Parent Learn to Play Program - Individual

The third format is an individualized one on one intervention with the parent, child and therapist. This format requires that the therapist meets the parents and child before the program begins to assess the developmental play level of the child and design a specific intervention targeted at extending the child’s play ability. The child’s current level of enjoyment in play is also noted and considered. The next paragraph outlines how the therapist works with the parent to increase their capacity to engage with their child.

Principles and Processes of Individualized Sessions

In individualized sessions, the therapist not only works to prescribe the targeted play skills intervention, but supports parents to act as co-therapist in the implementation of them. In addition, the therapist coaches the parents on how to tailor the therapeutic environment to optimize engagement in play. Additional clinical considerations include how to:

  • • Use only the number of toys or play materials needed.
  • • Be aware of not to overwhelm the child with too many toys, speed or complexity.
  • • Play beside and on the child’s physical level to convey a sense of togetherness, acceptance, and safety.
  • • Engage in play themselves to model scaffolding of play.
  • • Playfully gain the child’s focused attention.
  • • Welcome the child’s ideas and integrate them into the pre-planned activities.
  • • Use developmental^ appropriate language to talk about and describe the play.
  • • Meet the child in the positive emotional space, with fun and pleasure to amplify therapeutic change (Stagnitti & Casey, 2011).

The following case study illustrates a bespoke child-parent-therapist Parent Learn to Play therapeutic intervention.

Case Study

Following a referral from their medical doctor and initial intake, Austina, a two-and-a-half-year-old girl, was observed in a non-directive play session. The following case illustrates how the PPE-DC assessment was used to prescribe an individualized Parent Learn to Play intervention. Background information is provided to set the scene in relation to her family and the critical incident that led to this play therapy intervention.

Family Background

At the time of intake, Stacey was a sole parent of two children, Austina and Daniella (15 months of age). The family came from a middle class, Caucasian Australian heritage, living in a regional area of Victoria, Australia. The extended family included maternal grandmother and maternal grandfather, as well as Stacey’s sister and paternal grandmother. The paternal grandfather, Austin, passed away just prior to the birth of Austina and is who she is named after. Before the accident, Austina had been progressing well in every developmental domain, including play. Stacey reported that they had strong family bonds and Austina was well loved and cared for.

Motor Vehicle Accident

Austina experienced significant trauma at 18 months of age, when her whole family were involved in a fatal motor vehicle accident. As a result of this accident, she sustained multiple traumatic injuries, including: traumatic Acquired Brain Injury (ABI); two fractured ribs; spiral fracture to left arm; fractures to both right and left tibia and fibula; and a fractured femur. She was hospitalized for four weeks.

Stacey, who was sitting in the front passenger side of the car, also suffered from a traumatic brain injury. This impacted her short-term memory and ability to care for Austina and Daniella. She was hospitalized for 6 months and required significant rehabilitation to coordinate and sequence her own activities of daily living. Ned, Stacey’s husband and Austina’s father, who was driving, was killed. Daniella, 3 months of age, was protected by the baby capsule and did not sustain any physical injuries.

Austina was cared for by Beth and Brian under a kinship care arrangement for 12 months while Stacey undertook medical rehabilitation. Twelve months after the car accident, she was able to be reunited with her children, and she understood that Austina would require an age-appropriate mental health service. Austina’s psychosocial health and well-being required a scaffolded personalized therapeutic play intervention to recover regressed play ability by supporting Stacey to scaffold play. It was also hypothesized that because of disruption in caregiving and bereavement of her father, some attachment behaviors may need to be expressed.

As a result of the traumatic ABI sustained, Austina’s play level was recorded at 12 months developmental play age, showing an 18-month deficit in her play skills when compared with expected play ability for her chronological age. At this time, she showed difficulty in initiating play sequences. The PPE-DC guided and informed the play therapist to structure Austina’s play sessions and to teach Stacey the skills to facilitate home-based play sessions. Stacey was highly motivated and keen to support her daughter’s developmental needs and re-establish their family structure and relationships.

Over a period of 2 months, Austina and Stacey attended 8 hours of Parent Learn to Play sessions with the support of Beth and Brian. The initial sessions were scheduled for only half an hour to accommodate the significant effort required of Austina to engage in play. The play sessions then progressed from half an hour to 45 minutes, to 1 hour. Austina was reassessed and showed a 2- year level of play which was evidenced by: logical sequential actions; play scripts (both in and out of the home); and the incorporation of characters within her play. These results showed (over a short period of time) a significant advancement in her play ability, restoring the deficit from 18 months to 6 months.

