The Indian Journal of Occupational Therapy : Vol. 46 : No. 2 (May 2014 - August 2014)
To study the effectiveness of play based therapy on play behaviour of children with Down’s Syndrome. Author: Preetee Gokhale* (M.O.T.), Co-Authors : Punita V. Solanki (M.O.T.)**, Priyanka Agarwal***
Abstract Key Words: Down’s syndrome, Play Behaviour, Revised knox preschool play scale, Play based Occupational Therapy
Aims and Objectives: One in every 800 children suffer from Down’s syndrome, who lack development of age appropriate physical, mental, social andpsychological skills therebyaffecting child’s play behaviour skills. Aim of the study was to assess the play behaviour and effect of play based therapy in children diagnosed as Down’s syndrome. Our hypothesis was that the children’s play behaviour improves significantly with play based Occupational Therapy. Materials and Methodology: Male and female children diagnosed with Down’s syndrome in the age group of 2 - 6 years were randomlyobserved from an outpatient paediatric rehabilitation department of K. E. M Hospital, Mumbai in this one arm cohort observational study. Each child’s neuro-paediatric assessments and play behaviour assessments on Revised Knox Preschool Play Scale (RKPPS) were done. Children were observed when they were subjected to age appropriate play based Occupational Therapy intervention in an outpatient department, for a period of 1 month and were re-assessed on RKPPS. Results: 10 children were observed (6 males, 4 females). At the end of 1 month of therapy, each child showed significant improvement in their play behaviour. The results were analysed using Paired‘t’ test. The results werestatistically significant at the level of P<0.001 and Confidence Interval of (at 99% Confidence interval). However, factors affecting play behaviour in individual child were variable. Conclusion: Play based Occupational Therapy was found to be effective in improving play behaviour in a cohort of 10 children with Down’s syndrome. Abbreviations: RKPPS: Revised Knox Preschool Play Scale
* * Occupational Therapist Student M.O.T.-III ** Ex-Assistant Professor *** Occupational Therapist Institution: O.T. Training School & Centre, Seth GS Medical College & KEM Hospital, Mumbai-12 Period Of Study : January 2013 - December 2013 Correspondence : Dr. Preetee Gokhale Indraprastha, R-31, Dombivili (East) - 421203 Phone No. : 09819667230 E- Mail :
[email protected]
Paper was presented in OTICON ' 2014 : the 51st Annual National Conference of AIOTA at Bhubaneshwar and was awarded with KEMOT Youth Talent Trophy for Best Paper. IJOT : Vol. 46 : No. 2
Introduction 1.1 Background The first few years of a child’s life seem spent almost exclusively in play. Nothing gives us more uneasiness than to see a child who does not play. We consider it a sign of sickness, either of body or mind. As a result of playing the child grows. Growth is the primary use of play and this is as true of intellectual growth as of physical. [1-3] Down’s Syndrome is a chromosomal disorder, caused by the presence of an extra 21st chromosome, which is characterized by mild to moderate mental retardation, short stature, and a flattened facial profile. It is also called as trisomy21. The incidence of Down’s Syndrome is estimated at one per 800 to one per 1000 births.[8-10] Through play the child learns to explore, develop, and master physical and social skills. Children with Down’s Syndrome have tendency for more passive play and more repetitive play. Their play skills are influenced by delayed motor skill development [4] pertaining to manipulation, cognitive disabilities which implicate hampered capacities to direct and control one’s attention and to regulate one’s thinking and behaviour, and inadequate social development affecting their pretend play and interaction with peers. Since play is such an integral part of a child’s life, it seems only natural that it be used as a method for dealing with these children’s problems in a therapy setting. Children’s play is generally described as being spontaneous, purposeful, and involving roles and relationships, and the use of body space and force in the spatial and material environment of the home. Such descriptions enable observers to identify and explain deviations from expected patterns which may be attributable to a variety of environmental factors rather than the child’s own developmental status. [14,15, 21] Some studies have utilised play categories and their definable developmental features to make 41
May 2014 - August 2014
comparisons between different groups of children, and to arrive at prescriptions for intervention. In particular, the relationship between play and children’s cognitive and language development has frequently involved comparisons of the play behaviour of normally developing and retarded children.Play therapy [21] is a structured, theoretically based approach to therapy that builds on the normal communicative and learning processes of children. The curative powers inherent in play are used in many ways. Therapists strategically utilize play therapy to help children express what is troubling them when they do not have the verbal language to express their thoughts and feelings. In play therapy, toys are like the child’s words and play is the child’s language. Through play, therapists may help children learn more adaptive behaviours when there are emotional or social skills deficits. The positive relationship that develops between therapist and child during play therapy sessions can provide a corrective emotional experience necessary for healing. Play therapy may also be used to promote cognitive 5development and provide insight about and resolution of inner conflicts or dysfunctional thinking in the child.
