play companions and fewer adult family play fellows, spends more time involved in personal care activities, and participates an average of sixty-seven minutes weekly in special treatment programs. The additional treatment time is approximately equivalent to the additional time the "non-handicapped" child participates in play. Lieberman (1965) in reference to exercising, a primary activity in physical therapy treat- ments, states that, A small child is much more willing to "exercise" his muscles by using a specially adapted climbing frame, slide, see-saw, pedal car, tricycle, etc. or by participation in ball or action games with other children to make it more fun. He is also more likely to gain confidence (watching and imitating the other members of the group) and thus be spurred onto greater efforts. Parents are important. (McLovell 1973). Lemkau (1967) stated that preschool teachers have found that extensive physical therapy on mats in the gym is not enough. Free play is important for satisfactory development; it 32 provides the opportunity to show one another around and to feel other bodies reacting to one's own. Pearson (1972) stated that "Play therapy is an important adjunct of Physical Therapy, Occupational Therapy and Speech Therapy, which is an important way of coordinating treatment with the management of the child at home or in a nursery or hospital." In several play group settings developed around the country, physical therapists are called upon to recommend body positioning suitable to each individual child during play, to select types of play that would be beneficial to the child, and to suggest appropriate assistive devices to aide the child's movement and involvement in group activities (Harvey and Hales-Tooke 1972, Lieberman 1965, and Marx 1973). "The young child uses his body most vigorously in play with other children and in reSponse to toys and activities that he enjoys." This is true for the handicapped as well as for the "normal" child; therefore, therapy takes place naturally in the schoolroom or playground, rather than in a separate therapy room (Marx 1973). Early Intervention. Many are now realizing the importance of discovering potential neurological problems early and then initiating treatment. Hartley and Frank (1952) encourage early intervention because of "the great plasticity of the young during these years, their instant response to environmental impacts, their readiness to benefit from favorable experience and to assimilate these into their growing concept of self". 33 Developmental achievement depends on the acquisition of motor skills and the amount of sensory stimulation pro- vided in the critical developmental periods. Deprivation between six to fifteen months leads to basic irreparable deficiencies (Piers 1972 and Martin and Ovans 1972). Varied sensory input in the home environment is important (Caldwell 1964). Because children with neurological impairments do not have the same sensory and motor experiences that "normal" children have, additional stimulation early in life is needed. Studies have shown that with severe deprivation neither speech nor normal thinking processes are acquired, and communication is manifested through basic physical action (Barclay 1972). Wilson, a physician, states that ". . . the younger the child, the greater the change in the lesser amount of time." (Martin and Ovans 1972). Establishment of programs dealing with developmental disabilities should begin shortly after birth and continue until development progresses from sensory exploration to cognitive learning (Martin and Ovans 1972). PROGRAM DESIGN Use of a Group Situation. Play groups for the physically impaired child are starting to appear throughout the country. "For all the children, the group stimulation reinforces learning, and the joint teacher—therapist acti- vity planning widens the learning horizon". (Marx 1973). Programmed group instruction aids in the accrual of develop- mental abilities especially when, through total body movement, 34 learning is achieved, and when groups are conducted with six children or less (Marx 1973). Through group play activities and in conjunction with such ancillary services as Physical, Occupational and/or Speech Therapy, a child can achieve as full a potential as is possible as well as benefit from the group setting. The group setting allows children to meet other children and play in a happy, care— free manner (Fister, 1974, Leyland 1976, Marx 1973, McLovell 1973 and Pearson 1972). Group activities included in these play groups should emphasize