In addition, these sessions helped overcome an emotional and psychological trauma history and built their attachment relationship.

Assessment

Stacey and Austina were referred by their General Practitioner via an initial telephone call. Due to Stacie’s AB1 and memory loss, she was not able to fill out the Parent/Carer Pretend Play Enjoyment Developmental Checklist Scoring Booklet (Stagnitti, 2017b). Therefore, the first author completed the assessment using the Professional Scoring Booklet of the PPE-DC (Stagnitti, 2017b). The PPE-DC was completed both before and after the play therapy intervention. To ensure assessments were accurate, the first author carried out the pre-assessment and the second author carried out the post-assessment. It was important for the first author to carry out the pre-assessment for the Parent Learn to Play program as the therapist needs to understand the child’s play level in order to begin the therapy.

The PPE-DC informed the bespoke Parent Learn to Play intervention. The PPE-DC was not only used to gain an understanding of Austina’s play ability but was also used to monitor therapeutic change in Austina’s play level over the 2-month period. The results of the PPE-DC assessment by the first author are detailed in Table 4.4.

Based on observations using the PPE-DC Professional Scoring Booklet, Austina had pre-pretend play ability. She was 18 months behind in her pretend play ability, did not enjoy play and her sense of self was low with lack of confidence and curiosity.

Brief Description of Setting for Therapy

In the Learn to Play program the play room is set up differently from traditional play therapy rooms. This is because children are sequentially scaffolded to learn how to play. The toys are hidden in a cupboard in the early sessions, as often children who have developmental difficulties may be overwhelmed with too many accessible toys. The therapist, after speaking with the parents at the intake and assessment, chooses play materials that are suitable for the child’s developmental play age and interest. The toys are

Table 4.4 Pretend play enjoyment - developmental checklist (pre-intervention)

Play skill

Description of Austina’s play ability

Play stories

There were no stories in Austina’s play. She manipulated objects and repeated what she was doing (level A).

Sequences of play actions

She was highly repetitive. For example, she would put blocks in and out of a container (level A).

Object substitution

Austina manipulated and explored objects. She did not use them for any clear purpose (level A).

Doll/teddy play

Austina was not interested in characters such as teddy bears or puppets (level A).

Role play

Austina watched what the therapist did but only for short periods of time (level A).

Social interaction

Austina could wave goodbye. She liked peek-a-boo (level A).

Enjoyment score

2 (play was a task for Austina).

Description of behavior

Austina did not use personal pronouns, she was only fleetingly curious about toys. She did not anticipate events and became frustrated easily. She lacked confidence in doing things herself and often cried or seemed to give up. She could throw toys in frustration.

also bigger in size than play materials supplied in more traditional play therapies. For example, the dolls and teddies, vehicles and blocks are large. The types of toys used in early sessions for the Learn to Play program, for a child at Austina’s play level would be: a tea-set, teddies, large dolls, wooden fruit, play doh, a shoe box, fabric cloth, a ball, bath, bed, and large blocks.

Treatment Plan

Twelve 1-hour sessions over a 3-month period were planned. However, this changed when Stacey was offered government-assisted housing closer to her family, which was over 100 kilometers from the play therapy center. Thus, Austina attended a total of 8 hours of therapy.

The sessions began with activities to emotionally engage Austina, such as the large doll catching a ball, and stacking large rubber blocks and knocking them down. The play activities were pitched at a 12-18-month level of pretend play, e.g. feeding the teddy, giving the teddy a drink, putting the doll to bed, cutting up fruit. These play activities reflected body-based play scripts such as eating, drinking and sleeping. As Austina was at a 12-month level of play, to begin with the play actions were single repeated actions. The therapist used repetition of sequences with variation so that Austina could practice her ability to play.

Initially, Stacey watched the therapist and Austina’s play as she built her confidence to join in. If Austina added to the play ideas, the therapist would copy Austina, modelling to her mother how to engage Austina and extend her play. The therapist treated the dolls and teddies as if they were alive and enjoyed the play. The therapist also ensured that Stacey was engaged and enjoying playing with her daughter. The therapist responded to Austina and Stacy to ensure the therapy was emotionally engaging, pitched at the appropriate play level and including, when appropriate, play activities that were on a higher developmental level to extend her abilities. The therapist explained the play activities to Stacey and gave one-page handouts on each of the play skills. The handouts explained the play skills and why they were important.

Attention to the Stages of Therapy

In the Learn to Play program, therapy begins at the level of the child’s play. For many children who cannot play, play is not of interest to them, so the first sessions aim to engage children emotionally in the enjoyment of playing. Emotional engagement has been noted to be important in increasing a child’s engagement in wanting to play (Stagnitti &c Casey, 2011). Once the child is beginning to emotionally engage in the play and the therapist understands what play activities catch the child’s interest, the therapist then begins to slowly introduce other play activities at the same developmental level. At the early stages of the Learn to Play program with a child similar in presentation to Austina, five play activities need to be planned for each session.

When the therapist observes that the child begins to initiate their own play at that developmental level, the therapist then challenges the child by introducing play activities at a higher developmental level. All the while, the therapist is modelling play interaction beside the parent and explaining to the parent what play skill is being developed and why. The therapist is also cognizant of the range of play skills and plans for play activities that include scripts that the child can understand, appropriate number of play actions, object substitution, the inclusion of a character in the play, and the child carrying out a role in the play. Furthermore, the therapist is modelling to the parent how to socially engage the child in play through direct interaction with the child or through a doll, puppet or teddy.

When children understand how to use toys in play, initiate their own ideas in play, and begin to add spontaneous actions to the play, the therapist can reduce the number of pre-planned activities needed.

Post-assessment

Austina was reassessed by the second author after therapy. The second author had not been involved in the play sessions and was not aware of the progress in therapy. The PPE-DC Professional Scoring booklet was used to record Austina’s play level. Her results are described in Table 4.5.

Table 4.5 Pretend play enjoyment - developmental checklist (post-intervention)

Play skill

Description of Austina’s play ability

Play stories

Austina was showing play themes to a 2-year level with play scripts in and out of the home (doctors, eating, drinking, cutting cake).

Sequences of play actions

Austina showed simple, logical, sequential actions on a 2-year level. For example, she got the tea set, poured the tea, gave a cup of tea to mum, took cake from mum and gave to therapist, then ate some cake.

Object substitution

Austina showed ability to a 2-year level when she used the same object for two different things. For example, the box was a bed and a car.

Doll/teddy play

Doll/teddy play: Austina engaged in play where the snake was alive and “hurt.” She attributed properties to the snake. At this age children play “as if” characters are alive and Austina showed evidence of this.

Role play

Role play at this age is very fleeting and is more about copying others. Austina showed ability in this area.

Social interaction

Austina moved between mum and first author, engaging both in play. She imitated actions in play as well as initiated actions in play. She was aware of play materials she needed for play scenes.

Enjoyment score

Austina’s enjoyment was scored at 5, being an observable pleasure and enjoyment of play.

Description of behavior

Austina loved to come to the play sessions and would run into the room with anticipation of the pleasure to play. Her sense of self showed accomplishment of “1 did it!” and a confidence and curiosity not previously seen.

Case Summary

In summary, Austina showed play ability at a 2-year level. This was a pleasing increase of 12 months in 8 hours of play sessions. Austina requires ongoing play therapy to extend her play further to bring her to her age equivalent abilities. We anticipate that Austina will meet age equivalent play skills after a further eight 1-hour sessions. Stacey has demonstrated her capacity to provide positive parenting. We expect that if Stacey continues to provide play sessions at home in a secure relationship, Austina will demonstrate further reduction in emotional dysregulation and related behaviors and display an increase in healthy emotional regulation through therapeutic limit setting, play and communication. In relation to communication, Austina has already shown a significant improvement in narrative language and play skills. Stacey needs further support to continue with the work she has already undertaken with Austina. Austina was referred to another play therapist with specialist knowledge of the Parent Learn to Play program and with clinical supervision from the initial therapist to continue supporting Stacey in developing Austina’s play skills and psychosocial development.

Clinical Considerations

The use of assessments, such as the PPE-DC, may be used to enhance the identification for starting, scaffolding and tracking therapeutic play progress. It is important to access clinical supervision by a trained Learn to Play and Parent Learn to Play supervisor who is available to support the clinical reasoning before, during and after the therapeutic intervention. The toys were selected to enhance self-expression and increase pretend and imaginative play. Suggested toys and resources are included in the Learn to Play and Parent Learn to Play manuals (refer to the Recommended Resources list).

Conclusion

This chapter has provided the rationale to facilitate play development by utilizing the Parent Learn to Play program. This program is ideal to therapeutically meet the needs of children with developmental delays caused by traumatic ABI, neuro-atypical diagnosis and reduced neural growth, speech and language difficulties and other disabilities. The Parent Learn to Play program is recommended to expand the Learn to Play program in a sys- temically informed manner. The story of Austina has illustrated a Parent Learn to Play approach for a child with a traumatic ABI as an appropriate referral, as showcased by her rapid skill acquisition and progress over a 2- month period. It is important to respect the clinical considerations as part of a thoughtful case conceptualization that provides a highly individualized therapeutic intervention.

Recommended Resources

The Learn to Play Events website (https://www.learntoplayevents.com) provides several free resources. The following manuals and recommended assessment can also be purchased through the website:

  • • Learn to Play Manual
  • • Parent Learn to Play Manual
  • • Pretend Play Enjoyment - Developmental Checklist (PPE-DC)

Discussion Questions

  • 1 Under what clinical circumstances do you think the use of play assessments will inform your prescriptive approach in working with children and families? Why?
  • 2 Consider your current clinical caseload: Are there any children in your caseload with a play deficit that may suit this approach? Why might they be suitable? What might the long-term benefits to the child and family be?
  • 3 Under what clinical presentations do you think that the Parent Learn to Play program would not be appropriate?

References

Axline, V. M. (1969). Play therapy. New York: Ballantine Books.

Dooley, B., Stagnitti, K., & Galvin, J. (2019). An investigation of the pretend play abilities of children with an acquired brain injury. British Journal of Occupational Therapy, https://doi.org/10.1177/0308022619836941

Guerney, L. (2003). The history, principles, and empirical basis of filial therapy. In R. VanFleet. & L. Guerney (Eds.), Casebook of Filial Therapy. Boiling Springs, PA: Play Therapy Press.

Stagnitti, K., & Pfeifer, L. (2017a). Methodological considerations for a directive play therapy approach for children with autism and related disorders. International Play Therapy Journal, 26(3), 160-171. http://dx.doi.org/10.1037/pla0000049

Stagnitti, K. (1998). Learn to Play. A practical program to develop a child’s imaginative play. Melbourne, Australia: Co-ordinates Publications.

Stagnitti, K. (2014). The Parent Learn to Play program: Building relationships through play. In E. Prendiville 8c J. Howard (Eds.), Play therapy today (pp. 149- 162). London: Routledge.

Stagnitti, K. (2016). Play therapy for school-age children with high functioning autism. In A. Drewes 8c C. Schaefer (Eds.), Play therapy in middle childhood (pp. 237-255). New York, NY: American Psychological Association.

Stagnitti, K. (2017a). Parent Learn to Play facilitators manual and parent handbook. Melbourne, Australia: Learn to Play.

Stagnitti, K. (2017b). The Pretend Play Enjoyment Developmental Checklist. Manual and professional and parent/carer scoring forms. Melbourne, Australia: Learn to Play.

Stagnitti, K. ScCasey, S. (2011). II programma Learn to Play con bambini con autismo: considerazioni pratiche e evidenze. Autismo Oggi, 20, 8-13. Retrieved July 29, 2019 from: http://www.fondazioneares.com/index.php?id=369

Stagnitti, K., Bailey, A., Hudspeth-Stevenson, E., Reynolds, R., 8c Kidd, E. (2016). An investigation into the effect of play-based instruction on the development of play skills and oral language: A 6-month longitudinal study. Journal of Early Childhood Research, 14(4), 389-406. http://dx.doi.org/10. 1177/1476718X15579741

Stagnitti, K., O’Connor, C., & Sheppard, L. (2012). The impact of the Learn to Play program on play, social competence and language for children aged 5-8 years who attend a special school. Australian Occupational Therapy Journal, 59(4), 302-311. http://dx.doi.Org/10.llll/j.1440-1630.2012.01018.x

Vygostsky, L. (1934/1986). Thought and language (trans. and edited by A. Kozulin). London: MIT Press.

Vygotsky, L. (1966). Play and its role in the mental development of the child. Voprosy psikbologii, 12, 62-76. Retrieved July 29, 2019from: https://files.eric.ed. gov/fulltext/EJ 11.38861 .pdf

Winnicott, D. W. (1971). Playing and reality. London: Tavistock Publications.

 
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