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APPROACHES TO PLAY:

HOW CHILD DEVELOPMENT

RESEARCH CONTRIBUTES TO AN

UNDERSTANDING OF THE

SIGNIFICANCE OF EARLY

SENSORIMOTOR AND SYMBOLIC

PLAY IN PLAY THERAPY FOR YOUNG

DISABLED PEOPLE


2 TABLE OF CONTENTS Introduction -Piaget’s Cognitive-Developmental Theory

3. 4.

Approaches to Play

5.

Reilly’s Systems Approach

5.

-Play as exploratory behaviour

6.

-The biosocial nature of play

7.

The Psychoanalytic Approach -Catharsis

8. 9.

The Social Model Approach

10.

-Art experience and play

11.

The ‘pay-off’ of play

12.

Research into symbolic play for young people with developmental disorders 14. -Language Disorders

14.

-Autism

15.

-Visual impairments

16.

-Hearing impairments

18.

Play Therapy

19.

-Humanist play therapy

21.

-Play therapy for abused children

22.

-Parents as therapists

26.

Cultural considerations in play

27.

Conclusion: the case for inclusion

28.

References

31.


3 INTRODUCTION Hartley et al., (1952, in Schafer & O’Connor, 1983) state that to read the language of play is to read the hearts and minds of children. With this in mind, a review of the extant literature in developmental psychology was conducted under the general heading of ‘approaches to play’ in order to truly grasp what psychology has contributed to our understanding of children’s play and what theory and research into the sensorimotor and symbolic play of young people with a range of developmental disorders tell us about the value and function of play for the growing mind and how this knowledge might pay off with regards to treatment of these young people. It is the essence of this thesis that through understanding the needs of all young people in their playlife, and by adequately providing for their cognitive, emotional and social development through play, we help them unfold their wings and blossom into their fullest potential as human beings. The types of play to be discussed in this essay are introduced before ‘Systems’, ‘Psychoanalytic’ and ‘Social Model’ approaches to play are introduced as a basic framework for the discussion into the significance of early sensorimotor and later symbolic play for the growing mind. At this point we ask what it is that children gain from play: the pay off of play. Research into the symbolic play of several groups of young disabled children with Language Disorders (including Autism, Hearing Impairment and Visual Impairment) is discussed and inferences made about what this research contributes to the corpus of work into play as a therapeutic medium. Based on the findings from the studies included in this dissertation, the argument of the importance of sensorimotor and symbolic play, on the development of thinking and language as well as social skills and understanding, must not be ignored. The hypothesis that it is the social segregation of young people with developmental disorders, removing them


4 from their peer group and largely from the normalcy of everyday life, from an early age, that in turn impedes opportunities to play and learn and impacts on the development of social understanding and the critical symbolic functions seen to develop out of sensorimotor and symbolic play in the preschool period. Interventions designed to integrate young people who typically experience exclusion, in an environment where their typically developing peers and parents, play an active role in encouraging them to interact and play, comes out as a strong way forward in combating the damaging effects of social exclusion for these young people, and there are several good examples of this sort of inclusive intervention that the reader is directed towards for more detail (Stahmer, 2004; Koegel et al., 2001; Rogers, 2004).


5

Types of play: Piaget’s Cognitive-Developmental Theory Piaget’s Cognitive –Developmental (1952) account responds to the great regularities in the development of children’s thinking and provides a sequential stage theory about the type of discoveries, mistakes, and solutions children make during play. Infants actively investigate, adapt and, incorporate themselves and the physical properties of their world through sensorimotor manipulation and examination of objects and people. The process of adaptation, according to Piaget (1952) involves the construction of schematic knowledge through sensory and motor play in the first 18- to 24- months of life. This is Piaget’s ‘sensorimotor stage’ involving sight, touch, taste, hearing and, reaching as the child’s tools for understanding their reality, and their agency within it. At around 12- to 14- months the beginnings of symbolic play emerge with pretending and imitation, which evolve into the ‘sociodramatic’ role-playing commonly seen in the preschool years (Bee, 1992). Role playing and playing games with rules become popular as the school aged child develops more abstract mental representations and can begin to use internal symbolic modes that advance as the child moves from preoperational (18 months to 6 years) to concrete operational (6- to 12- years) thought (Piaget, 1952). Harris and Butterworth (2002) explain that symbolic play involves the child as agent, pretending to do things. Pretense and false representation reflect a major achievement for the typically developing child, as they begin to think in symbols, which are the germinal leaves of language development according to Piaget’s main opponent, Vygotsky (1962), who saw play as biosocial phenomenon requiring systems analysis. APPROACHES TO PLAY Reilly’s ‘Systems Approach’ to play