Material And Methods: Study Design: Observational Cohort study Sample Size: 10 children diagnosed as Down’s syndrome were included in the study. Study Sample: Randomised sampling method was used. Inclusion Criteria:
Both males and females
1)
Musculoskeletal disorders
2)
Other developmental conditions
3)
Other neurological conditions
Revised Knox Preschool Play scale: The RKPPS is an observational measure [13] that allows therapists to evaluate the play of children ages birth to72 months in their natural environments[7] . The scale has 12 categories in 4 components namely Material management, Space management, PretenseSymbolic & Participation. Observed play behaviour that matches the age discriptors is recorded and each factor is scored at the upper age of age grouping. (For eg. 6 to 12 months is scored at 12 months). Each dimension is scored with the mean of factor scores and overall play age is scored with the mean of the dimension scores. Study Procedure: •
1.3: Hypothesis: NULL HYPOTHESIS (H0): There is no statistically significant improvement in play behaviour of children with Down’s syndrome with play based Occupational Therapy. ALTERNATE HYPOTHESIS (H1): Improvement in play behaviour of children with Down’s syndrome is statistically significant with play based Occupational Therapy.
Aims And Objectives:
IJOT : Vol. 46 : No. 2
3)
Assessment Tools:
Therefore the purpose is to study the effectiveness of play based therapy on the play behaviour of children with Down’s Syndrome in the age group 2-6years which has future use in the acquisition of life roles. This therapy is based on the Occupational Behavioural Frame of Reference.
To study the effects of play based therapy on play behaviour of children with Down’s Syndrome.
Age group 2 -6 years
5) Untreated seizure disorder
The social development and play behaviour of children with Down’s Syndrome in the age group 1-2 years progresses in a manner similar to their same age typically developing counterparts. This is the reason that our study includes children with Down’s Syndrome in the age group 2-6 years, as the play skills acquired by them in these pre-school years lay an important foundation for further acquisition of school and adolescent life roles.
•
2)
4) Visual and hearing deficits
1.2: Purpose Of Study:
To assess the play behaviour of children with Down’s Syndrome.
Children diagnosed as Down’s syndrome
Exclusion Criteria:
Occupational Therapy can play an important role in assisting individuals with Down syndrome from diagnosis to adulthood. “Occupational therapy helps individuals with Down syndrome by creating programs (Play Based activities) to develop and utilize skills across the lifespan.” This enables them to live life to its fullest.
•
1)
10 children with a diagnosis of Down’s syndrome coming to Occupational Therapy; paediatric OPD of KEM Hospital, Mumbai were selected as per inclusion and exclusion criteria. Parents of children selected were explained the purpose and nature of the study. Written consent was taken from the parents in the language best understood by them. Any queries regarding the study were explained to the parents. Four week protocol was administered. Evaluations were done on the 1st day and at 4th week of Protocol using RKPPS.
Treatment protocol •
42
Occupational Therapy and Play Based Therapy. Subjects were called twice a week, each session lasting for one hour. 45 minutes of play based Occupational Therapy was given followed by 15 minutes of Free play.
May 2014 - August 2014
Occupational Therapy intervention was inclusive of – •
Parental counselling
•
Normalization of tone
•
Facilitation of normal mature motor patterns and equilibrium reactions
•
Therapy for arm-hand control
Statistical analysis was done using Student’s ‘t’ test. (Paired ‘t’ test) Test was used to assess the statistical significance of Play based Occupational Therapy intervention in the selected sample. Observations were noted pre and post intervention and ‘t’ value was calculated using following formula. x=Mean, S= Standard Deviation, n= Sample size
Play based Therapy consisted of different age appropriate play based activities pertaining to the dimensions of RKPPS scale. Free play was also included as a part of intervention. Play based activities were inclusive of•
Results and Tables:
SPACE MANAGEMENT:
Table 1 Gender wise distribution of sample:
Ball throwing & Catching activity in sitting & standing, initially with the mother; progressing to Ball throwing & catching in a group. •
MATERIAL MANAGEMENT: Stacking rings, Building blocks, Perfection board, Bead stringing activities to improve manipulation, construction, purpose & attention.
