Indian J Pcdiatr 1992; 59 : 53-(,0

Play Therapy with Young Children

Daphne Marcus

Department of Neurology and Developmental Pediatrics, hlstiltttc of Ofild Health, University of London, London

This article sets out to describe and evaluate the use of Play-Therapy with young handicapped children. The children, mostly of pre-school age, have been seen at the Wolfson Centre in London, over the last five years. The work is on-going.

The developmental programme adapted and followed, was designed at the Centre in the 1970s, by Cooper, Moodley& Reynell? It was used to teach children with specific language delays. It has proved ideal to use with children with a variety of problems in their learning, also those with developmentaJ de- lay.

The teaching/play sessions have taken place in the children's homes and Jn the Wolfson Centre. Parental involvement has been important for success of the programme. Other professionals beside the teacher have been in- volved at the Centre, for monitoring the childrens progress.

The results shown in the annual reviews, or when the child attends for for- mal assessment, are encouraging. They point to the conclusion that this form of therapy can not only help the child at home, bta also helps when he/she* starts school.

Key words: Home; Theory; Recording; Case; Teacher & children.

AIMS

What is Play-therapy? It is the use of a natural activity with a young child, to help him consolidatc the levels of dcvelopmcnt that hc has rcachcd and encourage him to

Rcprint requests : Mrs. D Marcus, DRLS, Teacher for Ihe Wolfson, The Wolfson Centre, ,".tecklenburgh Square, London. WCIN 2AP, England.

move on, to the next level. Using a struc- tured approach, the Tcachcr/Thcrapist can plan individual programmcs.

Play can be used to assess and rcmedi- ate. Many standardiscd Icsls use toys, but a child can scnse that hc is in a "tcsting" situ- ation. Playing with his mother or the teacher that he knows well, may glvc a truer picturc of his abilitics.

The Tcachcr can draw up her own "Pro- ill,:" of play and language and add this to

N.B. " We will refer to child as "he". although a number of girls have becn seen, the majority referred to the teacher have been b%'s.

53

54 TIIF INDIAN JOURNAl. OF PEDIATRICS Vol. 59, No. 1

formal assessment that the child will have had at the Centre.

Before each child starts Play-therapy, the teacher will have seen the initial reports and discussed the case with the referring Paediatrician. The child's parents are then ~sked, if they would like help from the teacher.

Most parcntswclcomc this support, they want ideas of activities to use at home that will help their child, the teacher does an ini- tial home visit, and will then visit at regular intervals. Play-therapy sessions at the Centre, which are called "The Friday Club", are arranged as convenient and pos- sible for the families.

Many of the children who are referred to the Wolfson Centrc, come from quite a dis- tance, so that frequcnt visits are not pos- sible. The tcacher will keep in touch with these families to discuss progress and help by sending toys, plus idcas on how to use them.

With the families who live within reason- able travelling distance, the teacher can be- come involved with thc local team, as they become aware of the child's handicap.

Schools are usually pleascd to have a visil from a leacher who knows the child well and is able to explain some of his diffi- culties.

Parents often need help in coming to terms with the fact that their child will still need special help whcn he goes to school. They can see and learn themsclves, about his problcms through continuing structured play.

The teachcr will work on the child's at- tention, communication, comprehension and expressive speech, symbolic play, audi- tory and visual skills. Fine motor skills if needed. Suggestions to improve large motor skills at home, are made where appropriate.

HOME

During the first home visit the teacher will just sit down and play with the child.

The main aim will be to make friends with him and build up a good rclationship with his mother or nanny.

From the Wolfson Centre assessment, the teacher will know what toys the child is probably going to like. She will take some suitable materials with her.

She will want to see what the child is al- ready playing with at home and how his mothcr plays with him.

The verbal language that the Mother uses is important for the child, especially the child with a language delay.

It has been found, that the best way to help a mother work with her child, is to model the activity and the appropriate speech. Many mothers are already working well with their child and simply want some new ideas. They also want a simple pro- gramme that they can follow and see re- sults.

Parents are usually very appreciative of explanations of the reasons behind intro- ducing a particular form of play. They are the people who know their child best and often make natural teachers.

Play sessions which usually last about one hour will include, one activity specifi- cally designed to improve attention/listen- ing, one activity to improve seeing/doing, and one symbolic play session.