6 Play is both a biological system in a sense that it is living behaviour that increases in complexity over time, and it is a social system with a complex structure, organised in response to experiences that are acquired from interaction with the environment (Reilly, 1974). Biosocial phenomena mandate a systems approach, which assumes the laws of hierarchical ordering as a function to transform behaviour so that a child can only run once the skill of walking has been mastered. For systems theorists play does not emerge in the presence of a need state and belongs to a class of behaviour called learning. Play essentially belongs to the behaviour of the imagination, which is explained by three action systems. They are paraphrased below, according to Reilly’s scheme (1974): The Neurological Substratum represents the processing action of the central nervous system seeking information from all possible sensory channels, noticing difference and unexpected stimuli and resulting in sensation acquiring meaning through sensorimotor investigation (play). The Symbolisation Substratum’s effectiveness is based on its capacity to act as an equivalent for something in the real world. Play is crucially connected to the imagination and symbol formation. Schemata construction is a major function of play. Symbols translate sensation into meaning and become instruments that help young people codify and create territorial maps of their experiences. The Language Substratum is based on Chomsky’s proposition of ‘universal grammaticity’ (1969), wherefrom all other particular grammars of behaviour are derived, including the vocabulary and grammar of play. Learning to symbolise involves understanding the ways symbols name, describe and speak for reality. If play can truly be explained by these three systems, it should be possible to correlate the particular problems in the sensorimotor play of young


7 people with developmental difficulties that have a neuropathological component with dysfunction in Reilly’s first subsystem which would best describe the process of sensorimotor exploration. Reilly’s implicit hypothesis is that deficits in this subsystem will have a subsequent negative impact on the full use and expression of the second and third action subsystems, which build upon the sensorimotor achievements made via the first subsystem and describe the process of symbolic play and language development. The law of hierarchical ordering insists that symbolization and language can only emerge from successful sensorimotor play exploration, and this matches Piaget’s, (1962) and Vygotsky’s (1962) account of how general symbolic functioning or inner speech (respectively) develops. Play as exploratory behaviour The systems approach to play provides a scientific foundation upon which play can be understood as an exploratory behaviour whose modus operandi is to puzzle, tease, and doubt reality, first through the sensorimotor capacities, then increasingly as the symbolic function appears out of object play and into social play experiences (Huizinga, 1944). Play seems to be the child’s natural medium for developing experiences with meaning because in the action of play, reality is explored via curiosity and conflict. As meaning is generated, the searching process produces learning. In play, inquisitive infants first seek sensorimotor rules, then rules about objects and people and finally the rules of thinking (Reilly, 1974). So, disabilities in the perceptual and sensorimotor capacities, as in the case of non-typically developing young people, can lead to limitations in the behavioural repertoire typically seen in developing children and this can be accounted for within a systems approach to the biosocial phenomenon of play. Play as biosocial phenomenon


8

Luria (1928) was an early proponent of the biosocial approach to childhood phenomena, noticing that the psychogenesis of the cultural forms of the child’s behaviour could be attributed to the differences in subject matter of the young people’s cultural experience and the methods used by different young people to realize their natural abilities. A year later, under the same discussion of ‘the problem of the cultural behaviour of the child’, Vygotsky (1929) stated that cultural development (as seen in play), results from the mastering of modes of behaviour which are based on the use of signs as a means of accomplishing psychological operations, marking the most important stage in the development of reasoning and speech as the transition from external (symbolic) to internal (inner-speech) in schoolaged children matching Reilly’s (1974) functioning Symbolisation and Language substrata. Within a Vygotskian framework, the child’s higher psychological functions and attributes, specific to humans, originally manifest as forms of cooperation with other people during sensorimotor play and afterward become internal individual functions of the child himself as seen in more symbolic (imaginative/pretend) play. This sociogenetic perspective highlights the crux of this thesis; that by progressing from sensorimotor to symbolic play modes in the first three years of life, the child not only learns to reason and think, but by default learns to interact socially and communicate verbally, and that disruption to this progression accounts for much of the psychological deprivation associated not only with language disorders but also with disorders of an emotional nature, seen frequently in samples of abused and neglected children, with whom, most of the research into the effectiveness of play therapy has been conducted. The ‘Psychoanalytic Approach’ to play Psychoanalysts saw child play as a sort of free association, allowing for the interpretation of internal emotional conflicts and Freud (1914) believed


9 that children repeated everything in their play that had made an emotional impression on them, so that they could ‘abreact’ the intensity of the experience and make themselves ‘master of the situation’. Oremland (1993) refers to Freud’s (1926) later explanation of abreaction as a mental process, in which repressed memories are brought to consciousness and relived, with appropriate release of affect. Ekstein (1966, as cited in Oremland, 1993) concurs that ‘abreactive enactment’ is enabled by supporting developmental progressions through ‘developmentallysupportive’ play, which suggests the potential for abreaction and allows young people to resolve passively experienced trauma through active repetition in their play. Thus the psychoanalytic function of play is to relieve anxiety, occurring during a time of extraordinary psychic and material malleability and when the boundaries between reality and fantasy are unclear and changing (Waelder, 1932). Psychoanalysis is the earliest discipline to offer a ‘Theory of Play’, which includes concepts of the past (through abreactive play), the present (‘surplus energy’ and ‘functional pleasure’ accounts) and the future (Groos’s ‘preparation for life’, 1899) and neatly maps out a concise history of approaches to play over the last hundred years or so (Waelder, 1933). Peller (1954) outlines the psychoanalytic framework to play as focused on the dynamics, motivation and changing form and style of play. Aborn (1993) believes that young people’s capacity for playfulness is based strongly within secure attachment, where positive affect contributes to, creates, and ensues from an endogenous sense of well being, fostering social, emotional, and cognitive development. It is from the psychoanalytic perspective that conflicts in the sensorimotor and symbolic play behaviour of children are seen as indicators of underlying psychic wounding, that is located in the realm of interpersonal and intrapsychic relations and therefore best remedied by play that allows the child to make sense of these conflicts, within a therapeutic environment (Aborn, 1993). Psychoanalysis also contributes an understanding of the need for