•
IMITATION AND DRAMATIZATION: Pretend play with Doll (feeding, dressing the doll etc.), Doctor set. Mother-Child interaction to improve Imitation & Dramatization.
•
INTERACTION AND PARTICIPATION: Playing in group of therapist & peers to improve Cooperation. Use of expressive language & gestures to improve linguistic skills of the child.
In play based therapy, following approaches were used1)
Free Play[3,5] –which is intrinsically motivated, fun and is performed for its own sake. Free play helped child’s inherent potentials to come out and allowed for exploration and expression of selves.
2)
Mother-child intervention techniques[5]-which included
3)
•
Parent child taking turn during interactions
•
Face to face interaction
•
Decrease physical directives
•
Use of ‘wh’ questions that continue established topic of conversation and are developmentally appropriate.
Parental modelling which included modelling of required roles by mothers and imitation of child’s behaviour Home program was also explained to parents.
Data Analysis: Statistical method used:
IJOT : Vol. 46 : No. 2
43
May 2014 - August 2014
Table 2 Comparison of means of RKPPS scores- pre and post Play based Occupational Therapy intervention:
Table 3: Comparison of Mean RKPPS scores
Above graph shows that there is 13 % improvement in means of RKPPS scores pre and post intervention. IJOT : Vol. 46 : No. 2
44
May 2014 - August 2014
Table 4 Comparison of Total scores of RKPPS (Pre and Post intervention)
Table 6 Comparison of scores of RKPPS ( Dimension : Space management)
Table 5 Comparison of scores of RKPPS ( Dimension : Material management)
IJOT : Vol. 46 : No. 2
45
Sr No.
PRE
POST
Expected Play Age
1
15
18
30
2
15
18
36
3
12
15
28
4
19.5
23
30
5
18.5
25.5
36
6
19.5
22
32
7
20.5
25.5
36
8
22.5
26
38
9
18
20
28
10
20.5
23
30
May 2014 - August 2014
Table 7 Comparison of scores of RKPPS ( Dimension : Pretensesymbolic)
Discussion & Conclusion : On the basis of above represented data, improvement was observed in play behaviour of children diagnosed as Down’s Syndrome. There was overall improvement of 13 % in Total RKPPS score following intervention, ‘t’ value for which was 8.13 at the confidence interval of (17.95±1.63) to (22.1±1.63). 11% in the dimension of Material Management,‘t’ value for which was 8.6 at the confidence interval of (19.75±1.29) to (23.2±1.29),10.8 % in dimension of Space Management, ‘t’ value for which was 7.6 at the confidence interval of (18.1±1.47) to (21.6±1.47).13.8% in Pretense-symbolic, ‘t’ value for which was 6 at the confidence interval of (17.4±2.39) to (21.9±2.39). & 14% in dimension of Paticipation,‘t’ value for which was 5.47 at the confidence interval of (17.8±2.67) to (22.4±2.67). More improvement in area of participation can be attributed to enhanced mother child interaction as a part of therapy programme. Least improvement was seen in area of Space management which can be attributed to low postural tone, Delayed balance and equilibrium reactions, Lack of postural control during activity performance (for eg. Difficulty in maintaining the required posture during play activities). The improvement in play behaviour was found to be statistically significant as the data analysis showed significance at the level of P<0.001 .
Table 8 Comparison of scores of RKPPS ( Dimension : Participation)
The results are very much similar to those found in the study titled ‘Mother–Child Play: Children with Down Syndrome and Typical Development’ by P. Venuti, S. de Falco, and G. Esposito and Marc H. Bornstein. In conclusion, they observed essential maternal contributions to child play development in children with Down syndrome that seemed to be achieved through mothers’ adaptation to their child’s limitations and potentialities alike. Also, the strengths in mother– child play that could represent areas of potential remediation through intervention for children with Down's Syndrome.
Conclusion: •
IJOT : Vol. 46 : No. 2
46
Thus it can be concluded that play based therapy was effective in improving play behaviour of children with Down’s Syndrome.
May 2014 - August 2014
Hypothesis testing:
Occupational Therapy Journal, 2004,vol.51,pg. 3-12.
The alternate hypothesis of the study ‘Improvement in play behaviour of children with Down’s syndrome is statistically significant with play based Occupational Therapy’ was accepted as all the subjects included in the study showed a statistically significant improvement in their play behaviour following a month of Play based Occupational Therapy intervention. The improvement in play behaviour was found to be statistically significant as the data analysis showed significance at the level of P<0.001 .
6.
Teaching & Learning, Pamela Sharpe, vol.17(2),pg.87-92.
7.
American Journal Of Occupational Therapy,2009, vol.114, no.4, pg.274-278.
8.
National Down Syndrome Congress, www.ndsccenter.com
9.
Down Syndrome Educational Trust, www.downsed.org
10.
Down Syndrome. Com, www.downsyndrome.com
11.
Social development for individuals with Down syndrome - An overview, www.downssyndrome.org
12.
Ancy Parry Bledsoe, A Study of reliability and Validity of a Preschool Play Scale (pediatrics, developmental disabilities, play, research) AJOT.36.12.783
Thus, Null hypothesis was rejected. Limitations: •
Small sample size
•
Short study duration
•
One arm Cohort Observational Study
American Journal of Occupational Therapy, December 1982, vol. 36 no. 12, 783-788
Further Recommendations: •
Similar study can be carried out on a larger sample after sample size calculation. This study can be used for sample size calculation.
13.
Hilda Harrison and Gary Kielhofner, Examining Reliability and Validity of the Preschool Play Scale With Handicapped Children, American Journal of Occupational Therapy March 1986, vol. 40 no. 3, 167-173
14.
Stagnitti, Karen; Unsworth, Carolyn, The Importance of Pretend Play in Child Development: An Occupational Therapy Perspective, The British Journal of Occupational Therapy, Volume 63, Number 3, March 2000 , pp. 121-127(7)
15.
Play based Occupational Therapy International Journal of Disability, Development and Education,Volume 46, Issue 3, 1999.
•
Duration of study protocol can be increased so that the long term effects of the therapy can be evaluated.
16.
•
Similar study on an older age group can be carried out with some different assessment tool so as to detect areas of development which are lacking.
Development of play behavior in handicapped and normal infants, Topics in Early Childhood Special Education, October 1982 ,vol. 2, no. 3, 14-27
17.
•
A randomized controlled trial can be conducted to study the efficacy of play based therapy in comparison to other therapies.
K. E. Wisniewski M.D., Ph.D.*,Down syndrome children often have brain with maturation delay, retardation of growth, and cortical dysgenesis, American Journal of Medical Genetics, Supplement: Trisomy 21 (Down Syndrome) ,Volume 37, pages 274–281, 1990
18.
Barbara H Connolly and Beth T Michael, Performance of Retarded Children, With and Without D ow n Syndrome, on the BruininksOseretsky Test of Motor Proficiency, Physical Therapy, March 1986 ,vol. 66 ,no. 3 344-348
19.
Petrisiamunday hill, Pretend play and patterns of cognition in Down’s syndrome children, Child Development , Vol. 52, No. 2, Jun., 1981
20.
A systematic review of the effects of early intervention on motor development, Developmental Medicine & Child Neurology,Volume 47, Issue 6, pages 421–432, June 2005
21.
Association for Play Therapy, Carmichael, 2006; Landreth, 2002; O’Connor & Schaefer, 1983,Gil, 1991, Landreth, 2002, Pedro-Carroll & Reddy, 2005, Moustakas, 1997,O’Connor & Schaefer, 1983; Reddy, Files-Hall & Schaefer, 2005
22.
http://www.aota.org/About-Occupational-Therapy/Professionals/CY/ Articles/Down.aspx#sthash.utc9nMrF.dpuf
References: 1.
Willard &Spackman’s Occupational Therapy; E. B. Crepeau, E.S.Cohn, B.A.B.Schell; 2003; 10th edition; Lippincott Williams & Wilkins publication.
2.
Willard &Spackman’s Occupational Therapy; H.L.Hopkins, H.D.Smith; 1993; 8th edition; J.B.Lippincottcompany.
3.
Occupational Therapy for Children; Jane Case-smith;2010;6th edition; Mosby Elsevier publication
4.
Down Syndrome Research and Practice,1994; vol. 2(1); pg 31-35.
5.
Understanding play: The Implications for play assessment ,Australian
Appendix - 1 on page no. 16
IJOT : Vol. 46 : No. 2
47
May 2014 - August 2014
IJOT : Vol. 46 : No. 2
48
May 2014 - August 2014
