Occupational Therapy International, 11(3), 131-144, 2004 © Whurr Publishers Ltd 131

The influence of virtual reality onplayfulness in children with cerebralpalsy: A pilot study

DENISE REID Department of Occupational Therapy, Toronto, Ontario

ABSTRACT: The purpose of this paper was to examine the effects of virtual playintervention on the level of playfulness of children with cerebral palsy. Thirteenchildren aged 8–13 years comprised the study group. Children attended eight one-hour virtual reality play sessions in which they were immersed and interacted withvirtual reality. The Test of Playfulness (TOP) was used as the measure to assessplayfulness. Participants were videotaped while they played during 12 differentenvironments over the course of their intervention time. Three randomly selectedvirtual reality play sessions were chosen to score three different virtual reality environ-ments within each session yielding a total of nine trials (environments) for eachparticipant. The types of virtual environments varied across participants. Overall, thedifferent virtual reality play environments produced varying levels of playfulnessaccording to the TOP’s four different subscale scores. Motivation ranged from 1.50to 2.25, internal control ranged from 1.00 to 1.88, suspension of reality ranged from0 to 0.26, and framing ranged from 1.33 to 1.78. The three environments producingthe highest playfulness ratings were called Paint, Trip and Island Sounds. Theseenvironments allowed creativity, persistence with the task, pleasure, and a certaindegree of control. Two environments did not appear to foster playfulness. A possiblereason was that these environments were too unpredictable and frustrating for partic-ipants. These results will be useful for creating new virtual reality softwareapplications that will encourage playfulness in children with disabilities.

Key words: play, virtual reality, the Test of Playfulness (TOP)

Introduction

Play has been described as both the earliest occupational behaviour and theprimary occupation of children (Reilly, 1974; Vandenberg and Kielhofner,1982). Play possesses characteristics that are believed to be mutually exclusiveand that arise from different theoretical perspectives. These have beendescribed by Rubin et al. (1983) as six factors: intrinsic motivation, focus on

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means rather than ends, organism-centred rather than object-centredbehaviour, relation to instrumental behaviours, freedom from externallyimposed rules, and active engagement. In play an activity is done for its ownsake; it is not governed by external rules. Play can be spontaneous and ischaracterized by self-imposed goals. Rubin et al. (1983) discuss the concept ofinternal locus of control in viewing play as organism-centred where theorganism becomes aroused and stimulated through play. Play does not use realbehaviours but pretend ones. Play has been seen by some theorists as beingdifferent to games, where there is more flexibility built in. Finally, the player isactively engaged in a play activity.

Parham and Primeau (1997) described several theories each contributingtheir own explanation of play. They classified these theories into classical andmodern theories. Classical theories attempt to provide reasons for theexistence of play and to determine its antecedent conditions and its inferredpurpose (Gilmore, 1971; Spencer, 1878/1978; Lazarus, 1883; Groos,1898/1978; Hall, 1908/1978). The modern theories address both the causes ofplay and the role of play in development (Rubin et al., 1983; Berlyne, 1969;Ellis, 1973; Mellou, 1994; Freud, 1961; Erikson, 1963; Sutton-Smith, 1980;Bruner, 1972; Piaget, 1951/1962; Gardner, 1982; Bateson, 1972).

Through the facilitation of physical and social development, play canenhance a child’s self-esteem (Bjorklund and Brown, 1998; Eppright et al.,1997; Erikson, 1963). Vygotsky (1976) added an additional dimension empha-sizing that the effects of play on a child’s development cannot be fullyunderstood without considering the context of the play experience.

Bundy (1997) operationalized the concept of playfulness as a means ofassessing a key characteristic of play. She included four important factors in herdefinition of playfulness: intrinsic motivation, internal control, freedom tosuspend reality and framing. These elements formed the basis of the Test ofPlayfulness that Bundy developed in 1993. Intrinsic motivation refers to someaspect of the activity itself, rather than to an external reward, that provides theimpetus for the individual’s involvement in the activity (Bundy, 1997).Internal control suggests that the individual is largely ‘in charge’ of his/heractions and at least some aspects of the activity’s outcome. Freedom to suspendreality means that the individual chooses how close to objective reality thetransaction will be. Framing refers to the ability to give and receive social cuesto maintain the play frame. Playfulness is associated with characteristics thatinclude motivation towards the accomplishment of self-imposed goals,tendencies towards active involvement, tendencies to attribute to objects orbehaviours their own meaning, and tendencies to disregard externally imposedrules (Glynn and Webster, 1992; Rubin et al., 1983).