10 cathartic release within children’s play. Catharsis For Amster (1982 as cited in Bow, 1993), play breaks down defenses via fantasy, facilitates verbalization and creates a distance from which the child can attempt to deal with their trauma through ‘catharsis’. Greenberg & Safran (1987, as cited in Ginsberg, 1993) discuss catharsis in relation to psychological problems, which result from the blocking or avoiding of potentially adaptive emotional experiences. Through affective play interventions, designed to overcome resistances to emotion, access to underlying affective experience is achieved (through catharsis) and this complete processing of specific emotional experience leads to the emergence of new, adaptive responses to problem situations. Systems and psychoanalytic approaches deal with the play of children, within the autosphere of the child’s microenvironment. To understand play, fully however, the macrosphere must also be considered, to see how children’s play interacts with society and culture, in ways that may promote or inhibit its expression. The ‘Social Model Approach’ to play The Social Model applies predominantly to educational and disability theory, but can inform a discussion on play because young people with disabilities have a right to an education with their peers that includes opportunities to all forms of play (UN Convention 2007) and since school is a primary source of socialization and predominant place of congregation for young people in our society, school also becomes a place of play, perhaps the only opportunity for play that some children have available to them. It is estimated that less than 3% of all young people with a disability worldwide complete their primary level education (Barnes & Mercer, 2004). This shocking figure highlights the relative deprivation


11 disabled young people face, in actually having opportunities for play, if play is not central to their family or institutional existence. The social model argues for the inclusion of disabled people in all aspects of life, including school, family, and play in that it has the unique ability to empower the lives of the young people who take part. This is especially true for young people who face systematic exclusion from education and society due to having a disability. When talking about the play of disabled children, it is paramount to consider the social model theory of disability and to try to integrate what offerings it brings in terms of evidence for social inclusion working for children with disabilities and also because the United Nations adopts a social model approach when dealing in disability issues (Barnes and Mercer, 2004). Michelman (1974) describes the standard of segregated provision for young disabled people as grim, intellectually sterile, aesthetically barren, with unnatural norms of silence, and enforced immobility. Specialist institutions are generally preoccupied with order and oppressive rules and adhere strictly to a timetable that has little bearing on the young peoples’ developmental needs. This constellation of factors contributes to the sensorial deprivation that accompanies the many forms of institutionalisation that young disabled people are vulnerable to when placed in segregative institutions. The global fight for the ‘Inclusion’ of these young people within the mainstream still goes on to this day, with many backward governments arguing for the segregation of their disabled citizens. The social model sees society as the thing that needs changing and rehabilitating, not the disabled person and prescribes an accessible environment for all children to learn together and that does not exclude any on the basis of their ability. This surely poses a challenge to the mainstream in that the question of how to include typically segregated young people within an integrated education system is still receiving scant attention, but there some are examples to be referred to (Stahmer, 2004; Koegel et al., 2001; Rogers, 2004). Since the issue of accessibility comes


12 out as one of critical importance, finding methods that engage young people with varying developmental disorders becomes critical also. Creative play presents itself as the perfect solution for this sort of inclusive learning. Art experience in play Bruner (1967) stresses that learning takes place most readily in an atmosphere of playfulness and suggests ‘Art’ as an ideal laboratory for growth and learning as it involves perception, reaction to the senses, interpretation and insight through multisensorial media. Art experience is easily accessible and extremely beneficial to all young people as it cultivates the senses and promotes direct experience of texture, colour and shape through multisensory investigation of the physical world (upon which all visual and cognitive learning is achieved), offering the basic nutrients for symbol formation. It would be intuitive to assume that unless certain, basic skills are mastered by young people in early infancy, through sensorimotor play, more elaborate thinking and social skills become increasingly out of reach, and in the case of young disabled people, this failure could be reinforced by a sense of defeat unless interrupted with an external source of contradiction. The play agenda evokes interaction with the environment, promotes mastery of symbols in art experience and develops risk-taking, problem-solving, and decisionmaking capacities, thus expanding the circumscribed existence of young disabled people beyond deprivation and disability (Bruner, 1967). Through manipulating their physical and social world actively, all young people develop basic skills and symbolic modes of representing and assimilating reality: play guides this balanced exercise of sensory, perceptual, and intellectual development. Providing activities that stimulate learning is a ‘play-concept’ in the development of competencies and applies equally to children of all ages and abilities, hence the relative importance of art experience in play for children whose sensory,