Parents find this quite a simple plan to follow. Extra time is always allowcd for in- formal discussion. Worries about behaviour and social skills are often brought up. Other professionals at the Wolfson Centre are quite happy to advise, between the child's formal assessments.

Home visits and getting to know the

3,L.XRCUS : P L A Y TI t E R A P Y WFI'I I Y O U N G CI IILI)R_F.N 55

whole family, has been the key to helping most of the children rcfcrrcd for Play-ther- apy. The sessions in the Wolfson Centre enable the teacher to use a wider range of teaching/play materials, also to work her- self on a particular skill that the child needs to improve.

T|IEORY

Cooper Moodlcy and Rcyncll believed that a child has levels of attention control and symbolic play that correspond to his levels of devclopmcnt.

Ascertaining what lcvcls a child has reached in these two areas, can form the basis of a rcmcdial programme of teaching/ therapy.

In the book, writtcn afler their study at the Wolfson Centre was completed, they describe in some detail, different language problems in young children. ~

Environmental dclay; caused mainly by social conditions. Developmental delay; caused by illness, part of a recogniscd syn- drome, or sometimes uncxplaincd. A Lan- guage dks-ordcr, where a child exhibits devi- ant patterns of speech. An articulation problem which may be Dyspraxic.

Wc havc seen children with a variety of Ihcsc language difficulties for Play-therapy.

The C.M.R. programme places emphasis on a child's dcvelopmcnt of symbolic under- standing, through play. It suggests that this h)rm of play is the most natural way to in- crcasc a child's comprehension and concept development.

That a young child builds up his "inner modcl" of his world through each new ex- perience. (Piaget)?

They give stages of play that a normal child would be expectcd to have reached.

At about 12 months old the child will rcccognise objects, examplc: his Teddy and

cup, at about 15-18 months old, the child will play with large dolls, Wendy-housc type furniture and dolls tea-sets. At about 22-24 months the child will reecognise pictures as representing objects. From 24 months, the child will begin to relate to smaller dolls, then miniature toys and dolls house sized furniture. His imaginative play should now extend. He reeognises, toys and pictures in a variety of situations, as symbolic of the original. Example: a doll can be the baby, a model car can be Daddy's car.

Many of the children seen for Play-ther- apy have immature attention control. C.M.R. quote the normal developmental stages.

In the first year of life, the child is very distractible, therefore hc has a very short attention span. His interest is held briefly by the most dominant stimulus in his environ- ment. Other distractions must bc kept away if he is to learn from this stimulus.

In the second year of life, the child can now concentrate for a short time on an ac- tivity that he likes and has perhaps chosen for himself, (rigid attention). He cannot tol- erate any intervention by another child or adult without losing interest. Direction at this stage, must form part of the play, to be successful. A child at this stage may like "cause and effect" toys, where he sees a definite rcsult to his action.

In the third year of life, the child's atten- tion is still single-channelled, that is he has to give full auditory and visual attention to the task in hand. But, he can now assimu- late some suggestions of instructions with- out losing interest. In teaching a particular skill, the teacher must take the lead and make sure that she has the child's full atten- tion, before she begins.

Fourth year of life; the child will now be- gin to control his own attention. Hc will

56 "1I IE INDIAN JOURNAL OF PEDIATRICS Vol. 59, NO. 1

seek help during his play, begin to take turns and enjoy another person playing with him. He can move from one play situation to another, linking them together and be- coming more creative. He can disregard some other noises in the environment.

Fifth year of life; the child is now pro- gressing to a stage where he can be taught in a small group and then a class. He can focus his attention on verbal and non-verbal instruction. This stage of attention control requires maturity in thinking and reasoning and shows a child's intellectual develop- ment.

Obviously, normal children are going to vary in their levels of attention. In some of the children that we have seen, immature attention has continued, although other ar- eas have seemed to be progressing well.

Children described as hyperactive, will have poor attention control which is very difficult to remediate.

MATERIAL AND METII()DS

Deciding what level of attention a child has reached, can come from observing his play and playing with him. To improve attention, almost any activity that the child enjoys can be used. In Play-therapy we often use musical toys or simple instruments, to "make" music, taped music and finger rhymes2 The teacher Mll sit opposite the child, a young child can sit on his mother's knee. The child is encour- aged to look at the teacher and respond to the bells or whatever initial stimulus is being used. He is hopefully going to imitate the teacher, clapping hands and shaking the bells himself.

Finger rhymes can follow, action rhymes and nursery rhymes are enjoyed. These are easy for the mother to follow-up at home.

As the child matures, taped "sounds" plus pictures can be used. Now the child can sit opposite or next to the teacher, listen to the sounds and find the picture that matches the sound. Activities like these that require the child to look at, listen and par- ticipate, do seem to be best for improving attention.

Activities designed to improve attention are going to improve other areas of learning too, particularly auditory and visual skills. The Finger rhymes will encourage the child to use his hands. A child who cannot pro- duce speech may use a simple signing sys- tem, such as "Makaton". 4

The teacher must try to eliminate any noisy distractions, to give the child every chance to attend to the activity.

Mothers are encouraged to spend at least two short sessions each day at home, to improve the child's attention.

Finding the child's level of symbolic play, the teacher will present toys and see how the child uses them. With a young child, she will use a large doll, cup & saucer, brush, comb etc. If the child has meaningful play at this level she will start there.

If the child is below this stage, the teachcr may have to start with object recog- nition, in a very simple way.

Most children we have seen have reached the 15-18 month level in this area of development. They have responded well to Wendy-house type furniture, cooker and sink. Also to a variety of large doll play. Dolls tea parties are very popular.

During this play, useful work can be done assessing the child's comprehension and recording his spontaneous speech, s It should be noted if the child responds to ver- bal instructions, suggestions and questions. It should be remembered that many chil- dren develop "situational understanding"

MARCUS : PI2XY T I t E R A P Y WITH Y O U N G CII ILDREN 57

and may not understand all the words being t,_sed to them. It is much easier to assess a child's own verbal ability, by using a tape- recorder during a structured play session.

We also use large bricks with younger children, building towers and bridges.

As the child progresses, we introduce smaller toys. Model cars and animals, smaller bricks, "Play-people" and dolls house size furniture. Large bricks are still used, and if a particular area of language is being worked on, e.g. Prepositions, this can be done through play. Example; "The car is going under the bridge". "The man is sitting b~ the car."

When the teacher first begins to work with the child, she may use a few words her- self. This is because too much verbal in-put may distract the child from the task in hand. As the child progresses, she will try and use the appropriate language for each activity. 6 Mothers will also be encouraged to con- tinue this at home.

It should be remembered that it is not enough just to provide the right toys for the child, it is the way that he is encouraged to use them that is important.

From the simple dolls tea-party to using miniature play-people in a variety of play- situations, the teacher/therapist must use her imagination and enter into the child's world.

RECORDING

The C.M.R. Programme provides check lists to record individual children's progress. These lists are very useful to the teacher/ therapist, as they cover verbal and non-ver- bal skills. This is a brief description; plus the teachers own check lists.

Attentkm control;stages as discussed 1-5.

Symbolic play/Understanding

1. Objects normal size/small size. (Cup, Spoon, Brush)

2. Large Doll Play; Recognition/Use in imaginative play.

3. Small Doll Play;, Recognition/Use in imaginative play.

4. Matching; Objective to picture, Toy/ picture, Picture/toy.

5. Gesture/Pictures.

Concept Formation

1. Matching colours, shapes, objects. 2. Categories by use. 3. Relative sizes; big/small, long/sh0rt,

etc. 4. Same/Different. 5. Quantities; More/Less/Same.

Positional Concepts

In/Out Up/Down, Over/Under. In front of Behind, Next to:

Visual Perception

Matching shapes. Circles, Squares, Tri- angles, Others.

Constructional Tasks

Building Towers, Bridges, Houses; Copying models.

Verbal Comprehension. (usually formally assessed at reviews).

Teacher can note; Situational understand- ing. Verbal labels. Relating two nouns. Re- lating noun + verb. Adj. + noun. 3 ele- ments.

Expressive Speech

Speech or Symbolic "noise" during play. Use of nouns as labels. Little situational

58 TI tE INDIAN JOU RNAL OF PEDIATRICS Vol. 59, No. 1

phrases. Social greetings. Use of Adj: + noun, noun + verb. Three word sentences; longer scntences. The use of"and". The use of pro-nouns. The use of questions. Is child's speech clear, accurate to the situ- ation and becoming descriptive.

The value of using the C.M.R. pro- gramme has shown by the steady progress made by most of the children rcferred to the teacher. The appreciation of the parents has also becn recorded. When the children come up for review, the teacher will also at- tend, this often puts the child at his case. The results of the formal assessments can show the teacher whcther the programme needs adaptation for a particular child.

One little boy wh~ has worked through the programme is Edwin. A very short case history is included.

CASE

Edwin was referred for Play-therapy in March 1986. He was thcn 23 months old.

Edwin had been seen at the Wolf son Centre for advice on feeding and general care.

Edwin had spent some months in hospi- tal for cardiac surgery, Edwin had also had a tracheostomy, the tube was still in place at this time.

Because of his illness, Edwin had not been able to actively use many toys. He could not walk, but was pulling himself up by the furniture.

Edwin liked to be shown toys and picture books, but even the vcry simplest game had to be initiated by the adult.

We started by naming objects and toys, also introduced symbolic play with a large doll.

During his time in hospital, Edwin had music playcd to him, using tapes. We ex-

tended this, using clapping and then rhymes to the music that he knew.

Edwin was seen for revicw at the Centre in August 1986. Hc had been walking for just tcndays. The assessment showed that Edwin now had good situational under- standing. He had reached the 15-18 month level in his symbolic play.

Edwin was not able to produce any ex- prcssive speech, but he had starlcd to point to and look at objects, that he was inter- ested in.

The Makaton signing system was started, play-therapy contlnucd.

In April 1987, Edwin was seen again for an annual review at the centre, l te now had a narrower trachco~tomy tube, and was able to produce some sounds.

Edwin was asscssed using the Reynell language scales, hc scored a 2 yr 2 month level for comprehension. He was using about 20 Makalon signs. Edwin was now enjoying communication. He had started attending a Nursery school in the mornings. His nanny accompanied him, as he needed extra care.

In June 1987 the tracheostomy tube was removed altogcthcr, and Edwin's expressive speech developed, backed up with signing.

The Nursery school activities wcre now very helpful to Edwin. Our teacher visited the school to discuss progress with the Nursery teacher.

Whcn Edwin was four years and two mouths old he had made considerable prog- ress with his language and play.

At the centre he scored 2 yrs 9 months - comprehension

2 yrs 3 months - without signing) expressive 2 yrs 9 months - with signing) speech

',t,\R('I.;S : Iq.,'kY "iIII.~R,\I'Y ~TII I 'YOLS(i C?! iA.I)RI!.S 59

Edwin now matched col{~urs, played with bricks and puzzles, and cnjoycd most of the Nurscry school activities.

In April 19S9, whcn Edwin was just 5 yrs old, he attcndcd the ccntrc h~r rcvicw. On the RDLS Edwin scored, 7

3 yrs 4 months - comprehension. 3 yrs 4 months - cxprcssivc spccch

The Griffith Dcv: scales wcrc also ad- ministered, and the same levels of ability wcrc found?'

The conclusion was that Edwin's lan- guage was now following a normal develop- mental pattern. As all his other areas of ability were on the samc levcl, hc could now fc~llc~w a normal cduca~tic~nal programme. t-dwi~l had now startcd in an infant class in a small privalc school. Wc advised thai, he would probably have moderate learning dif- ficulties and nccd somc cxtra support in schc~ol.

This year, 1990, Edwin still attends nor- real school, in a class of his own age group. 11c joins a younger class h)r some activitics.

Edwin has now been "s ta tcmenlcd" which initiates the procedure of cilhcr plac- ing a child in a "spccial" school or providing him with supp~rt in a normal school.

In Edwin's case, hc has some extra help from a support leacher and is very happy. ltis comprchcnsion and specch arc now good and hc is learning to react. His writing skills arc improving, hc has always nccdcd practice in hand/eye co-ordination. Num- ber concepts arc slow but extending.

The TWC tcachcr visits Edwin's home and school every 4-6 months, and talks to l:~',vin's mother and tcachcr. We arc hopc- ful for Edwin's future.

TEACHER & Cll lLDREN

The author has uscd the methods dcscrlbcd

in "Play-Therapy" with 40 young childrcn at thc Wolfson Centre sincc 1985. She holds a Post-Graduate Diploma in Rcmcdial lan- guage studics. She also draws on acquired knowledge and practical tcaching cxperi- cncc gaincd from working wilh young chil- drcn from 1974, till lhc present limc. It is not possible to ascertain exactly how much bcncfit the children rcccivc from attcnding the sessions and from home visits, but most make good progress.

Below arc somc dctails of other childrcn sccn for play-therapy. It must be appreci- ated that full medical and psychological re- ports arc available for professionals work- ing with the childrcJl.

L Boy. DOB 15.9.85. Sccn at thc TWC* aged 2 3/.s. P/Th* from Ocl. 88. (;Iobal de- lay, "Soltos Syndrome". Tcachcr worked on play &languagc. L. making slow bul steady progress, 6-7 months in each year. Diflicully with school placcmcnt. Teacher slill moni- toring.

J. Boy. DOB 2~.5.85. Sccn at the TWC agcd 2�89 P/Th. from Jan. 8,",t. Language de- lay. Vcry poor vcrbal comprchcnsion, few single words. Cause unknown, J. hospital- iscd as baby. Tcachcr workcd with mother and Nursery school..I, has madc vcry good progress, he now attends a normal infant class with part-linlc support.

D. Boy. DOB 18.684. Sccn al the TWC aged 3.10. P/Th. from May 88. Co-ordina- tion difficulties, language dclay. Bi-lingual family. Tcachcr worked on play & lan- guagc, extra spcech-thcrapy was nccdcd and support at school. D. now in normal school with some extra help, has made very good progrcss.

S. Girl. DOB 13.2.85. Sccn at the TWC aged 3.2 P/Th from May 88. Developmen- tal and languagc delay thought to have bccn partly caused by a very difficult home back-

60 TI IE INDIAN JOURNAL OF PEDIATRICS

ground. Teacher worked through play and home support and is now going into the school that S. attends. S. growing in confi- dence and language ability. An articulation problem is being remediated.

Z. Girl. DOB 29.7.86. Seen at the TWC aged 3.4. P/Th from Dec. 89. Language and play skills very delayed. "Williams Syn- drome". Teachcr worked on play and sup- ported nursery school. Z. has made good progress-she is now very verbal-but her comprehension is still delayed. Teaching monitoring progress. Z. in normal infant school waiting for support. * TWC - The Wolfson Ccntre * P/Th - Play Therapy

REFERENCES

1. Cooper J, Moodlcy M, Rcynell J. llelping

Vol. 59. No. 1

Language Developmenr London: Edward Arnold. 1978-1989.

2. Piaget J. The Orights of bltelligence in the Child. London: Routledge & Kegan Paul.

3. Caroe LL. Adv: Music Therapist. East- bourne. Contact through Marcus D.

4. Makaton Signing System. Information from Speech-Therapist, the Wolfson Centre.

5. Crystal D. Wo~ing ~r LARSP. London: Edward Arnold. 1979.

6. Crystal D. Child Language Learning & LhTguistics. Edward Arnold 1976.-1988.

7. Reynell Developmental Language Scales. Standartiiscd tcsts used at the Wolfson Centre, London.

8. Griffiths Mental Development Scales. Standardised tests used at the Wolfson Centre, London.

ARE ANTI-HISTAMINE DECONGESTANTS EFFE-CT1VE IN YOUNG CHILDREN

Although oral antihistamine-decongestant combinations are among the drugs most widely prescribed by pediatricians, there are few data regarding their efficacy. Hutton et al recently examined the ability of these preparations to provide relief from the symptoms of upper respiratory tract infections in young children.

The children were randomly assigned to one of three treatment groups; antihistamine- decongestant, placebo, and no treatment. There proved to be no significant differences among the three study groups in the proportion of children regardcd as "better" overall by the parent 48 hours after the initial assessment. Improvement was noted by the parents in 67% of the drug group, 71% of the placebo group, and 57% of those receiving no treatment at all. Parents who wanted medicine at the initial visit reported more improvement at follow-up, regardless of whether the child received drug, placebo, or no treatment. The authors conclude that the use of an antihistamine-decongestant is ineffective for relief of symptoms in children 6 months to 5 years of age.

. Abstractedffom : Hutton N et aI. JPediatr 1991; 118 : 125-130.