Children with disabilities have a more restricted play experience than able-bodied children (Howard, 1996). In a study conducted by Okimoto et al.(2000) there were significant differences in the playfulness of young childrenwith cerebral palsy or developmental delays when compared to young children

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with no disabilities. Howard found that accessibility to the environment was abarrier for children with disabilities that led to decreased participation in leisureactivities. Conceptualizations of playfulness have been suggested by others.Barnett (1991) assesses five dimensions of behaviour: physical spontaneity,social spontaneity, cognitive spontaneity, manifest joy, and sense of humour.Glynn and Webster (1992) propose a set of 25 items looking at characteristicssuch as creativity, imagination, enjoyment, spontaneity, and free-spiritness.

Csikszentmihalyi’s (1975, 1990) theory of flow states that individuals arehappiest when challenges and skills are equal. This balance between highskills and high challenges is referred to as the ‘flow channel’ (Csikszentmi-halyi, 1988). Further, Csikszentmihalyi (1975) showed that individuals whoenjoy an activity will probably want to repeat it. Flow involves an active useof skills which causes ‘enjoyment’ and growth, in contrast to the morepassive construct of ‘pleasure’ which does not require effort and is based ongenetically-programmed drives for survival of the species, such as eatingbehaviour (Massimini et al., 1988). Flow is sometimes called ‘optimalexperience’ or ‘autotelic enjoyment’ and is considered by some to be thehighest level of well-being (Csikszentmihalyi and Mei-Ha Wong, 1991).Often, autotelic activities involve competition, rules, and risks. Such wasfound in our research (Harris and Reid, in press). As well, researchers haverelated flow to happiness, self-esteem, work productivity, role satisfaction,and satisfaction with life (Carlson and Clark, 1991; Csitszentmihalyi, 1988;Kipper, 1992; Logan, 1988).

Virtual reality potentially offers children with disabilities the opportunityto engage in play situations otherwise inaccessible or unavailable to them inthe real world. The potential for use of virtual reality (VR) among childrenwith cerebral palsy (CP) holds tremendous promise as a new and effectiveintervention. Inman, Loge, and Leavens’ (1997) study showed that VR waseffective in training powered mobility skills in children with CP. Nemire andCrane’s (1995) study allowed children with CP to access educational experi-ences not otherwise provided to them. The results of these two studies suggestthat a simulated interactive environment available through VR can offerchildren with CP an opportunity to practise and try out newskills/movements without the worry of embarrassment or the risk of injury.This in turn can lead to improved motor performance, but perhaps even moreimportantly, a sense of personal control or self-efficacy. Virtual reality hasbeen described as having the potential to be a powerful tool for use in rehabil-itation with many people with disabilities (Christiansen et al., 1996;Greenleaf and Tovar, 1994; Kuhlen and Dohle, 1995; Wann et al., 1997;Wilson et al., 1997). Virtual reality is defined as an immersive and interactivethree-dimensional (3D) computer experience occurring in real time(Pimental and Teixeira, 1995). Virtual reality applications use 3D computergraphics, which respond to the user’s movements, thereby giving the user thesense of being immersed in the virtual environment.

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At the present time, the technology of VR and its application to the field ofpaediatric rehabilitation is in its infancy. Although there have been only alimited number of studies exploring the potential of VR in rehabilitation, andfewer still in paediatric rehabilitation, previous applications with children withdisabilities have demonstrated the potential of VR to improve life skills,mobility and cognitive abilities, quality of life, and social opportunities (Hiroseet al., 1994; Inman et al., 1997; Nemire and Crane, 1995; Muscott and Gifford,1994; Rose et al., 1996; Standen and Cromby, 1995; Stephenson, 1994;Strickland et al., 1996; Wilson et al., 1996).

In this study, play theory (Bundy, 1997; Rubin et al., 1983) and the theoryof flow (Csikszentmihalyi, 1975) are used to explain the impact of a VR inter-vention in children with cerebral palsy. Play theory states that behaviour ismediated by the strength of a person’s motivation, internal control and abilityto suspend reality. Applied to children with CP, play theory, especially theimportance of measuring play characteristics of intrinsic motivation, internallocus of control, suggests that the use of VR may enhance motivation inchildren and provide them with a sense of mastery or self-efficacy. Theoreti-cally, enhanced feelings of self-control will, in turn, result in improvedmotivation and satisfaction with performance. Csikszentmihalyi’s flow theory(1975) applied to children with cerebral palsy suggests that individuals whoenjoy an activity will probably want to repeat it and this is the nature ofengaging with VR. Flow involves an active use of skills, which causes‘enjoyment’ and subsequently satisfaction with life.

Recent research by Rizzo and his colleagues (1998) underscores theadvantage of the enjoyable game-like experience of VR and its relationshipto motivation, performance, and satisfaction with performance amongchildren. Thus, as shown in Figure 1, playfulness and flow theory offer atestable pathway as to the mechanism by which children with CP maybenefit from VR.

Research questions

" What is the level of playfulness among children with cerebral palsy engagedin virtual play?

" How does playfulness change according to different VR environments? " What features of the different environments relate to the levels of

playfulness?

Participants

Thirteen children with cerebral palsy between the ages of 8 and 12 yearsparticipated in the study. The mean age was 10 years, 5 months (SD 1 year, 3months. There were seven male and six female participants. There were seven

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wheelchair users and six participants were ambulatory with and withoutassistive devices. Muscle tone in 11 participants was determined to bemoderate to high based on observation and passive range of motion. Two hadmuscle tone within normal limits. They were recruited from a large rehabili-tation centre and the community at large on the basis of advertisements. Theywere all able to reach with one or both arms in order to play the VR games. Allchildren were seated on a bench or stayed in their wheelchair for the VRsessions. Ethical approval and informed consent were obtained prior tocommencing the study.

Procedures

Each child attended eight one-hour sessions of VR intervention in the virtualreality laboratory in the Department of Occupational Therapy at theUniversity of Toronto. Children sat in a demarcated spot approximately 1.5 min front of a large 60-inch television (TV). The television was interfaced withthe virtual reality system (see next section for details). Each session startedwith the child playing the game, ‘Birds and Balls’. This was followed by anygame that the child chose. The game Birds and Balls required the children toreach and touch floating balls of different colours that were coming towardsthem from either the left or right side of the screen. When the childrentouched the balls they turned into birds. Scores were recorded on the TV.Other games played included soccer, volleyball, painting, drumming, flying aspace ship, driving a car, snowboarding and others. Figure 2 shows a childplaying soccer against a robot. All sessions were videotaped so that the Test ofPlayfulness could be scored at a later time. The reference to games or applica-tions, and VR environments will be used interchangeably to denote playactivities that participants were engaged in.

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VR play is fun and engaging(children want to repeat actions)

Increased motivation and enjoyment

Increased self-control

Increased satisfaction

Playfulness

FIGURE 1: Testable pathway for playfulness.

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Virtual reality system

In this study we used the 1996 patented Mandala‚ Gesture Xtreme VR systemdeveloped by Vivid Group Inc., from Toronto1. This system uses a videocamera as a capturing and tracking device to put the user inside VR experi-ences. Users see themselves on a TV screen and the virtual environmentresponds to their movements. The user does not have to wear, touch or holdanything. Through the use of the system’s ‘video gesture’ capability,movements (e.g. reaching, bending) trigger visible or invisible icons to scorepoints and manipulate animations (e.g. playing a virtual drum kit, playingvolleyball). The system requirements include an intel Pentium ll BX Mother-board 400 mhz CPU, 128 MB RAM, 4.3 GB HD, 12 meg, 3D video card, CCDvideo camera and cables, capture board, 4 MB S-3 video card, 16 bit soundcard, and the patented Gesture Xtreme (GX) software.

Instrument

The Test of Playfulness (TOP) (Bundy, 1997) was used to measure playfulnessin children with cerebral palsy. This is the most suitable measure as it capturesthe characteristics of playfulness and flow theories, which provide theconceptual basis for this study. The TOP consists of 24 items scored on a 4-

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1Vivid Group, 317 Adelaide Street, Suite 302, Toronto, Ontario, M5V 1P9, Canada,www.vividgroup.com

FIGURE 2: Child playing VR soccer

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point extent scale, intensity scale, and skill scale. The ratings for the extentscale are: 3 = almost always, 2 = much of the time, 1 = some of the time, and 0= rarely or never. The ratings for the intensity scale are: 3 = highly, 2 = moder-ately, 1 = mildly, and 0 = not. The ratings for the skill scale are: 3 = highlyskilled, 2 = moderately skilled, 1 = slightly skilled, and 0 = unskilled. Four ofthe items were scored non-applicable because they were inappropriate for thecontext of virtual play. These were ‘appears safe’, ‘actively modifies complexityand/or demands of activity’, ‘plays interactively with others’, and ‘enters agroup already engaged in an activity’. The option of non-applicable is possibleas not all items are scorable, therefore the test psychometrics are not affected.Children were playing in a constrained context inside several virtual environ-ments where other children were not included. The VR environment requiredthe child to respond with movements to play the game that was prepro-grammed so there was no opportunity for the child to modify the complexity ofthe game. The children were restricted in the amount of space where theyplayed because of the virtual environment demarcated area where they sat andwhere the camera was set up. Therefore safety seemed not to be a relevantfactor to judge given the non-natural environment in which the children wereengaged. The items that were scored were grouped according to Bundy’s speci-fications to create four subscales: motivation, internal control, suspension ofreality, and framing (Bundy, 1997). Five items comprised the motivationsubscale, seven items comprised the control subscale, five items comprised thesuspension of reality subscale, and three items comprised the framing subscale.Appendix A contains a list of items with the corresponding subscales. TheTOP has undergone clinical utility testing with positive results (Cameron etal., 2001) and reliability and validity testing with promising results (Brooks,1995; Gaik and Rigby, 1994).

Data analysis

All eight VR sessions for each participant were videotaped. Three sessionswere randomly selected for each participant for analysis. Three random trials(VR games/applications) were selected within each of the three sessions toscore using the TOP. Therefore nine different activity contexts were scored foreach participant making a total of 117 trials analysed. To answer the firstresearch question, means and standard deviations were calculated for eachsubscale for the three types of ratings across subjects. To answer the secondresearch question means and standard deviations were calculated for eachsubscale for the three types of ratings across similar games/applications. Acrossthe participants the number of times a particular game was played variedaccording to how frequently participants requested it. Table 1 shows thenumber of times each game was played by the number of participants whoplayed it. To answer the third research question, a qualitative analysis of thecharacteristics of different VR environments was undertaken.

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Results

The overall means and standard deviations for the sample calculated for the foursubscale scores (motivation, control, suspension from reality, and framing) foreach of the three types of scores (extent, intensity, skill) are presented in Table 2.Over all the different environments, the mean motivation score ranged from1.50 to 2.25, internal control ranged from 1.00 to 1.88, suspension from realityranged from 0 to 0.26 and framing ranged from 1.33 to 1.78 (Table 3). Themotivation subscale mean was highest for both extent and intensity ratings.With respect to skill ratings, the internal control subscale was the highest.

The extent ratings for each of the four subscale scores were calculated foreach type of environment. Missing data were found for the intensity and skillratings due to a majority of non-applicable ratings. Three environmentsyielded ratings in the 2 range for motivation ratings. These were Trip, Paint,and Island Sounds. Table 1 shows the number of participants who played eachgame and the number of times it was played. No participant played a gamemore than twice. All ratings suggest that except for suspension of realityratings the behaviours were demonstrated 10% to 90% of the time. Sevenother games ranged in ratings from 1.67 to 1.94 for motivation and from 1.33to 1.88 for control. These results reflect that the behaviour was demonstratedsome to much of the time. Table 3 shows these results.

Discussion

The children in this study did exhibit playfulness according to the elements ofintrinsic motivation, internal control, suspension of reality, and framing thatconceptualize the construct of playfulness in the TOP. The results show thatthe sample on average received scores in the range of 1 to 2 reflecting amoderate level of motivation according to the rating scale of the TOP, where a

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TABLE 1: Frequency of VR environments played by participants

VR environment Times played N

Birds and Balls 23 12City (flying space ship) 3 3Island Sounds (musical instruments) 4 3Paint 9 6Snowboarding 16 11Soccer 10 6Speedroller (driving car) 11 8Trip (shape maker) 7 7Volleyball 19 11Shark (swimming game) 8 7Drums 1 1Gravball (ball game into hoops) 6 6

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score of 2 reflects much of the time. Participants were actively engaged. Theypersisted playing the games and repeated their actions to succeed, for example,in hitting the ball over the net in volleyball or blocking the ball in soccer goal.They were exuberant, laughing and shouting much of the time. There weremany times though that the participants did not demonstrate manifest joy,because they were concentrating so hard on the activity. The rating ofskilfulness of this element was not applicable given the situations.