13 perceptual or motor capacities are hindered in some way. THE PAY OFF OF PLAY Michelman (1974) reviewed the literature on sensorimotor and symbolic play in ‘deficit children’ and concluded that play is a critical part of life for these young people, having vital influence on behaviour, thinking, and performance that no other childhood activity enables. It is a deeply worrying fact then, that across the board, there is a chronic lack of play equipment, play ethos, and play facilities within segregated and integrated settings where play is often sandwiched between more classical corrective therapies or formal teaching (Lowenfeld, 1969). Some young developmentally disabled people may be unable to function in play unassisted and thus fail to acquire skills even at the lowest level of ability (Barnes & Mercer, 2004) indicating that we then, have an obligation to facilitate these young peoples’ participation in play activities, so that they too can receive what Berlyn (1960) saw as the pay off (of playing), to sensation, perception and the intellect. The pay off in play is most easily seen in its absence, in cases of nontypically developing young people. Sensorimotor impairment or socioemotional maladjustment (as expressed in behavioural and learning difficulties) leads to methods of manipulating the environment that may be seen as disruptive, disturbed or withdrawn (Michelman, 1974). The genesis of symbol formation (the foundation upon which all subsequent learning develops) is rooted in sensorimotor play, supported by empirical research as the earliest form of exploratory play behaviour identifiable in neonates (Piaget, 1962). Here, the position is that sensory and tactile stimulation through sensorimotor play is a necessary prerequisite for perceptual and cognitive development. If blocked, the symbolic functions do not develop typically (Solomon, 1961), leading to problems in thinking or reasoning and disturbances in the imagination and affective states.


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That early sensorimotor play forms the basis for all future learning, is echoed throughout the literature on play, to the extent that earlyintervention programs are now successfully implemented, which focus on improving opportunities for sensorimotor manipulation in samples of blind, deaf, autistic, learning disabled and emotionally disturbed young people in order to improve their chance of acquiring the basic cognitive skills and coping mechanisms that all humans develop through their early years play (Udwin, 1981; Bishop, 1997; Baren-Cohen et al., 1985; Koegel et al., 2001; Rogers, 2004; Stahmer, 2001; Vygotsky, 1925; Tait, 1973; Cattanach, 1992). These studies also tell us a lot about the nature of the core deficit in many of these developmental disorders, specifically it is impaired sensorimotor manipulation that leads to delay and disruption of symbolic representation, culminating in problems within the imagination as evidenced through pretend or imaginative symbolic play which cause delays in linguistic development and result in the social and cognitive impairment labeled as a disability (Thomas, 1968). Bee (1992) sees the behavioural and developmental difficulties that young disabled people face as consequences of the damaging sensory-environmental deprivation they typically experience in segregated settings and as a result of their restricted lives as children with disabilities that inhibits their opportunities for sensorimotor play. In relation to these studies it can be said that young disabled people like all children need a rich and varied sensory-play environment to learn because sensory and kinaesthetic experiences are the basis for symbolic thinking and cognition (Thomas, 1968; Solomon, 1961; Piaget, 1952). RESEARCH INTO THE SYMBOLIC PLAY OF YOUNG PEOPLE WITH DEVELOPMENTAL DISORDERS Language Disorders


15 Udwin (1981) studied the imaginative (symbolic) play behaviour of 15 boys with language comprehension and expressive disorders and compared them with a control group matched for IQ, SES, and age (without language disorders). Imaginative play was found to relate positively to language development, positive affect, concentration, social interaction, and intelligence although not to social class. Imaginative play reflects a child’s transcendence over the external constraints of time, space, identity and the bending of external stimuli in the service of their ‘inner world’ as they play pretend and internally represent their wishes in symbolic play (Udwin, 1981). This type of symbolic play is self-initiated, lacks structure, and represents the performance of roles where objects act as symbols for other objects or people that are not present. The richness and frequency of imaginative play grows from a set of optimal conditions including parental contact, acceptance of imagination, provision of positively toned, imaginative modeling opportunities, and physical and psychological space for practice and is therefore unlikely to occur during a need state (echoing one of the assumptions of the Reilly’s systems theory, 1974). Udwin (1981) found that young people with language disorders showed deficits in imaginative play, positive affect, concentration and social interaction. A significant positive correlation between imaginative play and expressive/comprehensive language abilities was found and this effect persisted after controlling for intelligence, supporting the notion of a generalised symbolic function that is common to both language and symbolic-imaginative play. Levick (1978) also studied the relationships between symbolic play, linguistic, and non-verbal ability in 14 young boys (3.5 - 6.5 years of age) with language disorders. There was a control group that was matched for age and social class. The play assessment demonstrated that play was more associated with language ability than IQ. The group with language disorders played less and scored lower than the control group on their IQ tests, as was to be expected. Levick could also predict scores on language


16 tests from observations of symbolic play, finding that impaired symbolic functioning in play and language was isolated to the group with language disorders. Rutter (1972, in Udwin, 1981) found that language disorders lead indirectly to emotional and behavioural difficulties through associated brain dysfunction, educational failure, lack of social integration, communication deficits in social relationships, and teasing or rejection. Piaget’s (1962) ‘generalised symbolic function’, supports and predicts the impoverished imaginative play in young people with language disorders, rendering imaginative play useful in understanding the acquisition of inner language and also helpful in highlighting delay or failure in learning to talk which would indicate problems in symbolic functioning. Observing children play is therefore an invaluable tool for the preliminary differential diagnosis of developmental language delay and for early referral and treatment. Autism Baren-Cohen et al., (1985) saw that young people with Autism hardly ever engaged in imaginative play, whereas young people with Down’s syndrome pretended very well despite having lower IQ scores, using this result to demonstrate that absences of pretend play stem from a ‘theory of mind’ deficit in Autism as opposed to being related to IQ per se. Leslie (1987) supports the theory of mind account and explains that pretending requires decoupling primary representations (what we perceive) and metarepresentations (what we perceive other people to perceive), which is something that young people with Autism typically find to be difficult (Cohen, 1993).