gross motor skills, language development, rhythm activities for auditory skills, physical coordination, manipulative and fine-motor skills (Marx 1973). Systems Approach. The systems approach applied to program development is a practical way to develop, implement and evaluate new programs with less emphasis on program content (Peterson 1974). Systems analysis "focuses on the utilization of a systematic procedure to enable a decision maker to choose a course of action based on surveillance of a total problem, including a search for objectives, analysis of alternatives and their possible outcomes, and an evaluation process." (Peterson 1976). In designing the program, desired outcomes specified as performance levels are deter- mined. Various procedures and content, selected to attain these criteria, are then analyzed and arranged to achieve the pre-determined objectives. Evaluation is initiated at the onset of the planning process and is ongoing and continuous throughout the course of the planning. 35 Modifications and adaptations are made when necessary (Peterson 1974). Systems can be incorporated into many different program levels, including organizations and/or direct practitioner - client interaction. Modifications can easily be made (Musgrove 1971). Many individual programs incorporate the systems approach by modifying it to meet their program needs (Marx 1973). Testing. Several tests were reviewed in order to select a developmental scale. This scale will be used to evaluate the developmental progress of the subjects in selected areas. These tests included: The El Paso Compre- hensive Developmental Evaluation Chart (Cliff, Carr, Gray, Comparetti and Gidoni 1967), the Denver Developmental Screening Test (Frankenburg and Dodds 1969), the Bayley Scales of Infant Development, the Cattell Infant Intelligent Scales, the Preschool Attainment Record (Krajecek and Tearney 1972) and the Wolanski Assessment (Wolanski 1973). Play assessment tools that were considered include the following: "Activities of Daily Living — Play" in the Vulpe Assessment Battery (Vulpe 1977) and the play assessment scales in Caplan and Caplan (1973), Sutton—Smith and Sutton-Smith (1974) and Knox (in Reilly, Ed., 1974). SUMMARY There is a large amount of documentation dealing with the topic - play. Over the years many theories of play have 36 been advanced by people working in a variety of fields. Many works concentrate on the benefits and values of child- hood play, and on the role of play in the child's development. Little documentation has been found on play and the physically impaired child, in particular the preschool child with neurological impairments. Much more has been written and researched on play and the child with mental or emotion— al impairments. There is also a lack of supportive literature on the use of play in developmental and educational programs for handicapped children. No research has been found by this writer on the effects of implementing play in physical therapy treatment programs. It is evident from this literature search that either too few studies have been done dealing with play and the physically impaired child and/or too few researchers or practitioners have reported their results. Hopefully more literature will be written on play and its importance for the neurologically impaired child, in addition to material dealing with implementation of play into physical therapy services. CHAPTER III RESEARCH PLAN The purpose of this study was to determine the develop- mental effects of incorporating play into a physical therapy treatment program for preschool, neurologically impaired children. Progress was determined by the improvement noted in the physical, social and cognitive areas of development after the implementation of an eight-week, experimental therapeutic play program. This investigation was conducted in conjunction with a companion study which attempted to determine the effects of a parent education program. The parent program focused on parental attitudes towards play, play's importance for the handicapped child and suggestions for adaptations and modifi- cations of toys and play activities for their children. SUBJECTS AND SAMPLING Twenty-seven children were selected from three physical therapy programs in southern Michigan. The subjects, both male and female, ranged in ages from one year zero months to four years eleven months at the onset of the study. All children had been diagnosed as having a neurologic impairment. They resided at their own homes or at foster homes. The available sample was selected from treatment programs at hospital-clinic settings and school programs. Physical thera- py program directors from several facilities in southern Michigan were contacted by mail and/or by phone. Included in the letter or phone conversation was a description of the 37 38 combined study and a request for their cooperation in pro- viding subjects. If the request was accepted, a letter describing both programs was mailed to each of three selected facilities and the therapists were asked to send a copy of the letter home to each child's parent. Three comparison groups were utilized in this joint study. Nine (9) children from each of the three (3) facilities were each assigned to one of the three comparison groups. Subjects in Group A, the control group for this researcher's study, continued with their prescribed biweekly physical therapy treatment for an hour. Subjects in Group B comprised the experimental group for this study and the control group for the companion study. These subjects were involved in a therapeutic play group held once a week for an hour, and attended their normally scheduled physical therapy treatment once a week for an hour. Subjects in Group C, the experimental group for the companion study, participated in the weekly experimental therapeutic play group and received their hourly physical therapy treatment once a week. In addition to this their parents were involved in a weekly parent education pro- gram on play. Figure 3-1 attempts to describe the comparison group set-up. 39 Location Group A Group B Group C (Physical Therapy) (Physical Therapy (Physical Therapy and Play) Play and Parent Groups) Flint 3 3 3 Lansing 3 3 3 Wayne 3 3 3 Control Experimental Ll Therapeutic Control Experimental Play Study \ /\ Parent Education Studv FIGURE 3-1. Number of Subjects by Location and Group. All twenty-seven subjects were matched according to their overall developmental quotient. The developmental levels in each area were measured after the pre-test, administered one week before the initiation of the study's program,and a Developmental Quotient was calculated. The sample for this study was then matched into nine pairs - one subject placed in the control group (A), the other subject placed in the experimental group (B). When matching into pairs the extent to which the subjects and their parents could participate in the study was considered. The results of this study can be applied only to the southern Michigan, neurologically impaired preschool population. The sample size was kept small in order that the principal investigator could evaluate all subjects and work with all those involved in both research studies, allowing little tester bias and variability in play group leadership. Only those children with neurological impairments who met the age and physical 40 therapy treatment requirements were included. Those with primary muscle disease, peripheral nerve injuries or mental retardation were not included. Demographic data was collected from the parents on the first night of the program. A sample of the form given to each parent is included in Appendix B. Questions concerning parents' attitudes towards play and an evaluation of their playfulness was reviewed as a part of the companion study. There was no attempt to analyze or match the subjects on this data. INDEPENDENT VARIABLE The independent variable for this study was the eight- week therapeutic play program. This program involved a play group which met for one hour a week in the evening at the subjects' treatment center. Different play activities were presented at each meeting via a therapeutic approach. The purpose of using a therapeutic approach was to ensure optimal positioning of each child and to encourage the use of all extremities, the trunk and the head. The program plan took into consideration each child's developmental level, by con— sidering each subjects developmental and motoric problems and formulating goals for each problem. Activities were then planned in order to meet these goals. A modified systems approach was incorporated in the design and implementation of the play program. Selected objectives and activities designed to enable the achievement of desired behaviors were organized into this weekly 41 therapeutic play program. These program objectives and acti- vities were selected from theneed seen by the primary investi- gators in their work with these children and from related literature sources (Caplan and Caplan 1973, Diamond 1971, Hartley and Frank 1952, Harvey and Hales-Tooke 1972, Leyland 1976, Lieberman 1965, Marx 1973, Marzello and Lloyd 1972, Moffitt 1972, Stein 1971 and Griswold 1972). Objectives and activities for both programs may be found in Appendix A. The emphasis during each weekly program was placed on 1) fun and play, 2) use of involved extremities, and 3) good balance in various positions i.e. four-point. The principle investigator with four trained volunteer aides led all play groups. Volunteers selected to help out in this study were undergraduate or graduate students in Therapeutic Recreation or interested people having experience with play and children. They were chosen on the basis of their experience and their demonstration of flexibility, versatility and playfulness (Lieberman 1965). All participated in a four hour volunteer training session focusing on the importance of play for these children, positioning and handling techniques for the children, organizational information and the program schedules for both programs. A cepy of this program format may be found in Appendix C. Pilot Study. A pilot study was conducted to determine the appropriateness of the activities in meeting the objectives and subnobjectives of the therapeutic play program. Two therapeutic play sessions were simulated using neurologically 42 impaired children found in an already existing physical therapy program. Two observers, experts in Therapeutic Recreation and Physical Therapy were present to evaluate the effectiveness and appropriateness of the play activities. These observers along with two other specialists were asked to study the program plan and to evaluate its validity. All activities and objectives for all sessions in the program were included. The ease and feasibility of the implementation of these activities were evaluated in addition to their thera- peutic value. Changes in the program plan were made, based on the evaluators' observations and written assessments. Control of Extraneous Factors. Provisions were made to control several possible confounding factors: 1. An attempt was made to control the developmental variability among the subjects by matching each subject in the control group with a subject in the experimental group. Matching was based on the subject's overall developmental quotient. This allowed for comparison between the two groups. 2. The two primary investigators in the companion studies evaluated each subject's developmental status during both the pre- and post—tests, to ensure an objective, reliable appraisal. Each. subject's physical therapist was then asked to review the test results to determine if the effect of two "strangers" performing the exam biased the data. If there was disagreement, a 43 concensus among all three therapists was made. Many children are apprehensive when confronted with someone they do not know, and may not per- form well for them during an evaluation. 3. Attendance of the subjects for each play session could not be controlled due to possible illness, lack of transportation or a change in work sched- ule. To help minimize this effect an additional volunteer was provided to take care of the subjects' siblings during the program hour. Also if trans- portation to the experimental site was a problem for the parents and their child the primary in- vestigators attempted to provide them transporta- tion whenever possible. TEST PROCEDURES Eighteen subjects from a common population were involved in a quasi-experimental study. A pre-test - post-test design was implemented. Developmental levels for five different areas were determined during both tests. The EPCDEC, the DDST and the Vulpe play assessment were administered to each subject the week prior to and the week following the eight week therapeutic play program under similar conditions. Developmental scores were recorded for each area and dif- ferences between the pre- and post-tests were compared. Data from all instruments involved except the Vulpe play assessment was then analyzed. 44 CONDUCT OF TREATMENTS An hourly therapeutic play session was held once a week for eight weeks. Group sessions were conducted at each of the three selected, experimental sites in order that the subjects be in familiar surroundings during the program. Three (3) subjects from the experimental group from this study and three (3) from the experimental group of the comparison study were included in each play group. Thera- peutic play activities were planned for this hour every week. Parents of the three children in the companion- study's experimental group were included in sessions seven and eight. A program schedule for the play program may be found in Appendix D. Large equipment used in the play groups such as the Bobath ball, the wedge and bolsters were found at each treat— ment center. The necessary equipment not available at each center was provided by the investigator. A proposal for funding was approved by the Michigan Easter Seal Society for the conduct of the two experimental programs involved in this overall study. These funds, six hundred and eighty-five dollars, were used to cover the costs of the equipment and supplies needed for both programs, and transportation between the three experimental sites. DEPENDENT VARIABLES The dependent variables in this study were all related to the developmental progress of the subject. The areas of development that were measured were those goals emphasized in 45 a physical therapy treatment program for neurologically impaired children. They included 1) gross motor, 2) re- flexes, 3) manipulation, 4) expressive language and 5) cognitive-social. These areas were evaluated by the chosen developmental scales for the appropriate age group. Instrumentation. The El Paso Comprehensive Developmental Evaluation Chart (EPCDEC) was chosen as the primary tool to evaluate the subjects' developmental progression. The EPCDEC measures development in each of the following areas 1) re— flexes, 2) gross motor, 3) manipulation, 4) expressive language and 5) cognitive-social. The first year of develop- ment is broken down into two-week intervals for each area. During the second year the breakdown broadens to three-month intervals. After the age of two, development is measured in six-month intervals. Two additional advantages of the EPCDEC included: 1) the test could be administered by a physical therapist or teacher and not a clinical psychologist, and 2) the test required observation rather than depended upon parental response. This instrument also evaluates the loco— motor prognosis for the child with Cerebral Palsy (a syndrome manifesting sensory and motor neurological deficits), the presence of seizure activity, head circumference measurement and body growth (Cliff, Carr, Gray, Nymann and Redding 1975). Research is now being conducted on the reliability, objectivity and validity of this exam. Because the EPCDEC is designed for ages ranging from zero weeks to thirty—six months, which does not include the 46 complete age range evaluated in this study, another develop- mental exam, the Denver Developmental Screening Test (DDST), was employed. This test was used to continue the evaluation of developmental progressions from the three to six years of age. Both these tests may be found in Appendix E. The DDST is broken down into four developmental areas -- gross motor, language, fine motor-adaptive and personal-social. Its measurement intervals span a one-month period during the first two years and a six-month interval between the ages of two and six years (Frankenberg and Dodds 1969). 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Iguzézofl -. w M R _ 824.1 00.3 I 3293 52.253 2:3 :3 92.. .203 3 I E | r . . . {I v - .. $620..an P .5 0.20:3 . may... 02...... 200% $3 _ .00_<0-. .<. 5: m».<: . 3.3..- 1 - .-| I. L ..- - 4 I L . - . m . - max-mala- mmam .. _ 3030m20m.wm..<=11_11 200255 J m I . .1- -m..-I-...-1.| . -..._. I J L 2:3 >2... 5.2.22. g — — — — — — — — — I I I I h .F L I ll, F L14 I L I I I L b I __ 0 5 I .30 I in n .3 In an 2 E m« 2 2 t 2 2 v. n.— E : 2 o I A o n I n I . a: at; 5T0. SIT DATE lfldfil DIRECTIONS BIRTHDAIL KOSP. NO. 1. Try to get child to smile by smiling, talking or waving to him. Do not touch him. 2. When child is playing with toy ,pull it away from him. Pass if he resists. 3. Child does not have to be aole to tie shoes or button in the back. 4. Have yarn slowly in an are from one side to the other, about a" above child’s face. Pass if eyes follow 90° to midline. (Past midline; l8’°) 5. Pass if child grasps rattle when it is touched to the backs or tips of fingers. 6. Pass if child continues to look where yarn disappeared or tries to see where it went. Yarn should be dropped quickly from sight from tester's hand without arm movement. 7. Pass if child picks up raisin with any part of thumb and a finger. 8. Pass if child picks up raisin with the ends of thumb and index finger using an over hand approach. 9. Pass any en- lO. Which line is longer? ll. Pass any 12. Have child copy closed form. (Not bigger.) Turn crossing first. If failed, Fai l contin’i ous paper upside down and lines. demonstrate round motions. repeat. (3/3 or 5/0) When giving items 9, ll and l2, do not name the forms. Do not demonstrate 9 and ll. 13. When scoring, each pair (2 arms, 2 le-. gs, etc.) COJnt s as one part. L. Point to pi ictu re and have child name it. (Io cre ed; t is given for sounds only.) s~+ 3: . at T” i '- 2 3‘ } ‘\\ * “2:: ..I" M' ' .‘ II. 15. Tell c;ild to: Give block to Mommie; put block on table; put block on floor. Pass 2 of 3. (Do not help child Dy pointing, moving head or eyes.) l6. Ask child: What do you do when you are cold? ..hungry? ..tired? Pass 2 of 3. 17. Tell child to: Put block on table; under table; in front of chair, behind chair. Pass 3 of 4. (Do not help child by pointing, moving head or eyes.) 18. Ask child: If fire is hot, ice is ?; Mother is a woman, Dad is a ?; a horse is big, a mouse is ?. Pass 2 of 3. 19. Ask child: What is a ball? ..lake? ..desk? ..house? ..banana? ..curtain? ..ceiling? ..hedge? ..pavement? Pass if defined in terms of use, shape, what it is made of or general category (such as banana is fruit, not just yellow). Pass 6 of 9. 20. Ask c1 lild: What is a spoon made of? ..a shoe made of? ..a door made of? (No other objects may be su as tituted. ) Pass 3 of 3. 2l. Wlen placed on stomach, child lifts chest off table with support of forearms and/or hands. 22. When child is on back, grasp his hands and pull him to sitting. Pass if head does not hang back. 23. Child mar use wall or rail only, not person. May not crawl. 2‘. Child must throw ball overhand 3 feet to within arm's reach of tester. 2C. Child must perform standing broad jump over width of test sheet. (8-l/2 inches) 26. Tell child to walk forward, macaw-p- heel within 1 inch of toe. Tes ter may demonstrate. Child must walk 4 consecutive steps, 2 out of 3 trials. 27. Boun e ball to child who should stand 3 feet away from tester. Child must catch ball with hands, not arms, 2 out of 3 trials. 28. Tel l child to ..alk backward, «CIDQOOQZJ toe within 1 inch of heel. Tester may demonstrate. Child must walk 4 consecutive steps, 2 out of 3 trials. DATE AND; EHAVIO .AL OB: ATIO"S (how child feels at time of test, relation to tester, attention span, ve al oehavior, self-confidence, etc,): 157. 10-70 Distributed as a service by Mead Johnson Laboratories APPENDIX 101 PILOT PROJECT EVALUATION THERAPEUTIC PLAY_PROGRAM AND PARENT EDUCATION PROGRAM ON PLAY As you observe the play/parent education pilot session, please comment on the following areas: 1. Organization (time structure, order of presentation, etc.) 2. Preparation 3. General Atmosphere 4. Leadership and Direction 5. Participant Interaction 6. Activities (therapeutic, fun, motivating, etc.) 7. Additional Comments Ff? ..7‘ ifi‘fi‘r‘jv w‘vwwv .VY" fl "TV‘V‘V‘TVV‘VTTVVV ti V fijtv1‘fiij T—v fivfififi—V‘W‘ v W APPENDIX 102 ANECDOTAL DATA FORM THERAPEUTIC PLAY PROGRAM NAME Li . DATE :_ SESSIONtfifi EVALUATOR:H_w Y V 1 ' I ‘ V Answer the following questions with brief descriptions of interactions observed. Use direct quotations whenever appropriate. Describe the subjects' approach to the activities. (fearful, withdrawn agressive, etc.) fifi r7 r —v v-v v Describe the subjects' degree of involvement during the session. v Describe the energy expended by the subjects (passive, active, hyperactive) jvi‘w V Describe adjustment to group activities during the session. V‘f) 7v . vv 7 v r'v—f Did the subject(s) exhibit appropriate behavior? V7 f ——w f Describe the interaction among the subjects.fiw fiwfifi‘f—v—v ‘v‘v'vv— fit? f W Comment on the verbalization of the subjects. w 7' f Describe the subjects' ability to perform the activities. fit 7 ff, Describe the amount of direction the subject(s) needed to perform the activities v—V—‘V "f‘r v v r Describe the playfulness of the subject(s). fi—wfv v rw wv—q—YV 7w .Vw-v T—‘ Describe the subjects' and their parents responses when they reunite at the end of the session. ;*Y \ 1 h. j. fifi. fivfi "\\\‘~\\~~\‘\ \ TjfiTVf—v‘wi‘rvvfij‘fiV'vv-v ‘Wfi V‘ General Comments: \ \ \ ~\\\\\~\\\\\\\ \x\ \ \\\ \\ m.‘ j~“‘1:—“—(—“~—‘,“ 1anvw‘fi'vfi fjwfv‘vV "Y’W ‘V—v“ w ‘ BIBLIOGRAPHY 10. 11. 103 BIBLIOGRAPHY Axline, V. ‘Play Therapy. New York: Balantine Books, 1969. Bobath, B. "The Very Early Treatment of Cerebral Palsy," Deyelppmental Medicine andghild Neurology, 9:373- 390, 1967. Brown, Nancy S. "Three—Year—Old's Play." Plgyvand_Devel— opment. (Piers, M. ed.) New York: W. W. Norton and Co., Inc. c 1972 pp. 119—126. Caldwell, B. M. "What is the Optimal Learning Environment for the Young Child." American qurnal of Orthopsyghiatry, 37:8—21, 1967. ‘ Caldwell, B. M. and Drachman R. H. "Comparability of Three Methods of Assessing the Developmental Level of Young Infants." deiatrips, 34:51, 1964. Caplan, F. and Caplan, T. The Power of Play. Garden City: Anchor Press/Doubleday, 1973. Cliff, S., Carr, D., Gray, J., Nymann, C. and Redding, S. The El Paso Comprehensive Developmental Evaluation Chartfl Mothers Can Helpiv ThegEl PasorRehabilitation Center, El Paso, Texas: Guynes Printing Company, 1974. Collard, R. R. "Exploration and Play in Human Infants." Play: Practice and Research in the 1970's. Leisure Today - American Association of Health, Physical Education and Recreation, June, 1972. Cratty, B. J. Perceptual and Motor Development in Infants -§nd'Childrenzv New York}‘ ThefiMacMillan ES), 1970. Curry, N. and Tittnich, E. "Four Year Old's Play." 222_ ~Childetrives Towards Self-Realization. (Arnaud, S. ahfipfiurrijN:TEds)r'PYBEEEHings'by‘the Arsenal Family and Children's Center, Western Psychiatric Institute and Clinic, University of Pittsburg and the National Association for the Education of Young Children, 1972. Diamond, F. "A Play Center for Developmentally Handicapped Infants." Children, 18:174~178, Sept.eOct. 1971. V‘wfiV 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 104 Ellis, M. J. "Why Do Children Play?" Play: Practice and Research in the 1970's. Leisure Today - American Association of Health, Physical Education and Recreation, June 1972. Ellis, M. J. Why People Play. Englewood Cliffs: Prentice Hall, Inc., 1973. Erikson, E. H. Childhood and Society. New York: W. W. Norton Co., 1972. Finnie, N. R. "Play." Handling the Young Cerebral Palsied Child at Home. New York: E. P. Dutton and Co., Inc., 1975 (second edition). Fister, S. "Parents and Children Discover Group Play." Children Today, 3:2-6, 35, Sept. - Oct. 1974. Florey, L. "An Approach to Play and Play Development." The American Journal of Occupational Therapy. Volume XXV No. 6 1971, pp. 275-280. Frankenburg, W. K. and Camp, B. W. "Developmental Examination." Pediatric Screening Tests. Springfield: Charles C. Thomas Publishing, 1975. Frankenburg, W.and Dodds, J. Denver Developmental Screening Test Manual, University of Colorado Medical Center, c 1969, 1970. Freeman, R. D. "Emotional Reactions of Handicapped Children." Rehabilitation Literature, 28:274-282, Sept. 1967. Fretz, B. A., et. a1 "Intellectual and Perceptual-Motor Development as a Function of Therapeutic Play." Research Quarterly, 40:687-691, 1969. Garvey, C. Play: The Developinnghild Series. Cambridge: Harvard University Press, 1977. Goodman, L. V. "A Bill of Rights for the Handicapped." American Education (reprint), June 1976. Gralewicz, A. "Play Deprivation in Multiply Handicapped Children." The American Journal of Occupational Therapy, 27:70-72, 1973. Griswold, P. Play Toggther - Parents and Babies. Distrib- uted by United Cerebral Palsy of Central Indiana, 615 North Alabama Street, Indianapolis, Indiana, 46204, March 1972. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 105 Hartley, R. E., Frank, L. K. and Goldenson, R. M. Understandigg Children's Play. New York: Columbia University Press, 1952. Harvey, S. and Hales-Tooke, A., eds. Play in the Hospital. London: Faber and Faber, 1972. Herron, R. and Sutton-Smith, B. Child's Play. New York: John Wiley and Sons, Inc. 1971. Huizinga, J. Homo Ludens: A Study of the Play Element in Culture. Boston: Beacon Press, 1949. Lemkau, P. "The Importance of Play for the Child in the Hospital." The Hospitalized Child and his Family. (Haller, A. ed.). Baltimore: John Hopkins Press,l967. Leyland, S. J. "Special Playgroups in an Assessment Centre." Nursing Times, 72:1815-1817, 1976. Lieberman, J. N. "Playfulness: An Attempt to Concept- ualize a Quality of Play and of the Player." Paper presented at the meeting of the Eastern Psychological Association, New York, April 1966. Lieberman, J. N. "Playfulness and Divergent Thinking: An Investigation of Their Relationship at the Kindergarten Level." The Journal of Genetic Psychology, 107:219-224, 1965. Knox, S. "A Play Scale." Play As Explorative Learning, (Reilly ed.) Beverly Hills: Sage Publications, c. 1974. Krajicek, M. and Tearney, A. eds. Detection of Develop- mental Problems in Children: A Reference Guide for Communipy Nurses and Other Health Care Professionals. Baltimore: University Park Press, c. 1972. Martin, M. M. and Ovans, P. M. "Learning Games are Pathways to Cognizance for Young Handicapped Children in Therapeutic Recreation." Therapeutic Recreation Journal, 6:153-157, 1972. Martinello, M. L. "Play - Grounds for Learning." Elemen- tary School Journal, 74:106-114, 1973. Marx, M. 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