The sample received on average, moderate ratings (from 1 to 2) for internalcontrol. Participants engaged in challenging behaviours often requiring themto reach and stretch their arms. When they played in situations where therewas more than one player they shared the task requirements willingly andplayed along well with a partner. For example, in the volleyball game, they hadto take turns deciding when to hit the ball. When they wanted the game to bemodified to make it faster, or for more objects to appear on the screen theymade their desires known to the researcher who did the modifications. Afterthe first session with all participants, they knew what they had to do and didnot need repeated instructions.

On average, suspension from reality scores were in the 0.1 to 1.9 range.

TABLE 2: Means and standard deviations for subscale scores (N = 13)

Extent Intensity SkillM C S F M C S F M C S F

Mean 1.86 1.59 0.12 1.54 1.96 1.67 1.93 0.0 0.0 2.25 1.77 2.13SD 0.77 1.05 0.41 0.79 0.49 0.63 0.46 0.0 0.0 0.79 0.51 0.46

M = motivation, C = internal control, S = suspension from reality, F = framing

TABLE 3: Mean for playfulness ratings across VR environments

VR game M C S F

Paint 2.06 1.79 0.11 1.62Soccer 1.79 1.33 0.06 1.41Shark 1.77 1.46 0.10 1.48Drums 1.50 1.00 0.0 1.50Volleyball 1.91 1.73 0.15 1.53Birds and Balls 1.67 1.37 0.09 1.48Trip 2.25 1.70 0.26 1.42Snowboarding 1.94 1.58 0.10 1.61City 1.83 1.78 0.0 1.78Speedroller 1.81 1.88 0.09 1.63Gravball 1.50 1.50 0.07 1.72Island Sounds 2.13 1.67 0.50 1.33

M = motivation, C = internal control, S = suspension from reality, F = framing

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Participants did not really pretend except for a few comments made to say theyfelt like something or someone else while they were playing the game, forexample, ‘I’m a airplane pilot’. They made some jokes and teased staff. Theydid not exhibit mischievous behaviour very much. One participant tried toreach under the net to his partner’s side to hit the ball. Use of objects inunconventional ways did not occur too often. One example of this was when astaff member was asked to strum the second mandolin on the screen because itsdistance was too far for the participant to reach. Opportunities for showing thisbehaviour were restricted by the set parameters of the virtual environments.

Framing scores were in the 1 to 2 range. Participants were moderatelyskilled at showing they were able to give and respond to people’s cues. Againbecause of the individualistic nature of the virtual play, the opportunity to giveand receive facial and body cues was restricted.

The three VR environments that yielded the highest scores were Trip, IslandSounds and Paint. Each of these activities encouraged the participant to remainengaged. Participants repeated their actions and tried many variations of actionsto produce results. With Trip, especially, the participants were thrilled to be ableto produce their own dance video. By moving their body in various ways theycreated interesting shapes on the TV, which were videorecorded. They expressedpleasure while they persisted in their own creation. With Paint, the same elementof creativity appeared to be at play. Participants were able to choose whichcoloured paint ball they wanted to drag across the screen to create an image. WithIsland Sounds they had to play different instruments but the sound hearddepended on how they were played. Participants had to regulate the rhythm ofthe instrument. With all these environments, the individual’s awareness of thebody in respect to a variety of media with different sensory ‘textures’ such ascolour, rhythm, and sound was seen. This concept is called entexturement (Reid,2002). Entexturing may be thought of as an individual’s regulation of activity, ofaural and visual stimuli, and colour, and other sensory media that surround thebody in order to produce, if possible, a finely articulated and satisfying whole.

The two environments with the lowest ratings were Drums and Gravball.These two games were frustrating to the participants because they did notrespond with accuracy or they were too challenging. For example, with Drumsthere was a delay in which the drum responded to the user’s motion causing theparticipant to be unable to play with much speed. With Gravball, the ballswere very unpredictable, causing participants to guess and lose points. Thismay have caused participants to feel that they were not in control of theactivity in these two situations.