17 Baren-Cohen (1985) judged that pretend play appears around the one-year mark and he found that all studies into Autism showed either delay or absence of pretend play, criticizing many studies for not looking into spontaneous (free) play activity in children with Autism, which may have contained symbolic elements. He believes that symbolic play can aid in the developmental progress of young people with Autistic Spectrum Disorders. Koegel et al., (2001), Rogers, (2004) and Stahmer (2004) provide clear enough indication that there are major benefits to the Autistic child being included in an integrated, inclusive setting, where resources are available to offer them the one-on-one support they need. It was the peer-mediated approach, whereby, typically developing young people assist the non-typically developing child that most positively impacted on the Autistic child’s learning. If including children with Autism within integrated settings improves their social skills and opportunities learning, there is no reason to assume this type of intervention would fail for children with other disabilities. Visual Impairments Blind young people do play in the sensorimotor stage of infancy and there is no evidence that visual impairment leads to a basic inability to pretend, although the symbolic play of blind children does differ in some ways from their sighted peers in that it tends to be less imaginative, more concrete and less varied or flexible for example, due to limited vision the child’s grasp is limited to objects they can feel around them, and does not extend into the outer realm where vision would be a strong cue for object presence (Singer & Streiner, 1966). Tait (1973) studied the play of 4- to 9- year olds with visual impairments and found that these young people were as likely to manipulate objects in their play as sighted children. The differences were quantitative as opposed qualitative, meaning that young people with visual impairments require a sensory-rich environment including materials with varied textures to facilitate frequent engagement in play


18 and the creation of tactile maps of their play environment through the use of sounds, sand, woodchips, carpeting or other materials on the floor. Young people with visual impairments can practice and encode motorically when they are given liberal amounts of reinforcement and encouragement in an environment modified to their sensory-motor and perceptual capabilities. It is with this in mind that a play setting, in which blind children can practice becoming more confident exploring their reality, without the aid of sight, within safe boundaries and with an encouraging parent, can been seen a good use of play in the treatment of these children. Bishop (1997) conducted three studies of 4- to 9- year old blind young people matched with sighted young people with equivalent IQs. The blind and sighted groups were divided into subgroups who were measured as either capable of a greater or lesser degree of interpersonal relatedness. Data was taken from direct observations of free play with peers in the first study, from comprehension tests of understanding differences between mental processes and reality in the second study and from semistructured, symbolic play sessions in the third study. Bishop found no significant difference in the free play or symbolic play of the blind young people from their visual counterparts, suggesting that blindness per se is not an impediment to the development of social understanding. Further, it was in fact young people who showed poorer peer relations in the free play study who were also impaired in aspects of their social understanding as shown through their symbolic play in the third study. Since play is a natural tool for children’s development of social understanding, it would appear that supporting play experiences might reduce problems related to social understanding, as evidenced by Bishop’s study. These clinical and experimental reports support previous findings (Parmalee et al., 1959) that delays and impairments in the social development of blind young people, as well as sighted young people, are


19 more attributable to the quality of their interpersonal relationships than to the condition of blindness per se. Bishop’s (1997) hypothesis was that congenital blindness limits engagement with others in specific ways that have a knock-on effect on the development of social understanding and symbolic play. He states that the difficulty for blind young people is in distinguishing between other peoples’ mental states and the things in the world that those states are about. In this sense, impairments are not related to levels of general cognitive intellect and there are other, nonvision-dependent routes to co-reference between the child and others (including the use of sound and touch to map their territory, communicate and interact), such that some blind children circumvent visual impairment by becoming successfully engaged via these alternative routes and therefore progress in their social understanding and symbolic functioning. Bishop illustrates the range of social and intellectual adaptive responses that congenitally blind young people can make to the profound constraint of visual impairment and advocates that young people with visual impairments, as well as sighted young people with interpersonal relationship struggles, would both benefit from a play therapy that fostered first and foremost cooperative and adaptive interpersonal relations as well as multisensory exploration, within an inclusive setting.


20 Hearing Impairments Deaf children show rich symbolic play despite speech and language problems and use symbolic signing to communicate very well, but Deaf children’s main difficulty is that of hearing, not symbolic thinking or learning. Mann, (1984, as cited in Hughes, 2006) and Darbyshire, (1977) found that young people with hearing difficulties tended to be less cooperative in their make-believe play and less symbolic in their use of objects than their hearing peers, though no specific play deficit was implied. Lovell et al (1976, as cited in Udwin, 1981) found a significant relationship between the time spent in symbolic play and later language development, suggesting that it is the secondary effects of speech impairment that limit social opportunities for expressive symbolic play which then lead to the development of difficulties in communication, again implying the need to provide social play opportunities for children with hearing impairments to reduce the negative impact such impairments can have on social understanding and well-being. PLAY AS THERAPY If play can have so many benefits for children with developmental disorders, perhaps it could provide pay offs to children with emotional and behavioural difficulties too. Amster (1982, as cited in Bow, 1993) summarises that play provides opportunities for diagnostic assessment of socio-emotional functioning and helps develop the working relationship between the child and a therapist within an enjoyable, natural setting which affords intense interpersonal interaction. Jackins’s (1962) ‘Reevaluation Therapy’ is an example of how catharsis has been made central to the healing process of play. For the Reevaluation Therapy community, young people play in order ‘to get to their feelings’. When feelings become visibly apparent and distort the