The seven remaining environments resulted in fairly similar levels ofplayfulness. Snowboarding and Volleyball were both two-player games givingan opportunity for participants to play with others, and to assume leadershiproles. City and Roadroller were liked by the participants because there was anelement of danger. In City, if participants were not careful in flying the spaceship they crashed into a building causing them to bounce off. In Roadroller,

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participants liked to be able to run and crash their speedcar into oncomingcars. They described being in control of their actions, and they felt a bitmischievous breaking unspoken rules, ‘We don’t crash into people’. There wasalso an element of pretend in these two games. Participants sometimesremarked they felt like a pilot or a racecar driver. The foregoing analysis helpsto interpret the ratings on the Test of Playfulness. The observations reportedform the items that comprise the four subscales of the TOP.

In summary, the Test of Playfulness was useful in measuring playfulness inchildren who experienced virtual reality play. It is helpful to understand whichplay environments are more conducive to playfulness. When promoting playwith children with disabilities, knowing which environments are better suitedwill enhance the play of children. This is the same with VR environmentswhere play is a suitable goal for disabled children. Overall, it was found thatseveral VR environments stimulated playfulness in children. Designing newVR environments with elements to enhance motivation, control, suspensionfrom reality and framing is a recommendation for future research. Involvingchildren in this work would be particularly helpful. What we found was thatenvironments which allowed creativity, expression, and control over theactivity were the most motivating. Environments that did not have goodtiming and reaction time to user inputs were frustrating. Environments shouldnot be too challenging so that the skills of the user are not matched to therequirements of the programme as this is frustrating.

Acknowledgements

This study was in part supported by a grant from Kids Action Research,Ontario. I wish to acknowledge the assistance of Diane Jones for scoring theTOP and to Kristan Harris and Stacey Miller for videorecording. Thanks alsoto Edmond Lai for data analysis.

References

Barnett L (1991). The playful child: Measurement of a disposition to play. Play and Culture 4:51–74.

Bateson G (1972). Steps to an ecology of mind. New York: Ballantine Books.Berlyne DE (1969). Laughter, humor, and play. In G Lindzey, E Aronson (eds.) The handbook of

social psychology (Vol 3). Reading, MA: Addison-Wesley, pp 795–852.Bjorklund DF, Brown RD (1998). Physical play and cognitive development: Integrating activity,

cognition, and education. Child Development 69(3): 604–6.Brooks L (1995). Reliability and validity of the revised Test of Playfulness. Master’s thesis.

Colorado State University, Ft. Collins.Bruner JS (1972). The nature and uses of immaturity. American Psychologist 27: 687–708.Bundy A (1993). Assessment of play and leisure: Delineation of the problem. American Journal of

Occupational Therapy 47: 217–22.Bundy A (1997). Play and playfulness. In D Parham, L Fazio (eds.) Play in occupational therapy

for children. St. Louis, MO: Mosby Year Book.

Virtual reality and playfulness 141

OTI 11 (3) 25/7/04 8:28 am Page 141

142 Reid

Cameron D, Leslie M, Teplick R, Pollock N, Stewart D, Toal C, Gaik S (2001). The clinicalutility of the Test of Playfulness. Canadian Journal of Occupational Therapy 68: 104–11.

Carlson M, Clark F (1991). The search for useful methodologies in occupational science.American Journal of Occupational Therapy 45: 235–41.

Christiansen C, Abreu B, Huffman RK (1996). Creating a virtual environment for brain injuryrehabilitation and research: A preliminary report. Journal of Medicine and Virtual Reality 1:5–9.

Christiansen C, Baum C (1997). Occupational therapy: Enabling function and well-being (2ndedn.) Thorofare, NJ: Slack Incorporated.

Csikszentmihalyi M (1975). Beyond boredom and anxiety. San Francisco, CA: Jossey-Bass.Csikszentmihalyi M (1988). Introduction. In M Csikszentmihalyi, I Csitszentmihalyi (eds.)

Optimal experience: Psychological studies of flow in consciousness. Cambridge: CambridgeUniversity Press, pp 364–83.

Csikszentmihalyi M (1990). Flow: The psychology of optimal experience. New York: Harper andRow.

Csiksxentmihalyi M, Mei-Ha Wong M (1991) The situational and personal correlates ofhappiness: A cross-national comparison. In F Strack, M Argyle, N Schwartz (eds.) Subjectivewell being. Toronto, ON: Pergammon Press, pp.193–212.

Ellis M (1973). Why people play. Englewood Cliffs, NJ: Prentice Hall.Eppright T, Sanfacon J, Beck N, Bradley J (1997). Sport psychiatry in childhood and adolescence:

An overview. Child Psychiatry and Human Development 28(2): 71–88.Erikson EH (1963). Childhood and society (2nd edn.) New York: Norton.Freud S (1961). Beyond the pleasure principle. New York: WW Norton.Gaik S, Rigby P (1994). A pilot study to address the reliability and validity of the Test of

Playfulness (TOP) – Research Version 2.2 and to compare the playfulness of children withphysical disabilities with age-matched able-bodied peers. Research Report submitted to theNeurodevelopmental Clinical Research Unit, Hamilton, Ontario.

Gardner H (1982). Art, mind, and brain: A cognitive approach to creativity. New York: BasicBooks.

Gilmore JB (1971) Play: A special behavior. In RE Herron, B Sutton-Smith (eds.) Child’s play.New York: John Wiley and Sons, pp. 311–25.

Glynn M, Webster J (1992). The adult playfulness scale: An initial assessment. PsychologicalReports 71: 83–103.

Greenleaf WJ, Tovar MA (1994). Augmenting reality in rehabilitation medicine. Artificial Intel-ligence in Medicine 6: 289–99.

Groos K (1978). The value of play for practice and self-realization. In D Muller-Schwarze (ed.)Evolution of play behavior. Stroudsbourg, PA: Dowden, Hutchinson and Ross, pp. 16–23.(Reprinted from The play of animals, pp. 72–81, by K Groos, trans. by EL Baldwin, 1898, DAppleton and Company)

Hall G (1978). Growth of motor power and function. In D Muller-Schwarze (ed.) Evolution ofplay behavior. Stroudsbourg, PA: Dowden, Hutchinson and Ross, pp. 24–29. (Reprinted fromAdolescence, its psychology and its relations to physiology, anthropology, sex, crime, religion,and education, Vol 1. pp. 202–17, by GS Hall, 1908, D Appleton and Company)

Harris K, Reid D (in press). The influence of virtual reality play on children’s motivation.Canadian Journal of Occupational Therapy.

Hirose M, Taniguchi M, Nakagaki Y, Nihei K (1994). Virtual playground and communicationenvironments for children. IEICE Transactions on Information and Systems, E77D, 12,1330–4.

Howard L (1996). A comparison of leisure-time activities between able-bodied children andchildren with physical disabilities. British Journal of Occupational Therapy 59(12): 570–4.

Inman DP, Loge K, Leavens J (1997). VR education and rehabilitation. Communications of theACM 40: 53-58.

OTI 11 (3) 25/7/04 8:28 am Page 142

Kipper D (1992). The dynamics of role satisfaction: A theoretical model. Group Psychotherapy,Psychodrama and Psychology 4: 141–60.

Kuhlen, T., Dohle, C. (1995).Virtual reality for physically disabled people. Computers in Biologyand Medicine 25: 205-211.

Lazarus M (1883). Die Reize des spiel. Berlin: Ferd, Dummlers Verlagsbuchhandlung.Logan O (1988). Flow in solitary ordeals. In M Csikszentmihalyi, I Csikszentmihalyi (eds.)

Optimal experience: Psychological studies of flow in consciousness. Cambridge, UK:Cambridge University Press. pp. 172–80

Massimini F, Csikszentmihalyi M, Delle Fave A (1988). Flow and biocultural evolution. In MCsikszentmihalyi, I. Csikszentmihalyi (eds.) Optimal experience: Psychological studies of flowin consciousness. Cambridge, UK: Cambridge University Press, pp. 60–81.

Mellou E (1994). Play theories: A contemporary review. Early Child Development and Care. 102,91–100.

Muscott HS, Gifford T (1994). Virtual reality and social skills training for students with behav-ioral disorders: Applications, challenges and promising practices. Education and Treatment ofChildren 17: 417–34.

Nemire K, Burke A, Jacoby R (1994). Human factors engineering of a virtual laboratory forstudents with physical disabilities. Presence 3: 216–26.

Nemire K, Crane R (1995). Designing a virtual science laboratory to accommodate needs ofstudents with cerebral palsy. In Proceedings of the 1995 CSUN Virtual Reality Conference.Northridge: California State University.

Okimoto AM, Bundy A, Hanzik J (2000) Playfulness in children with and without disabilities:Measurement and intervention. American Journal of Occupational Therapy 54: 73–82.

Parham D, Primeau L (1997). Play and occupational therapy. Early Child Development and Care102: 91–100.