21 naturalness of their play the adult therapists (parents/allies) pay attention to the child, encouraging them to release the affective charge into the permissive and accepting therapeutic space. After which, the child’s attention goes back to play, and continues in its growth inducing ways, until the next feeling state arises and again distorts the organic nature of the play as it seeks catharsis. It is the role of the therapist to understand and know when and how to interrupt this ‘distressed form of play’ and facilitate the young person’s ‘cathartic discharge of emotion’ within a safe and playful atmosphere. Play contains a substantial emotional element and play therapy in this sense, tackles the emotional dimension directly. We can assume that the experience of disability in the emotional, physical or intellectual realm would also bring with it a psycho-emotional valence that could potentially be handled within a play therapy situation (Barnes & Mercer, 2004). Under the cathartic notion, failure to express emotions tied to traumatic events is responsible for maladaptive attitudes and behaviour. In Guerney’s (1964) Filial therapy (involving parents as therapists), aggression and emotional expression were found to increase as the sessions went on and subsequently fall below initial levels with increased game playing, cooperative behaviour, and conversation about life matters. So it becomes evident than affective experience within parental-accepting play forms a central feature of its healing function as a therapeutic medium. O’Connor (1991) defines ‘play therapy’ as a cluster of treatment modalities in which young people engage primarily in and make use of the therapeutic aspects of play whilst relying on highly-developed theoretical orientations and technical strategies which direct the thinking and behaviour of the therapist as the child moves systematically towards mental health. The common goal of all play therapy is to reestablish the young person’s ability to engage in play by maximizing the fun,


22 intrinsically complete, person-oriented, flexible, noninstrumental, and ‘natural-flow’ activities. Success is considered to be a child’s demonstrable ability to play with joyous abandon (O’Connor, 1991). Schafer (1993) includes in play therapy the overcoming of resistance, communication, mastery, creative thinking, catharsis, abreaction, roleplay, fantasy, attachment formation, relationship enhancement, and enjoyment. It is clear to see how the psychoanalytic contribution to the play of childhood (specifically, its emotional dimension) has had lasting impression on the practice of play therapy. Humanist play therapy, differs from psychoanalytically oriented play therapy, in that it seeks not to delve into the past, but deals in the present especially focusing on the self-expressive function of play, in helping to encourage young people to be confident in being themselves and to strive towards their full potential. Humanist Play Therapy For humanists play defies classification, as it is a behaviour that varies across situations. However, the behaviour of the individual at all times is believed to be caused by the one drive for complete self-realisation that when blocked by external pressures does not stop growth but frustrates it due to the generative force of the tensions that are created (Axline, 1947). Humanist play therapy sees the child as active agent, capable of directing the therapeutic process and is based on the assumption that given a chance young people can and do become more mature and positive in attitude and more constructive in methods of expressing their inner drive. Non-directive Humanist play therapy fosters an acceptance of the child and a strong faith in their capacity for self-determination. Non-directive play therapy starts where the child is at and lets them go as far as possible in their play sessions. Taking the therapy back to the child’s past (as in the psychodynamic techniques) rules out the possibility that they have grown since then and as such probing questions are ruled out also


23 (Axline, 1947). This kind of thinking seems prescriptive for all parents since it is fundamentally positive and children with disabilities may also benefit from having a humanist perspective applied to their learning and growth. West (1996) describes the results of 130 children with psycho-emotional disturbances undergoing ‘child-centered’ play therapy, a variant of the non-directive school, where only five young people showed no improvement. Three of the five withdrew and the other two were at the mercy of the courts and unable to take part fully. Child-centered play therapy was found to improve the chances of young people being fostered or adopted into appropriate families much faster than usual and young people were also enabled to remain within their own homes or in a placement where there had been breakdown (West, 1996). Carers and teachers consistently described considerable improvements and reported that most presenting problems disappeared after play therapy interventions (West, 1996). It is from this humanist approach that we can truly see play as a liberating act indeed, as freedom epitomized to the child. In play, children naturally make use of their sensorimotor and symbolic capacities, and play therapy is no exception, and since we can be confident that most play has many pay offs for children, play therapy is clearly an obvious choice for young people with and without developmental difficulties. Getting to play, in itself would be a major achievement for many of the young people already mentioned, but having a trained therapist there who could further empower the child to fully express themselves would be an added bonus. Play therapy for abused or traumatized children Green (1978b) reviewed the work done into the treatment of abused children and saw psychoanalytic play therapy as the most appropriate way to prevent crystallization and internalization of disturbed parent-


24 child interactions into the personality structure of the child. Mann and McDermott (1983) describe the use of play, in the psychodynamic treatment of 3- to 12- year olds referred by the Child Protective Services to the Child Guidance Centre of Kapiolani in Hawaii. The sample of 25 children were presenting with behavioural problems and a history of abuse and or neglect. Half of the sample came from foster homes, the other half were referred from their own homes. The goals of the programme were to help the young people master the multiple stressors of abuse and neglect, and to correct or prevent deviations in future psychosocial development. Play was useful because abused young people more than the general population express their innermost feelings and fantasies much more readily through action than verbalization (Mann & McDermott, 1983). Therapy took into account that to the abused child adults are unpredictable and dangerous. For these young people fear of physical assault or abandonment, failure to meet parental expectations, difficulty achieving separation and autonomy, and multiple rejections can lead to a variety of symptoms including depression, anxiety, aggressiveness, distrust, impulsiveness, defective object relations, struggles over dependency, internalization of a ‘bad child’ self-image associated with low self-esteem and further depression (also seen as consequences of developmental disabilities, Barnes & Mercer, 2004) and can be dealt with effectively within play therapy (West, 1996). One wonders where, in the real world, the many children who suffer psychological distress due to abuse or neglect or indeed disability, actually get to face these issues with an understanding caring adult? Certainly, the education system fails in this sense, by being so regimented and under-resourced, and the home, if a source of distress, clearly cannot provide such safety for a child in need. The first three months of play therapy for abused children involves establishing contact and learning how to play. The next phase (up to seven months) necessarily involves regression and abreaction of trauma, until the child is ready to test real


25 relationships, develop impulse control and improve self-esteem which becomes the focus of therapy until around 14 months into the process when the termination sequence begins for the remaining two months. Follow-ups are recommended with this group of young people as the abusive situation may have resurfaced. Preschool and early school age children with emotional disturbances are appropriate candidates for play therapy designed for abused children, although a prerequisite must be that the abusive situation has been stabilized to prevent reabuse or neglect. Hence, the treatment of parents is critical, as is the counseling of foster carers concerning the child’s need for re-enactment and how not to collude with this. 16 months, however, is a long time to resource such necessary intervention, and speaks to the lack of almost any intervention programmes that are available to children in these dire situations (Green, 1978b). Play therapy can be important for nonabused children who have experienced trauma also. Terr (1983) refers to his study of play therapy treatment for the 23 Chowchilla bus crisis victims, delineating ‘posttraumatic play’ as a type of play observed in young people who had undergone sudden, unanticipated and intense psychic trauma. The psychological effects of posttraumatic reactions on nonabused young people from the bus kidnapping were fear of further trauma, traumatic dreams and repetitive reenactment. These fears and actions persisted long after the event and it was the monotonous ritualisation of posttraumatic play and the fact that the reenactments were played the same way each time that distinguished it from other types of play. Green (1978b) concludes that abused young people are also preoccupied with violent fantasies, suffering periodically from acute anxiety states in anticipating trauma, as evidenced by their symbolic play. Psychologically, a child who is assaulted by a parent, on whose care he or she is dependent, will be on constant guard to try and prevent further attack, resulting in hypervigilence and exaggerated startle reactions (Green,


26 1978b). The expectation of being hurt can then generalise to any person, including peers, pointing towards the parental, pedagogical and psychosocial obligation of providing a play therapeutic environment for young people who suffer a range of psychological trauma as indicated by posttraumatic play, as a place for them to deal with the effects of these events. Cattanach (1992) suggests that the centrality of play experience as the child’s preferred mode of creative expression renders it a dynamic form of therapy for abused young people. Symbolic play in play therapy allows young people to explore their experience of abuse, safely distanced from reality, whilst finding symbols as metaphors to describe their pain. For these young people, going back to the childhood they might have had through embodiment play (also known as dénouement play), nurturing themselves with their therapist as ‘mother’, projecting a need to nurture (though feeding dolls) and a desire to become the ‘good mother’ touches on a Jungian idea which understands that there is a hunger and yearning for love, care, and attention that can be overwhelming for young people who have had disturbed interactions with caregivers, resulting in there always being a corner of the person which can never be satisfied and never be loved enough (Jung, 2006). Jackins (1962) called these corners ‘frozen needs’ because they can never be met. Play therapy for abused children is based on Pringle’s (1974) four basic needs for healthy development, which include love and security, new experiences, praise and recognition and responsibility. These needs surely apply to all children and can be easily seen as sensible goals for typically and non-typically developing young people as well. Since most young people who are abused by their parents are typically removed from them in the interests of their own physical safety, it is often the case that loss of parents can bring relief from fear concomitant with a strong sense of emptiness, which Cattanach (1992) believes can be dealt with through


27 symbolic play in play therapy. So far, play therapy establishes itself as an extremely useful tool for children with emotional needs that may have been exaggerated by an experience of abuse or trauma. There is an implication that disability comes also with a psycho-emotional dimension (Barnes & Mercer, 2004) such that play therapy would also be useful for disabled young people. Parents of children with a range of disabilities, or indeed none, would do well to create play therapeutic opportunities for their children, in order to aid them in their psycho-emotional development as well as for the pay off of play in general (West, 1996). Parents as ‘Play Therapists’ Guerney (1983) discusses non-directive play therapy in terms of its use for nonprofessionals, as a potential technique that could be incorporated into the lives of all children, at home, and at school. Stollack et al., (1975) conducted two large-scale studies which demonstrated that nonprofessional undergraduates trained and supervised in child-centered non-directive play therapy could produce therapeutic conditions and positive changes in typical young people and in clinical samples, compared with a control group taking part in untrained, naturalistic play. This positive change in child-centered play therapy consistently took place between the years of three to ten even with inexperienced, nonprofessional ‘therapists’. Wall (1979) also studied three variations of play therapy conducted by graduate trainees, untrained parents, and parents under supervision in the Axline tradition of Humanist non-directive play therapy. The latter group showed improved ability to communicate emphatically, and stood out as the favoured approach because it was believed that acceptance of negative feelings by a parent during free play has a more powerful impact on young people than acceptance from nonparents. This supports the notion behind Guerney’s Filial Therapy (1964)