Piaget J (1962). Play, dreams, and imitation in childhood. (Translated by C Gattegno, FMHodgson) New York: WW Norton (original work published in 1951).

Pimentel K, Teixeira K (1995). Virtual reality: Through the new looking glass. Toronto, ON:McGraw Hill.

Reid D (2002). Virtual reality and the person-environment experience. CyberPshychology andBehavior. 5, 559-564.

Reilly M (1974) Play as exploratory learning: Studies of curiosity behaviour. California: SagePublications.

Rizzo AA, Buckwalter JG, Neumann U, Kesselman C, Thiebaux M (1998). Basic issues in theapplication of virtual reality for the assessment and rehabilitation of cognitive impairmentsand functional disabilities. CyberPsychology and Behavior 1: 59–78.

Rose FD, Attree EA, Johnson DA. (1996). Virtual reality: An assistive technology in neurologicalrehabilitation. Current Opinion in Neurology 9: 461–7.

Rubin K, Fein G, Vandenberg B (1983). Play. In PH Mussen (Series ed.) Handbook of ChildPsychology (vol 4). EM Hetherington (Vol ed.). Socialization, Personality, and Social Devel-opment (4th edn.) New York: Wiley, pp. 693–774.

Spencer H (1978). Aesthetics sentiments. In D Muller-Schwarze (ed.) Evolution of Play Behavior.Stroudsbourg, PA: Dowden, Hutchinson and Ross, pp. 10–15. (Reprinted from Spencer H.(1878) The principles of psychology (Vol 2) Appleton and Company, pp. 627–32).

Standen PJ, Cromby JJ. (1995). Can students with developmental disability use virtual reality tolearn skills which transfer to the real world? In Proceedings of the 1995 CSUN Virtual RealityConference. Northridge: California State University.

Stephenson J (1994). Sick kids find help in a cyberspace world. Journal of the American MedicalAssociation 274: 1899–901.

Strickland D, Marcus LM, Mesibov GB, Hogan K (1996). Brief report: Two case studies usingvirtual reality as a learning tool for autistic children. Journal of Autism and DevelopmentalDisorders 26: 651–9.

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OTI 11 (3) 25/7/04 8:28 am Page 143

Sutton-Smith B (1980). Children’s play: Some sources of play theorizing. In KH Rubin (ed.) Newdirections for child development: No. 9. Children’s play. San Francisco: Jossey-Bass, pp. 1–16.

Vandenberg B, Kielhofner G (1982). Play in evolution, culture, and individual adaptation: Impli-cations for therapy. American Journal of Occupational Therapy 36: 20–8.

Vygotsky L (1976). Play and its role in the mental development of the child. In A Bruner, A Jolly,K Sylva (eds.) Play: Its Role in Development and Evolution. New York: Basic Books.

Wann JP, Rushton SK, Smyth M, Jones D (1997). Rehabilitative environments for attention andmovement disorders. Communications of the ACM 40: 49–52.

Wilson PN, Foreman N, Stanton D (1997). Virtual reality, disability and rehabilitation. Disabilityand Rehabilitation 19: 213–20.

Wilson PN, Foreman N, Tlauka M (1996). Transfer of spatial information from a virtual to a realenvironment in physically disabled children. Disability and Rehabilitation 18: 633–7.

Address correspondence to Denise Reid, Professor, Virtual Reality Laboratory, Department ofOccupational Therapy, 160–500 University Avenue, Toronto, Ontario M5G 1V7, Canada. Tel:(4516) 978 5937, Fax: (416) 946 8570, Email: d.reid@utoronto.ca

Appendix A

Motivation itemsIs actively engagedRepeats actions, activities; stays with same basic themeEngages in process aspects of activityDemonstrates obvious exuberance, manifest joyTries to overcome difficulties, barriers, or obstacles to persist

with an activityControl items

Appears self-directed. Decides what to do and how to do itEngages in challenges (motor, cognitive, social)Negotiates with others to have needs or desires metPlays with othersAssumes leadership roleInitiates play with othersShares playthings, play equipment

Suspension of reality itemsEngages in mischief or commits minor infraction of implicit

or explicit rulesPretendsTeases or jokes with others (verbal or nonverbal)ClownsIncorporates objects or people into play in novel, imaginative,

creative, unconventional, or variable waysFraming

Gives facial, verbal, and body cues appropriate to the situation and that say, ‘This is how you should act towards me’

Responds to other’s facial or body cuesMaintains cohesiveness of play frame

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