28 and Jackins’ (1962) Reevaluation Therapy and provides support for the notion that parental-accepting play in itself can be therapeutic for all children, not least because children ultimately love to play with and get attention from their parents, but because children all over the world, with their differences in needs, anxieties, and abilities are emotional beings who play in order to make sense of their lives and resolve conflicts as well as to learn the sensorimotor rules of objects and symbolic rules of thinking and speech. CULTURAL CONSIDERATIONS IN PLAY Haight et als., (1999) longitudinal study into the universal, developmental and variable aspects of the pretend play of Irish American and Chinese children. The universal dimensions were found to include the use of objects and the social narratives in pretend play. Developmental dimensions that were found to change with age (between 2.5 and 4 years old) included the increase of social pretend play initiated by young people (particularly with caregivers), the level of initiation by pretend partners (found to decrease in caregivers as the child grows up), the various functions of social pretend play in interaction, and the specific themes it deals with (which were found to vary considerably over cultures). The ‘universal object-use’ supports Vygotsky’s (1962) claim that objects and people facilitate the transition from literal (interpersonal) to non-literal (intrapersonal) thinking (inner speech). The content of symbolic pretend play was found to differ across cultures, highlighting the social function of pretend play and how differences in value systems that exist in Western and Eastern cultures, including parenting practices, can impact on the varying expressions of symbolic play globally. How much time and who is typically available for play, and the differing non-play uses of symbolizing that are implemented by parents and caregivers from America or China, depend largely on ecological and economic factors as well as culturally distinct methods of socialization. Play can thus be understood as a


29 culturally mediated, biosocial activity, as Luria and Vygotsky were alluding to more than 70 years ago. CONCLUSION: the case for inclusion Considering the play of young people with emotional (West, 1996; Green, 1978b), visual (Bishop, 1997), hearing (Darbyshire, 1977), language (Udwin, 1981; Levick, 1978), and autistic spectrum (Baren-Cohen, 1985) impairments indicates that play can and does offer psychologists a well of rich and descriptive data that allows for an appreciation of the significance of early sensorimotor and symbolic play in childhood and as tools for play therapy, in that they overwhelming contribute to the child’s growing capacities to represent, manipulate and adapt to objects, events and people in order to make sense of and understand their experiences. These data certainly present the case that disadvantaged young people gain much from having ample opportunities to play especially when thought has been made to their specific needs and areas of developmental struggle. It is clear that there is a definite psycho-emotional dimension to disability that opens the door to there being psychic wounding that may be appropriately addressed within psychoanalytic play therapy and since much of the experience of disability in childhood is one of great disempowerment, nondirective techniques may be best suited to contradict the learned helplessness and powerlessness that is so often married with developmental delay or disorder. All the evidence presented suggests, some form of therapeutic intervention involving developmentally appropriate play of a sensorimotor or symbolic nature, can aid in the healthy growth of the whole child. Play is the most natural thing young people do (Bruner, 1967). It is a unique medium facilitating development of expressive language, communication skills, emotional development, social skills and cognition. In play, young people explore (Reilly, 1974) and discover interpersonal


30 relationships (Vygotsky, 1935), experiment with adult roles (Piaget, 1962), and attempt to understand feelings (Freud, 1926). Multidimensional and multidisciplinary play is adequately explained by a Systems theory approach to biosocial phenomena (Michelman, 1974). The Psychoanalytic microscope helps to demonstrate that play can have significant healing effects when it allows for catharsis (Ginsberg, 1993) and the Social Model approach to disability and education highlights the need to establish inclusive practices that oppose the detrimental effects of segregation, for young people who have specialist needs in order to play and learn with their peers. Guerney’s (1983) work provides the final component in promoting parents as play therapists, who have been proven to bring out positive effects simply by playing with their children and this is not exactly a profound or novel idea, but in an era when time spent ‘with the family’ is increasingly interrupted with the distractions of modern living, the point must be made, that play is an essential part of the child’s life, and if parents played more, and understood more about the nature of sensorimotor and symbolic play (as this essay has attempted to do), there can be many pay offs to the child and this has been supported by empirical research into the play of typically and non-typically developing children. The significance of sensorimotor and symbolic play for the development of inner speech and symbolic reasoning has been considered and some broad theoretical approaches to play have sketched a rather minimalist framework for a discussion into the effectiveness of different therapies involving these types of play for samples of young people with a range of developmental disorders. This thesis could have gone any number of ways, but it is with respect to the significance of play, as a right for all children, and in light of recent disability discrimination legislation (Disability Rights Commission 2007) that this discussion has dealt with as few mandatory issues as possible, in order to illuminate the fact that we currently have more than enough information and research available to us, to do a much better job for our young children, especially those at the


31 mercy of the medical establishment, through understanding their need to play and what playing does for the child. This paper shows that play, as a medium for healing, presents itself as the most natural choice in treating typically developing children, young people with a range of impairments or young people who have suffered traumatically at the hands of their protectors. Neglecting play as a key that unlocks the door to learning and growth can go on no longer.


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Approaches to Play: