Serenella Besio, Daniela Bulgarelli and Vaska Stancheva-Popkostadinova (Eds.

)
Play development in children with disabilities
Serenella Besio, Daniela Bulgarelli
and Vaska Stancheva-Popkostadinova (Eds.)

Play development
in children with
disabilities
ISBN 978-3-11-052211-2
e-ISBN (PDF) 978-3-11-052214-3
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© 2017 Besio, Bulgarelli, Stancheva-Popkostadinova

Published by De Gruyter Open Ltd, Warsaw/Berlin
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Cover illustration: Enzo Sanny (8 years), Italy
Contents

Acknowledgements XI

Serenella Besio, Daniela Bulgarelli, and Vaska Stancheva-Popkostadinova

Introduction 1

Serenella Besio
1 The Need for Play for the Sake of Play 9
1.1 Defining Play 9
1.2 Play Characteristics 11
1.3 Fundamentals of Play 14
1.4 Functions of Play 29
1.5 Play and Education: the Need for Play for the Sake of Play 34
1.5.1 A Short Historical Overview 34
1.5.2 The Difficult Relationship Between Play and Education:
Controlling Play 37
1.5.2.1 Play and Play-like Activities 38
1.5.2.2 The Role of Adults in Supporting a Child’s Play 41
1.5.2.3 Need for Clarity: Roles, Terminology, Activities 43
1.5.2.4 Play for the Sake of Play 45
References 47

Keith Towler
2 Children’s Right to Play, Whoever They Are, Wherever They Are.
The Play Rights of Children and Young People with Disabilities 53
2.1 The UNCRC 53
2.2 Barriers, Voice, and Play Practice 54
2.3 Article 31 and General Comment No. 17 55
2.4 Conclusion 57
References 57

Daniela Bulgarelli and Nicole Bianquin

3 Conceptual Review of Play 58
3.1 Definition of Play 58
3.2 Classifications of Types of Play 59
3.3 LUDI Classification of Types of Play 64
3.4 Type of Play: Areas of Development and Child’s Abilities 68
References 69

Nicole Bianquin and Daniela Bulgarelli

4 Conceptual Review of Disabilities 71
4.1 LUDI Definition of Disability 71
4.2 LUDI Categories of Childhood Disabilities 73
4.3 Description of the LUDI Categories of Childhood Disabilities 80
4.3.1 Intellectual Disabilities 81
4.3.2 Hearing Impairments 82
4.3.3 Visual Impairments 82
4.3.4 Communication Disorders 83
4.3.5 Physical Impairments 83
4.3.6 Autism Spectrum Disorders 84
4.3.7 Multiple Disabilities 85
References 86

Daniela Bulgarelli and Vaska Stancheva-Popkostadinova

5 Play in Children with Intellectual Disabilities 88
5.1 Play in Children with ID 88
5.2 Cognitive Play 89
5.3 Social Play 90
5.4 Conclusion 91
References 91

Anna Andreeva, Pietro Celo, Nicole Vian

6 Play in Children with Hearing Impairments 94
6.1 Play and Language Development in Children with Hearing
Impairments 94
6.2 Play between Parents and Children with Hearing Impairments 96
6.3 Pretend Play in Children with Hearing Impairments 96
6.4 Symbolic Play in Children with Hearing Impairments 97
6.5 Free Play in Children with Hearing Impairments 97
6.6 Social Play in Children with Hearing Impairments 98
6.7 Conclusion 99
References 99
Mira Tzvetkova-Arsova and Tamara Zappaterra
7 Play in Children with Visual Impairments 102
7.1 Basic Issues on Play in Children with Visual Impairments 102
7.2 Strategies for Compensation of the Delays and Difficulties in Play by
Children with Visual Impairments 106
7.3 Conclusion 107
References 108

Natalia Amelina and Vardit Kindler

8 Play in Children with Communication Disorders 111
8.1 Some Characteristics of Mental Processes in Children with
Communication Disorders 112
8.2 Play Activities of Children with Communication Disorders 113
8.3 Environmental Factors: Augmentative Alternative
Communication 114
8.4 Conclusion 117
References 118

Serenella Besio and Natalia Amelina

9 Play in Children with Physical Impairment 120
9.1 Motricity and Mind 120
9.2 Children with Physical Impairments 121
9.3 Technologies and Children with Physical Impairments 123
9.4 Play and Children with Physical Impairments 125
9.4.1 Practice Play 126
9.4.2 Symbolic Play 127
9.4.3 Constructive Play 128
9.4.4 Play with Rules 129
9.5 Social Aspects of Play in Children with Physical Impairments 130
References 132

Sylvie Ray-Kaeser, Evelyne Thommen, Laetitia Baggioni, and Miodrag Stanković

10 Play in Children with Autism Spectrum and Other Neurodevelopmental
Disorders 137
10.1 Play Skills of Children with ASD and Other Neurodevelopmental
Disorders 137
10.2 Types and Form(s) of Play Favoured by Children with ASD 140
10.3 Play Environment and Participation of Children with ASD 141
10.4 Conclusion 142
References 142

Francesca Caprino and Vittoria Stucci

11 Play in Children with Multiple Disabilities 147
11.1 Introduction 147
11.2 Play and Multiple Disabilities: the Literature 147
11.3 Impairments in Functions Linked with Play and Ludic Activities 148
11.4 The Role of the Environment for Participating in Play Activities 149
11.5 Facilitating Play in Children with Multiple Disabilities 150
11.6 Conclusion 152
References 153

Sylvie Ray-Kaeser and Helen Lynch

12 Occupational Therapy Perspective on Play for the Sake of Play 155
12.1 Definition of Play from the Discipline of OT 157
12.2 Play in OT (how OT Contributes to the Topic) 157
12.3 Conclusion 161
References 162

Michele Mainardi
13 Contribution of Special Education to the Promotion of Play for the Sake of
Play 166
13.1 Introduction 166
13.2 Development of the Child, Developmental Disability, Special Education
166
13.3 Development and Play in Special Education 167
13.4 Spontaneous Play in Special Education 168
13.5 “Let me (them) Really Play”: a Priority in Special Education 170
References 171

Vaska Stancheva-Popkostadinova and Tatjana Zorcec

14 Play in Early Intervention for Children with Disabilities 174
14.1 Introduction 174
14.2 Play in Early Intervention 174
14.3 Play-based Assessment 176
14.4 Challenges in Using Play in Early Intervention 177
14.5 Conclusion 178
References 178
Odile Perino and Serenella Besio
15 Mainstream Toys for Play 181
15.1 Introduction 181
15.2 Devices for the Play of Children with Intellectual Disabilities 183
15.3 Devices for the Play of Children with Hearing Impairments 184
15.4 Devices for the Play of Children with Visual Impairments 187
15.5 Devices for the Play of Children with Communication Disorders 189
15.6 Devices for the Play of Children with Physical Impairments 191
15.7 Devices for the Play of Children with Autism Spectrum Disorders 193
15.8 Devices for the Play of Children with Multiple Disabilities 196
15.9 Conclusion 197
References 199

Angharad Beckett, Carol Barron, Nan Cannon Jones, Marieke Coussens, Annemie
Desoete, Helen Lynch, Maria Prellwitz, and Deborah Fenney Salkeld
16 Influence of Environmental Factors on Play for Children
with Disabilities – An Overview 201
16.1 Introduction 201
16.2 Barriers to Play for Children with Disabilities within Four
Key Contexts 203
16.2.1 Barriers in the Built Environment 204
16.2.2 Barriers in Educational Settings 205
16.2.3 Barriers at Home 206
16.2.4 Barriers in the Natural Environment 206
16.3 Discussion 207
References 208

Serenella Besio, Daniela Bulgarelli, and Vaska Stancheva-Popkostadinova

Conclusion 213
Acknowledgements
We would like to warmly thank the LUDI reviewers of the whole text, Angharad
Beckett and Rianne Jansens: their contribution has been precious. A particular thank
also to Anna Andreeva, Francesca Caprino, Sylvie Ray, Hilary Gardner, Odile Perino,
and Mira Tzvetkova-Arsova for their competent and careful reciprocal revision of the
chapters.
Serenella Besio, Daniela Bulgarelli,
and Vaska Stancheva-Popkostadinova

Introduction

Why Play and Which Play for Children with Disabilities?

Article 31 of the Convention on the Rights of the Child (United Nations, 1989) grants the
child the right to rest and leisure, be able to engage in play and recreational activities
appropriate to the age of the child, and participate freely in cultural life and the arts. 1
The same Convention also pursues the right to social inclusion, intended as
a general framework for democratic societies, and as a model of intervention that
promotes everyone’s participation, respecting possibilities and constraints, cultural
stories and differences.
Every nation is currently involved in the efforts towards general inclusion in
societies, particularly with regards to education and training institutions and to
legislative systems. This may result in further deprivation, given the importance of
social sharing in peer play: in this sense, the inclusion of children with disabilities
remains an unreached goal.
But these children have the right to play, and without it, they have limited
chances for development. The Convention of the Rights of Persons with Disabilities
(United Nations, 2006) recognises this risk and dedicates Article 7 to the expression
and protection of the rights of children with disabilities, emphasising the need to
guarantee them proper educational process in an inclusive and life-long educational
system (Art. 24), as well as the right to participate in recreational activities, sports,
and entertainment, including those that take place in schools (Art. 30).
It can then be stated that play is widely recognised as the fundamental activity
for the overall development of every child. It drives a major role in the acquisition of
cognitive, socio-psychological, and relational skills, but it is also an innate ‘engine’
for curiosity, challenge, motivation towards action, and social relationships.
Play is spontaneous and voluntary, and it has no extrinsic goals: it is never lazy,
while on the contrary, it requires concentration, intensity, and it produces enjoyment
and fun.

1 This paragraph of the Introduction and partially the second one are highly inspired to: 1) Besio, S.,
& Carnesecchi, M. (2011). Memorandum of Understanding of the COST Action “LUDI. Play for Child-
ren with Disabilities”. COST Association, Bruxelles, retrieved from: http://w3.cost.eu/fileadmin/do-
main_files/TDP/Action_TD1309/mou/TD1309-e.pdf; 2) Besio, S., Carnesecchi, M., & Encarnação, P.
(2015). Introducing LUDI: a Research Network on Play for Children with Disabilities. Studies in Health
Technology and Informatics. 217:689-95.

© 2017 Serenella Besio, Daniela Bulgarelli, and Vaska Stancheva-Popkostadinova

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License.
2   Introduction

Children with disabilities may be deprived from playing as a direct consequence

of their impairments and/or because the environment is not adequate enough or
suitably accommodated, so that they can have access to forms and contexts of play in
which they can take part.
The scientific core issue adopted by LUDI, as the following figure shows, lies at
the crossroads of three autonomous research areas: disability (impairments’ types,
functioning characteristics), play (play characterisation and development, play
assessment, right to play), and environmental factors (technology, contexts, play
situations and scenarios).
These three areas also reflect the main domains of the International Classification
of Functioning, Disability and Health promoted by the World Health Organisation in
2001,2 which enables to describe the human functioning in relation to the activity and
the participation and with respect to the contextual aspects of daily life, in particular,
environmental and personal factors.

Figure 1. Factors involving children with disabilities’ play activity (Besio, Carnesecchi, & Encarnação,
2015)

2 International Classification of Functioning, Disability and Health—ICF (WHO, 2001). The version for
Children and Youth (ICF-CY) has been delivered in 2009.
Introduction   3

A large collection of studies of excellence has been devoted in the last decades,
in different countries, to the topic of play for children with disabilities. Anyway,
they have been mostly confined to specific niches, without exploring these areas of
research from a fully interdisciplinary perspective; for example, they have included:
development of social robotic tools, implementation of adapted toys, or creation
of new accessible playgrounds; creation of new tools of evaluation for specific
impairments; studies in the field of design.
Those initiatives, however, still lack a common systematisation, thus making play for
children with disabilities a not yet recognised area of research; furthermore, in almost all
these areas of study, these children’s play is viewed only as the mean through which they
can accomplish clinical and therapeutic goals. The extrinsic goal of these educational and
rehabilitation projects is mainly the functional recovery of impairments; they should be
considered more as ‘play-like’ activities, rather than truly play activities per se: in other
words, children are not engaged purely for the sake of play.
To grant children with disabilities the full exercise of their right to play means
to focus on the engagement connected with ludic activities as an end rather than as
a mean. By taking into account ‘play for play’s sake’ activities, the purpose of LUDI
is to create general awareness on their impact in the quality of life of children with
disabilities, and to initiate a process of cultural and social change that will break
down the barriers that hinder the full exercise of their right to play and the realisation
of a true social inclusion.

The COST Action ‘LUDI—Play for Children with Disabilities’ and its
Challenges

‘LUDI—Play for Children with Disabilities’ is an Action (2014-2018) financed by COST

(European Cooperation Science and Technology); it is a multidisciplinary network
including now 32 countries and almost 100 researchers and practitioners belonging
to the humanistic and technological fields, aimed at studying the topic of play for
children with disabilities.3
The LUDI Action has the primary objective of spreading awareness of the
importance of providing children with disabilities the opportunity to play. Given the
importance of play for child development, the Action stems from the belief that it
is necessary to ensure an equal right to play and to put play at the centre of both
multidisciplinary research and intervention practices directed at children with
disabilities. The LUDI network is organised into four Working Groups (WGs):
–– WG1: Children’s play in relation to the types of disabilities
–– WG2: Technology for the play of children with disabilities

3 The Action websites are the following ones: www.cost.eu/TD1309; www.ludi-network.eu.

4   Introduction

–– WG3: Contexts for the play of children with disabilities

–– WG4: Methods, technology, and frameworks for the development of the child
with disabilities’ play

WG1 provides the Action framework, including operational definitions of the

main concepts around play and disability. WG2 compiles and distils the existing
knowledge on technology to support play for children with disabilities. WG3
analyses the different contexts of play and identifies current barriers hindering
children with disabilities the right to play. Finally, WG4 builds on the work of all the
other WGs and proposes methods, technologies, and frameworks to support play for
children with disabilities.
To accomplish its objectives, the LUDI Action will carry out three main tasks:
a) collecting and systematising all existing competence and skills: educational
research, clinical initiatives, and using the know-how of resources centres and
users’ associations; b) developing new knowledge related to settings, technology
(devices, services, strategies, and practices) associated with the play of children
with disabilities; and c) disseminating the best practices emerging from the joint
effort of researchers, practitioners, and users.
The LUDI network is entrusted with a really ambitious and ground-breaking
goal, branching into many prospects of exploration and susceptible to significant
developments in several fields. New knowledge is expected in all the scientific-
related areas, not only in the ‘speciality’ of disability, but as overall acquisitions
about play (development, tools, relationships, activities, human rights, and so on)
and child development.
This new knowledge will creatively nurture, in its turn, the fields of
technological and tool development, clinical and engineering research, education
and rehabilitation practice. A more stable and consistent awareness on the child’s
play development would give more suitable frameworks to professionals and
researchers to make their interventions and proposals more effective. A more
widespread sensibleness on the social aspects and value of play would result in
disseminating inclusive contexts and methods.
At the same time, a shared belief on the importance of play—for the sake of
play—for children with disabilities as for any other child, as well as on the role of
inclusion for the upcoming human societies, will demand changes in many aspects
of cultural and social life: to make only some examples, the accessibility of the
mainstream play sites and tools, the concrete application of the right to play for
every child, the adoption of a new mindset on disability, less focused on recovery
and more interested in childhood’s fundamentals.
The main challenge is already inside the network, which is both international
and multi-disciplinary. Researchers and professionals who belong to LUDI come, in
fact, from many European countries, bringing with them their social and cultural
beliefs and experiences, which should be explored and compared, and are expert
Introduction   5

in different fields, which should be merged together through deep and patent
discussion. The purpose of this massive mediation activity is to reach reciprocal
understanding and to develop new common, collective wisdom, in the light of the
basic statements shared since the beginning of the work.
But this is an extensive process, as shifting to new paradigms always requires
a long time and a lot of determination.4 This means, for example, that at the initial
life of LUDI, in its first publications—as this one is—some incoherence still exists
between authors and proposed approaches, and that the debate is currently open
and active. Any product of LUDI is then a part of a recursive process, whose results
should be considered, until its end, as partial steps of a long road.

The Purpose of this Book

This book is the first deliverable of the WG1 ‘Children’s play in relation to the types
of disabilities’, part of the LUDI network. As already said, WG1 is devoted to the
topics of definition of play, classification of impairments accordingly to DSM-5 and
ICD-10, and classifications of types of play with respect to the cognitive complexity,
and the degree and type of social interaction. This book is the result of the first two-
year of activities of WG1.
The main objective of this book is to bring the LUDI contribution to the
important topic of play and children with disabilities, because an international
consensus on these two areas is still lacking in the related literature and also in
the overall practice. In particular, there is not a shared and general agreement on
a clear definition of play and play activities, especially when they are related to
children with some kind of impairments, and/or when ludic contexts accessible for
these children are drawn up.
Three steps should be achieved to support the right to play of children with
disabilities, ensure equity in its exercise, and spread awareness on the importance
of giving them the opportunity to play: first, adopt a ‘common language’, at least
all over Europe; second, to put play at the centre of the multidisciplinary research
and intervention regarding the children with disabilities; third, to grant this topic
the status of a scientific and social theme of full visibility and recognised authority.
In fact, children with disabilities face several limitations in play: they might
not be able to play; might not want to play; might not know how to play; might
not recognise a situation or a object for their ludic characteristics; they can isolate
themselves from the others’ play; might be scared by a play situation; might prefer
to repeat the same play, in the same way, in the same site.

4 We thank Dr. Ute Navidi, who served as first reviewer for the LUDI activities, commissioned by
COST, for this very encouraging statement, that we immediately incorporated in our vision.
6   Introduction

These limitations can be due to several reasons: impairments to body functions

and structures can impede or make some actions and activities very difficult;
playgrounds, toys, and other play tools can prove not to be accessible and usable;
social and built environments and contexts may be neither accessible nor inclusive.
Furthermore, the world of the adults around these children might show several
lacks: in educational awareness and intentionality; in specific psycho-pedagogical
and rehabilitative competence; in effective intervention methodologies. Moreover,
these children’s lives are dominated by medical and rehabilitative practices, in
which play is always considered as an ancillary but very fruitful activity able to
reach an instrumental objective or to pursue an improvement.
Play for the sake of play is considered, mainly for children with disabilities, a
waste of time.
The concept of play for the sake of play strongly refers to the distinction between
‘play’ and ‘play-like’ activities. Play activities are initiated and carried out by the
player (alone, with peers, with adults, and so on) only for the purpose of play itself
(fun and joy, interest and challenge, love of race and competition, ilinx and dizziness,
and so on). They have of course consequences on growth and development, but
these consequences are not intentionally pursued. Play-like activities are initiated
and conducted by an adult (with one or more children), in educational, clinical,
social contexts; they are playful and pleasant, but their main objective is other than
play: for example, cognitive learning, social learning, functional rehabilitation,
child’s observation and assessment, psychological support, psychotherapy. This
book would intend to contribute to make a clear distinction between play and play-
like activities that, hopefully, will bring to new developments in play studies.

Organisation of the Contents

This book sets itself as the basis for the further work of the COST Action ‘LUDI—Play
for Children with Disabilities’, by establishing some important cornerstones, after
a careful overview of the literature existing in the related fields. Its contents are
organised as follows:
–– Chapter 1 presents the theme of children’s play in its countless facets, with
special reference to ‘The need of play for the sake of play’ (Serenella Besio).
–– Chapter 2 deals with one of its special characteristics, the fact that play
should be considered a child’s right, also in the case of disability: ‘The right
of Children with Disabilities to play’ (Keith Towler, from the International Play
Association—IPA).
–– Chapters 3 and 4 are, respectively, focused on the ‘Conceptual review of play’
and ‘Conceptual review of disabilities’; they take into account the existing
definitions of these two crucial constructs as well as the major scientific
classifications existing in the international literature, and finally, propose the
Introduction   7

LUDI Classifications of play and of disability to be adopted (Nicole Bianquin

and Daniela Bulgarelli).
–– Chapters 5 to 11 deepen the characteristics that play might assume in case of
different types of impairments, according to the LUDI Classification; the authors
of each chapters tried to take into account the aspects of play for the sake of
play, as far as possible with reference to the existing literature. In particular,
they are the following ones:
–– Play in children with intellectual disabilities (Daniela Bulgarelli and Vaska
Stancheva-Popkostadinova)
–– Play in children with hearing impairments (Anna Andreeva, Pietro Celo,
Nicole Vian)
–– Play in children with visual impairments (Mira Tzvetkova-Arsova and
Tamara Zappaterra)
–– Play in children with communication disorders (Vardit Kindler and Natalia
Amelina)
–– Play in children with physical impairments (Serenella Besio and Natalia
Amelina)
–– Play in children with Autism Spectrum Disorders (Sylvie Ray-Kaeser,
Evelyne Thommen, Laetitia Baggioni, and Miodrag Stanković)
–– Play in children with multiple disabilities (Francesca Caprino and Vittoria
Stucci)
–– Then, three chapters follow, which discuss about the contributions of different
fields of research and clinical intervention to the promotion of play for the sake
of play.
–– Chapter 12 reports the experiences from occupational therapy: The
contribution of occupational therapy perspective to the promotion of play
for the sake of play (Sylvie Ray-Kaeser and Helen Lynch).
–– Chapter 13 concerns the special pedagogy perspective: The contribution of
special education to the promotion of play for the sake of play (Michele
Mainardi).
–– Chapter 14 faces the theme of early intervention: Play for Early Intervention
for children with disabilities (Vaska Stancheva-Popkostadinova and Tatjana
Zorcec).
–– Chapter 15—Mainstream toys for play—is related to an overview of mainstream
toys, accompanied by some hints to single out their characteristics with respect
to the different types of impairments, but also to the different types of toys
(Odile Perino and Serenella Besio). It is not intended to be exhaustive of the
issue ‘tools for playing’, but it wants to propose a first framework to interpret
the world of commercial toys and to learn how to navigate inside, from the
perspective of a generic adult, like, for example, a parent.
–– The final and last Chapter 16 devises some reflections about the environmental
barriers that can be found in the environment to establish interesting and
8   Introduction

playful activities for children with disabilities—Influence of Environmental

Factors on Play for Children with Disabilities–an overview. As this chapter
is contemporarily an excerpt and a reworking of a publication that has been
completed by members of LUDI WG3, the authors of this chapter are the same of
that publication (Angharad Beckett, Carol Barron, Nan Cannon Jones, Marieke
Coussens, Annemie Desoete, Helen Lynch, Maria Prellwitz, Deborah Fenney
Salkeld).5

5 Barron, C., Beckett, A. E., Cannon-Jones, N., Coussens, M., Desoete, A., Fenney, D., Lynch, H., &
Prellwitz, M. (Forthcoming). Barriers to play and recreation for children with disabilities. Berlin, D: De
Gruyter.
Serenella Besio
1 The Need for Play for the Sake of Play
Put more simply, play as we know it is primarily a fortification
against the disabilities of life
Brian Sutton-Smith

1.1 Defining Play1

“I believed that, when most of [the] scholars talked about play, they fundamentally presupposed
it to be either a form of progress, an exercise in power, a reliance on fate, a claim for identity,
a form of frivolity, an issue of the imagination, or a manifestation of personal experience. My
argument held that play was ambiguous, and the evidence for that ambiguity lay in these quite
different scholarly ways of viewing play. Further, over the years it became clear to me that much
of play was by itself—in its very nature, we might say—intentionally ambiguous (as, for example,
is teasing) regardless of [...] general cultural frames” (Sutton-Smith, 2008:112).

So, what is play, then? It is seriousness and frivolity: reality and make-believe: rules
and freedom. Within these antinomies lies the human experience of play, which must
cope with a frustrating dichotomy that is always resolved through action. This duality
is so deeply rooted in the phenomenon of play that Sutton-Smith based his last ‘theory
of play’ on it—called ‘coevolutionary multiplex of functions’—where play is described
along five adaptive layers of ‘dualudics’.
Rivers of ink have been spilled in an attempt to find a universally accepted
definition of play, especially in different cultural environments. A now old but
fascinating definition is provided by Fink: “Play resembles an oasis of happiness that
we happen upon in the desert of our Tantalus-like seeking and pursuit of happiness.
We are abducted by play. By playing we are released a bit from the mechanism of
life—as if we were transported to another celestial body, where life appears easier,
more ethereal, happier” (Fink, 1986).2

1 For the purpose of this chapter, it is important to stress here again that, within the LUDI frame-
work, for children with disabilities, play has the same meaning and the same value that it has for all
the children. This fact has one main consequence: all discourse surrounding play and children with
disabilities must derive from and be strictly connected to the discourse concerning play in general. For
this reason, the reflection on play here is developed from the overall immeasurable literature on play.
2 This paragraph has been inspired by Besio (2008).

© 2017Serenella Besio
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License.
10   The Need for Play for the Sake of Play

Since ancient Greece, play has been recognised as a peculiar activity of the human
being, at any age.3 According to Aristotle, it should be distinguished from work,
because it lacks necessity, and like virtue and happiness, it is rather characterised
by freedom and self-sufficiency. Centuries later, Kant associated it to an aesthetic
condition, because it is able to make imagination and intellect act together.
But since it began to be studied and analysed in an effort to recognise and
understand it, play escaped any definition that tried to fix it, define it, encode it.
A fundamental attempt to find a comprehensive definition of play is offered by
Huizinga in his famous book Homo Ludens, where it is described as the driving force of
all human activities, a sort of primordial big bang from which civilisation itself comes
from: “culture arises in the form of play, […] it is played from the very beginning”
(1967:46). While fulfilling the physiological and biological functions, according to
the author, play can be defined as “a free activity standing quite consciously outside
‘ordinary’ life as being ‘not serious’, but at the same time absorbing the player
intensely and utterly. It is an activity connected with no material interest, and no
profit can be gained by it. It proceeds within its own proper boundaries of time and
space according to fixed rules and in an orderly manner. It promotes the formation of
social groupings which tend to surround themselves with secrecy and to stress their
difference from the common world by disguise or other means” (1967:13).
In literature, from the educational, psychological and legal fields,4 different and
overlapping definitions have been proposed that focus attention on certain aspects.
Each of them gives a sense of fulfilment and seems both to compensate for a
lack of interpretation and to underline an absence. After all, as stated by Bondioli
(2002), each of these models seems only to reduce a huge theme to one of its small
and basically limited aspects.
In short, play is indefinably play, to the point that Miller (1973) proposes to
abandon the challenge of finding a single definition. In front of the baboon cage at the

3 Play, according to Gily, “is not a right for only a few men, if anything younger people, but it is a
necessity for all. It interprets taking action according to spontaneity, originality, and the free exercise
of one’s faculties. Depressed by prolonged labor, the play instinct remains on the edges of ordinary
human life, but emerges as soon as ease and hope liberate a space for its insurmountable need, such
an obvious and recognizable need that man did not lose time to explain or to deify it. Its meaning is so
clear that it does not require arguments, so urgent to overcome poverty and sadness: it has only end
in itself, it justifies by itself” (2006:16).
4 The International Play Association Declaration on the child’s rights to play maintains that “play is
an essential part of childhood. All children have a right to experience play which, in the words of the
Declaration, is free, open, boundless, sometimes chaotic, sometimes transformative. Play is a right
which all adults have a responsibility to uphold. [...] The IPA Declaration highlights the growing evi-
dence of the effects of lack of time and space for play and the serious and life-long effects on children’s
bodies and minds. IPA wishes to alert the wider community to this evidence and call for action to
address this deprivation before the effects cause lifelong damage to more children”. Theresa Casey,
President, IPA, http://www.ipaworld.org.
 Play Characteristics   11

zoo, people know—and there is general agreement on it—if the animals are playing,
but they cannot explain why, and on what criteria they base their assertion. Similarly,
Bundy (1993; 2000), who introduced an interesting test of playfulness,5 concludes:
“everyone knows whether a child or some children are playing. That is play: what is
recognized as such by common observers”.
To develop its project, the COST Action LUDI—Play for Children with Disabilities
chose to adopt the definition proposed by Garvey: “Play is a range of voluntary,
intrinsically motivated activities normally associated with recreational pleasure and
enjoyment” (1990:4).
Even if the identification of a definition establishes an important point of
agreement and sharing for researchers in the network, this is not enough, for the
same reasons discussed earlier, to exhaust the discussion on the theme of play.
In what follows, some in-depth proposals are presented on certain aspects of play
that have been considered important to study this phenomenon and its development
in children with various types of impairments: in particular, the characteristics of
play, its fundamentals, and the main functions it accomplishes.
It is believed that these elements can be useful for analysing, on the one hand,
the difficulties that children with disabilities may encounter in their play activities
and, on the other, the specific consequences that any deprivation of fun activities may
cause to their development as a whole.

1.2 Play Characteristics

There are numerous proposals of ‘essential traits’ or ‘characteristics’ of play in

literature in this field. According to Bateson (1956), they can be summarised in:
unfinalisation, creativity, not literalness, flexibility, pleasure. Levy’s proposal (1978)
includes the following three traits: intrinsic motivation (motivation for the activity for
the sake of the activity itself), suspension of reality (putting reality aside), and internal
locus of control (the child has self-control); and Lillemyr (2009) adds interactions in
play.
Within LUDI, play characteristics are the distinctive qualities of play, common
to all its types, which contribute to giving the phenomenon its special peculiarity;
only some proposals—among those highlighted by the various authors who have
studied play—are presented as follows: they have been chosen as important elements
of attention, harbingers of reflections and developments when it comes to play and
children with disabilities. These qualities, shortly described in what follows, are:
the feeling of freedom, its association with concentration and intensity (rather than
with laziness), as well as with pleasure and/or with fun; in addition, the fact that

5 See also Bundy et al. (2001); Meakins et al. (2005).

12   The Need for Play for the Sake of Play

play is always conducted in serious ways, driven by curiosity and surprise, intrinsic
motivation, and finally, by challenge.
The first feature that infant play brings to everyone’s mind is the freedom it allows
to experiment and express.6 It is also the first of the traits marked by Caillois, who
here is influenced by Huizinga. He stresses that as controlled play is no longer play,
it loses its nature of attractive and joyful fun. Interestingly for the purposes of LUDI,
Caillois gives to the construct of freedom, more properly, the meaning of spontaneity,
immediacy, carefreeness, means of desire and action: “a basic freedom is central to
play in order to stimulate distraction and fantasy. This liberty is its indispensable
motive power and is basic to the most complex and carefully organized forms of play.
Such a primary power of improvisation and joy, which I call paidia, is allied to the
taste for gratuitous difficulty that I propose to call ludus” (Caillois, 2001:27). But to
Caillois, play is free also because it can only belong to free men: “it is a luxury activity
and it belongs to free men. Hungry people don’t play” (ibid:14).
Freedom in play has also overlooked implications, perhaps slightly embarrassing,
in field studies; in fact, it also means license and licentiousness: in play gestures
and words, and in jokes and diatribes. Sutton-Smith, in this regard, underlines the
extreme aspect that these kinds of play may show: “At the very least, they suggest
that for the children who take part in the jokery, there need be no limit to the shocks
they can include in this kind of unorthodox play—so long as they make them funny”
(Sutton-Smith, 2008: 91).
The characteristic of freedom often made it possible to counterpoise play to work,
both in the case of the activities of children and adults, and in the case of leisure time
and organised time, for example, through pedagogical activities. However, freedom is
never associated with laziness or boredom, but rather with concentration, intensity,
and density; and these are additional notable features of our object of study. Poetic
expressions have been used to describe the condition in which a child plays: if Fink
(1960) talks about dense reality, where life is highly concentrated and children appear
to be totally absorbed by it, Huizinga talks about tension, that is the desire to achieve,
to be successful, and to interrupt that same tension. But these are conditions that are
both powerful and knowledgeable: “Play demonstrates that two different attitudes
co-exist: to be fully involved in what one is doing and to be aware of the fact that we
are within a relative, delimited and conditioned dimension” (Besio, 2008: 1).
According to Huizinga, “this intensity of, and absorption in, play finds no
explanation in biological analysis. Yet in this intensity, this absorption, this power of
maddening, lies the very essence, the primordial quality of play” (Huizinga, 1938:3).
Nature might have given to her children the power of “discharging superabundant

6 Vygotskij (1967) contrasts this interpretation by putting the bond, the limit, at the basis of the
pleasure inherent to play.
 Play Characteristics   13

energy, of relaxing after exertion”; but “no, she gave us play, with its tension, its
mirth, and its fun” (ibidem).
Here is another important characteristic of play: it is, in fact, always associated
with fun and/or pleasure. According to Freud (1920), play responds, is led by the
“principle of pleasure”, which first appears in the children’s ludic activities: in his
famous example of the nephew who enjoys playing toss and catch with a spool
whenever the mother leaves the room, he sees the proof that the child feels joy in
anticipating or representing the possible, desired, return of his mother. The active
role exercised by the child acting on the spool allows the desire to materialise, and
the child to dominate an unpleasant emotion—which is no longer passively suffered—
and replacing it with a pleasant one. 7
The pleasure produced by play does not seem to run out spontaneously in the
excitement of the moment, an end in itself; on the contrary, it seems to leave traces, an
imprint on the individual’s feelings in relation to life itself: “[play’s positive pleasure]
makes it possible to live more fully in the world, no matter how boring or painful or
even dangerous ordinary reality might seem” (Sutton-Smith, 2008:95).
Although sometimes play, in its beautiful swing between opposites, positively
makes use of the scheme, the repetition, the use of known and familiar, its underlying
backbone lies in what is new, in discontinuity.8 In fact, it pursues and uses flexibility:
not only does it tend towards reproduction, imitation, but it constantly seeks changes,
“in form or in content. Play is a phenomenon to the extent of what is possible”
(Bondioli, 2002:55).9
Fun comes often from the unexpected, from surprise (Eberle, 2014): here are
some of the attributes of play listed by Sutton-Smith: chanciness, fluidity, ambiguity,
particularity, diversity of perspective (Henricks, 2015:117). Teasing, a specific type of
play studied by this author, seems to be specifically related to the feeling of surprise
or even shock; it takes different forms according to the cultures in which it can be
found, and it seems relevant in the play relationship between the child and the adult,
becoming a means of social learning.
Even if it happens often, fun does not necessarily, however, become laughter, joy,
relief, or cheerfulness, or even sometimes excitement: “Of course, it must be stressed
that the pleasure of play is not always manifested in delight or glee or laughter. Play,
as Huizinga (1967) points out at great length, can be a very serious business but still

7 This wish, according to Freud, is a wish to be adults and to act like them (Metra, 2006).
8 With reference to a sociological perspective, Sutton-Smith adds: “The challenge for scholars is to
explain the social, personal and cultural implications of this quest for disorder, excitement, and dis-
connection. […] One can also look at all kinds of games […], as well as at all of the play in the arts […]
and see that in all of them the world is a more exciting place in which to live for a player or spectator,
at least for a time” (Sutton-Smith, 2015: 249).
9 All quotations of Italian authors have been translated by the author of this chapter.
14   The Need for Play for the Sake of Play

within play the act of doing is clearly rewarding in the sense that it incites its own
repetition” (Miller, 1973:91).
The play in which the child is involved is always seriously challenging,10 driven by
intrinsic motivation not only or not so much to achieve a result, but rather to keep alive
the play process itself and to continue to belong to it, along with fellow players, if any.
According to Miller, both the practice play and rule-based play or team game provide
the same pleasure of ‘being in’ the play, rather than to achieve a result. Winning a
game or achieving a result is “important insofar as they are symbols for the dynamics
and the challenge that were involved in their attainment” (ibid:93).
Play ends and finds meaning in itself, therefore, in the pleasure of doing and the
process of playing;11 “The interest of the subject is addressed to the process rather
than to the product; the usual means-ends relationship is reversed. In other words,
the game is intrinsically motivated, does not tend to satisfy primary physical needs,
and does not depend on external rules or social obligations. The presence of rules
does not contradict the principle of freedom, as submission to the ludic conventions
takes place thanks to autonomous choice” (Bondioli, 2002:55).
Play is a challenging process and from the player—child or adult—demands
commitment and seriousness (a careless player is reprimanded by his or her
companions and is asked to ‘play for real’). But, notes Bondioli, the dividing
line between play, especially that of fiction, and reality must always be clearly
maintained: “The seriousness with which the child or the adult takes their games and
their pastimes, the fact that play often requires compliance with detailed rules and
procedures, does not eliminate the ‘not serious’ quality of these activities in relation
to ordinary life. The confusion between the two plans is not allowed: the children
are reprimanded or reassured if they take their play too seriously; they are reminded
that it is just a game”(ibid:40). In fiction or in playful concentration, several ‘make-
believe’ acts are accomplished ‘seriously’, but the realism of such acts must never let
the two contexts overlap.

1.3 Fundamentals of Play

A ludic activity has many facets and has been described under many aspects. In this
section, an attempt is made to identify and describe some essential parameters of

10 It seems important to point out that Milner (1952), quoted by Winnicott (1971), proposed a connec-
tion between children’s play and adults’ concentration.
11 Some authors speak of ‘autotelic activities’. In his well-known theory of flow, Csikszentmihalyi
(1990; 1997) increasingly uses the term ‘autotelic activity’ instead of ‘playful activities’ or play. And,
Suits proposes one of the shortest existing definitions of play as follows: “a temporary reallocation
to autotelic activities of resources primarily committed to instrumental purposes” (Suits, 1977:124).
 Fundamentals of Play   15

the phenomenon, as it manifests in childhood that should be considered crucial for

studying play by children with disabilities.
Six fundamental have been identified in the related fields and will be discussed
in their various facets, in what follows, with respect to the existing literature, they are:
the concept of frame and of being involved, the need of doing, the role of imagination
and fantasy, the importance of the rules, the social aspects of play, its capacity to
evolve in childhood.
The first fundamental of play to be considered is the special condition of life
that is experienced and acted during this activity: this experience can be defined as
being in the game, or in-lusio (Huizinga, 1967). Play, as inlusio—Latin origin of the
word—is “a transformation of reality into a hypothetical connection, without claims
to objectivity: it moves away from reality, but it does not transcend it” (Gily, 2006).
Bateson (1956) identified and highlighted this feature of play as a frame better
and before other authors. “Play is a context, or what Bateson calls a ‘frame’. It is a
mode of organization of behaviour—one way of fitting pieces of activity together”
(Miller, 1973:92).
The essence of play is in its being a meta-communication; a player must be able
to state: “This is play”. This message creates a frame, a psychological framework,
serving as a filter for the interpretation of what there is inside. By playing, one gets
into a context and into a dimension different from reality, governed by specific rules,
shared by and known to players; play implies a change of perspective, or rather, of
paradigm.12
By playing, one makes a logical leap, from learning a content (a ‘type one’
learning) to ‘deutero learning’, which concerns contexts, relationships, and their
modes of functioning. It is in this sense that Bateson can highlight the paradoxical
feature of play: it requires an agreement among players on what ‘is true’ and what
‘is make believe’; the parties must agree on the framework within which they find
themselves, by defining the ludic status of their activity, and maintaining it as it is
during its development (Bondioli, 2002).
The players agree willingly and quickly, and show a common desire to inhabit that
frame, to indeed ‘be in play’; they defend their ludic activity against intruders, who
would like to introduce a coherence criterion, unrelated to the proposed rules, because
they don’t want play to distort into something different. If a child violates the rules
and does not seem really involved in play, he or she is considered a troublemaker,13
and is, in fact, ruled out, or play disappears. But play is not totally an illusion,
because it is not confused with the real data, thus generating misunderstandings; to

12 Bateson himself refers to the notion of paradigm in Kuhn.

13 Bondioli (2002) refers to a story—entitled Childhood—by Tolstoj, in which he vividly describes his
brother’s listless participation in collective play.
16   The Need for Play for the Sake of Play

stop it, another meta-communication should happen—“I won’t play any more”—that
dissolves the frame, the previously established scenario.
A second fundamental aspect that is necessary to highlight concerns the theme
of doing, and its relationships between means and ends, within the play activity.
It was Winnicott who declared the game inseparable from doing. Postulating an
indeterminate place between an ‘inside’ of the child—without further defining it—
and an ‘outside’ where what for him or her is a ‘not-me’, the author points out that
“to control what is outside, one has to do things, not simply to think or to wish, and
doing things takes time. Playing is doing” (1971:41).14 Winnicott refers here to a third
potential space between the mother and the child, which is not the inside or the
outside, in which the objects and the transitional phenomena may be acted out and
do their job of separation. This area is indeed experiential.15
What is interesting to point out here is the emphasis Winnicott places on doing,
on action, in a space and a time that are specifically created; this ‘doing’ has very
specific characteristics, which have been well studied by Miller (1973) and concern
the relationship between means and ends.
Focussing first on practice play,16 the author highlights three important aspects,
related to his notion of ‘galumphing’17: a) “a lack of streamlining or task oriented
efficiency” (ibid:91), it seems that children deliberately complicate their play activities,
they make things difficult for themselves;18 b) play “is pre-exercise of undeveloped
skills that will be needed later. The skills used in practice play are played with after
they are acquired. They may not have been completely mastered, but some amount of
competence must already have been attained. Practice play can certainly be exercise,
but it is more often post-exercise than pre-exercise” (ibid:91); and c) when activities
appear in the learning or in the task mode, they are “under the control of goals: means
are marshalled at the service of ends. In play, the means are given much freer sway.
The process becomes play when it becomes interesting in itself. It is repeated and
repeated, and then some part or new consequence of the process becomes the object
of interest and is elaborated in its turn. The distinction between process and end state
is an important one” (ibid:91).

14 This assertion of Winnicott, in particular, has triggered numerous applicative studies of play, in
psychotherapy, but also in education, based precisely on the ludic value of ‘doing’.
15 It is the “third part of the life of a human being, a part that we cannot ignore, an intermediate area
of experiencing, to which inner reality and external both contribute” (Winnicott, 1971:3).
16 With reference to the first developmental stage of play proposed by Piaget (1972).
17 The author admits to use the “appropriately ridiculous term ‘galumphing’ […] as an onomatopo-
etic description of a baboon’s flailing in play fights. […] I will use ‘galumphing’ as a shorthand term
for ‘patterned, voluntary elaboration or complication of process, where the pattern is not under the
dominant control of goals’” (Miller, 1973:92).
18 This is underlined also by Groos (1901), who speaks about “a process in which the player sets
obstacles in his path to prolong and increase the enjoyment of his play” (cited in Miller, 1973:91).
 Fundamentals of Play   17

Fun solicited by practice play—one of the main characteristics of play mentioned

in the previous paragraph—is a sort of gratification pleasure: “The fun of practice play
is most concisely described by Buhler (1930) as Funktionslust—functional pleasure. It
is a pleasure of doing, of the act of producing an effect, not of attaining the effect or
result itself” (ibid:91).
Afterwards, in his study, the author maintains that the other two Piagetian types of
play, that is, rule-based play and symbolic play, cause the same functional pleasure in
relation to the process rather than the goals. In fact: “the goal of a game like baseball
or chess is by itself meaningless—it attains meaning and motivational value as it
is magnified by the lengthening and elaboration of the path that leads to it”. Since,
according to him, “the difference between symbolic and rule-bound games is one of
form and of the source of the patterns along which the player elaborates his action”,
the assumption also applies to symbolic play. The thesis maintained by the author on
the reversal of the means/ends relationship in the ludic activity is not only particularly
attractive for the underlining feature of autotelic play, but also because from here, Miller
draws arguments for the role play can assume as an adaptive function.
But another crucial aspect of the action in play is that children usually impose
constraints, obstacles, limitations to their play activities, in order to make them more
interesting, more fun. Acting is more desirable if it is imposed by oneself: “But clearly
there is somehow something very desirable about acting, at least for a time, in a
framework designed by ourselves rather than by the existential forces that run most
of our life” (ibid:97).
Ellis views play as a word useful to “categorize behaviours that elevate arousal”
(Ellis, 1973:107); but individuals try to assure themselves that they are in control of
those arousal-seeking processes. According to White (1959), in fact, creatures try
to position themselves within “a protected occasion that contains both familiar
and unfamiliar elements and that possesses problems or challenges they consider
intriguing or significant. In this light, play activities seem self-motivated attempts to
create and solve problems” (Henricks, 2015:2).
This is true at every level and in every type of play, ending up an interesting
element of the feeling of challenge that pertains to play, and constituting for some
authors, first of all Sutton-Smith (2008), one of the numerous ‘dual’ or better yet
‘dualudic’ elements that form the ‘multiplex functions’ of play.
A fundamental factor of play of huge significance, perhaps the first one that comes
immediately to mind when talking about children’s play, is the role of imagination
and fantasy, of the ‘pretend’, or the symbol if you want. In short, we might say, the
relationship between the real and the unreal; or, in Erikson’s words, “a step sidewards
into another reality”19 (Erikson, 1963:221-222).

19 Actually, this sentence refers to the play of adults; the author, in fact, continues: “The playing adult
steps sideward into another reality; the playing child advances forward to new stages of mastery”.
18   The Need for Play for the Sake of Play

The importance of symbolic in play for Piaget is well known, and so much
so as to induce him to devote an entire stage of child’s play; he considers it as an
inevitable consequence of the fact that play is driven by the process of assimilation,20
and that among the attributes of the latter, there is distortion: “as soon as we leave
the sensorimotor level to the representational thought” (Piaget, 1976:679) the
phenomenon of symbolism manifests itself.
Unlike the previous stage—practice play—symbolic play gradually disengages
from the frequent link with repetition, and some daily behaviours appear unrelated
to their original purpose, simply by evocation. Repetition without a purpose is used
to disengage the representation from the evocative situation, and then to be free to
combine the representations in a form that anticipates thought.
The schemes drawn from real life are first applied to inadequate objects and later
evoked, up to the consciousness of ‘pretend’; symbolic play “marks the primacy of
the representation both on the action and on the perception as well as of the meaning
on the object” (Bondioli, 2002:411). There cannot be pretence before the birth of the
representation; it is from pretend play that the real symbol, the language, as well
as human creativity, a free combination of symbols, metaphorical transformation of
reality, will arise.
However, there is an undeniable relationship, for Piaget, between practice play and
symbolic play: “symbolic play is to practice play how the representative intelligence is
to sensorimotor intelligence. This matching at two different levels should be added to
another at the same level: symbolic play is to representative intelligence how practice
play is to sensorimotor intelligence” (Piaget, 1976:690).
Vygotskij (1967; 2004) does not like the expression ‘symbolic play’ because it is too
tied to the semiotic meaning of ‘sign’, which tends to intellectualise the construct and
overly emphasises the cognitive aspects of play, while neglecting the circumstances
and motivation. He rather prefers to use the concept of imagination: in establishing
some criteria for distinguishing the play of a child from other forms of activity, he
concludes that, in play, the child creates an imaginary situation; this is not considered
a type of play, but the peculiar characteristic of play in general.
Play is a ‘transitional stage’ in the development of imagination; in this way,
Vygotskij totally reverses a common previous belief that imagination precedes play:
“Imagination is a new formation that is not present in the consciousness of the very
young child, is totally absent in animals, and represents a specific human form of

20 Assimilation and accommodation are, for Piaget, the two processes that govern the child’s adapta-
tion to the environment. Assimilation is the incorporation of an event or an object in a behavioural or
cognitive pattern already acquired (for example, the child uses the tail of a puppet like a pillow to lean
his or her head on and pretend to sleep). Accommodation guides the modification of the cognitive
structure or of the behavioural pattern to include new objects or events yet unknown (e.g., to change
a gripping method, to change an approach to a problem). Assimilation and accommodation take turns
in search of the necessary homeostasis in the relationship with the environment.
 Fundamentals of Play   19

conscious activity. Like all functions of consciousness, it originally arises from action.
The old adage that children’s play is imagination in action can be reversed: we can say
that imagination in adolescents and schoolchildren is play without action” (Vygotskij,
1967:8).
Play is not driven by the symbol, but by desires; the child realises them, puts them
into practice, and in this way, the basic categories of reality pass through his or her
experience. While thinking, desiring, the child acts. Internal and external action are
inseparable: imagination, interpretation, and will are the internal processes brought
about by external action; soon the child will not need an object to play, the meaning
of the action will become dominant over the real action. This is the way to develop
abstract thinking, but also of the will and the ability to choose.
Some objects, however, at least according to Winnicott (1971), are not like the
others because they play a special role in the child’s development: these objects are
symbols, in the sense that they are for something else, namely they ‘stand for’ the
child’s mother. They are called transitional objects, and during early childhood,
are treated by the child in a special way: they cannot be changed or removed, must
be concrete, have a separate existence for the child, but at the same time, they are
part of that child. With these objects, the child establishes a relationship, consisting
actions that, on the one hand, lets him or her enter the play world, and on the other,
allows him or her to experience separation and distance from his or her mother, by
representing her through this symbol. It is an object of ‘transition’, in fact, between
self and non-self, between the real and the imagined, just like in make-believe play,
where objects are something different and are animated. For Winnicott “the symbolic
act is a creative one, that defines a particular dimension of the experience, somewhere
between purely subjective reality and objective reality” (Bondioli, 2002:72). The
symbolic makes it possible to separate these two worlds and to create a third one,
called by Winnicott ‘play space’ and ‘illusion space’ (once again in-lusio), a space of
the experience that is not given, but is created by the child, as a product of his or her
mental activity and of his or her action on reality.
Rules are the fourth fundamental factor of play to be considered: how they arise,
their detection, and their role in the child’s play development.
One of the basic lines of demarcation in the interpretation of play between the two
giants of the field, Piaget and Vygotskij, for example, is placed precisely on this point.
For Piaget, according to his theory of child development, pretend play or symbolic
play is not based on rules, because the rule is grafted on social skills—for example
of bargaining and mediation—which occur only when the phase of egocentrism has
been surpassed. Consistently, the author singles out ‘rule-based play’ as a standalone
play stage, the last one in the hierarchy he proposes.
One rule, for Piaget, can exist on an individual basis—thus, it can be changed
at will—and has an objectual content (e.g., making a certain number of steps before
throwing a ball), or it can have a social basis and result from an agreement between
the players, who find a compromise between different wills and intentions—and
20   The Need for Play for the Sake of Play

therefore, it has a binding value. Both types of rules are based on conventionality;
thus, they are not compatible with pretend play, which cannot be guided by rules, as
it has a subjective nature.
However, Piaget seems to remain isolated with respect to other scholars: in
fact, according to Huizinga, for example, every type of play, even pretend play, is
characterised by rules: “Rule creates the typical magic circle of play, it allows you
to separate the ludic actions from the not-ludic ones, thus creating the inlusio, the
feeling of “being in play” (Bondioli, 2002). And Caillois, who keeps the Piagetian
meaning of a rule as a convention, however, considers that, in make-believe play, the
meaning of ‘as if’ is to replace the rule and to fulfil the same function.
Vygotskij’s position is completely antithetical to Piaget’s: the rule is intrinsic to both
rule-based play and pretend play;21 it has an important psycho-developmental function,
but also a critical and direct influence on the effectiveness and success of the ludic
activity. In fact, it obliges the child not to follow his or her immediate impulses, even by
acting against them: within competition games, one must submit to data constraints,
in pretend play “the action is subject to the meaning, while, in real life, the action wins
out over meaning” (Vygotskij, 1976:552). Thus, Vygotskij can state that, in play, freedom
is only illusory: “While playing, children are free, they determine their actions starting
from their self. But [...] their actions are subject to a well-defined meaning, and they act
according to the meanings of things” (ibidem). For example, the child does not eat a
piece of candy if within the play activity it is considered poisoned.
However, self-control of the immediate impulses has a direct consequence on the
play activity: “It is in fact through the line of maximum resistance—self-submitting
to the rule of giving up spontaneous and impulsive actions—that the maximum of
pleasure is achieved in play” (Bondioli, 2002:31). For Vygotskij, “the essential attribute
in play is a rule that has become a desire. Spinoza’s notion of ‘an idea that has become
a desire, a concept that has turned into a passion’ has its prototype in play, which is
the realm of spontaneity and freedom” (Garvey, 1976:580). Play gives the child a new
form of desires, it shows him or her how to relate his or her desires with a dummy ‘I’,
with its role in the play activity and with the play rules.
Obviously, the theme of the rule recalls the classical division between play and
game. For Geertz (1973) and Caillois, play could result in the game being predominantly
made up of rules: “Tout jeux est système de règles... ces conventions sont à la fois
arbitraires, impératives et sans appel. Elles ne peuvent être violées sous aucun
prétexte, sous peine que le jeu prenne fin sur-le-champ et se trouve détruit par le
fait même” (Caillois, 1967; préface). Bateson and Winnicott, however, were primarily
interested in the playful dimension of play: “Let’s look at what is good and what is
bad about ‘playing’ and ‘games’. First of all, I don’t mind—not much—about winning

21 Instead, the sensorimotor play of the child’s first 3 years remains, according to Vygotskij, without
rules.
 Fundamentals of Play   21

or losing” (Bateson, 1972:14). Bateson does not play to win, but to create; rules exist
because they can be broken and put us in trouble: this is the gist of play, trying to get
out of it and finding out which rules are obeyed while playing.
Avedon and Sutton-Smith (1971) described play as a behaviour characterised by
the interest in the actions in se, per se, in which the goal is secondary, individual
and not durable; games, on the contrary, have rules and specific purposes and are
characterised by repeatable patterns and predictable results. Between game and play,
there isn’t a relationship during human development because at any age, the child
can be involved in play or in games.
Bettelheim (1972; 1984) instead makes a separation; first comes play with self-
imposed rules, which does not produce intentional results in the external reality, then
the games, which are characterised by agreed-upon rules, often imposed externally,
by the need to use tools for their intended use and not by imagination. If the examples
of play and games made by Bettelheim make reference to the distinction between
pretend play and rule-based play, their respective characteristics are similar to those
of Avedon and Sutton-Smith. Also, the transition from play to game seems to be
inspired, according to Vygotskij, by an increase in impulse control, by the acquisition
of the sense of reality, and social adaptation. Finally, for Bettelheim, games are social
materials with an institutional existence; they are a part of tradition and culture.
The fifth characteristic of play concerns the social aspects of play, that were
already mentioned here, and in particular, were introduced by the Batesonian
construct of ‘frame’. This theme opens at least two lines of study: on the one hand,
the fact that children learn to play, in dual relationships or in group: with siblings,
peers, but also with parents and adults.22 On the other, because most of the types and
modes of play create and require social contexts.
Starting from this last aspect, Coplan et al. suggest that play involving dyads or
groups can be defined ‘social’ when the child “(a) is motivated to engage others in
playful activities; (b) is able to regulate emotional arousal; (c) possesses the skills
necessarily to initiate interactions with another child, such that; (d) the social
overtures are accepted in kind” (Coplan et  al., 2015:96). Any possible type of play
can take place with a social mode; “it also comprises active conversations between
children as they go about interacting with each other, negotiating play roles and game
rules”. On the contrary, “non-social play is defined as the display of solitary activities
and behaviours in the presence of other potential play partners”. Taxonomies of
social play exist; the best known and used in the field have been developed by Parten
(1932).23

22 Including education in formal, non-formal, and informal contexts, for example, the available
means of communication.
23 It is based on the following four categories: (1) unoccupied behaviour; (2) onlooker behaviour;
(3) solitary play; (4) parallel play.
22   The Need for Play for the Sake of Play

The importance of the involvement of peers has always been valued in the sector
studies; Piaget, for example, “suggested exposure to instances of interpersonal
differences of opinion and thought with one’s peers (as opposed to interactions with
adults) and opportunities for discussion and negotiation about these differences,
aided children in the acquisition and development of sensitive perspective-taking
skills in interpersonal relationships” (Coplan et al., 2015:99).
This somehow echoes Garvey’s definition, which states the social game as “a
condition of commitment, in which the successive and abstract behaviours of a partner
are contingent to the abstract behaviours of the other. [...] This means leaving space in
one’s behaviour to the reactions of the other and changing one’s own behaviours as a
result of the actions of the other” (Garvey, 1976:697).24
Peer interaction through play has been considered crucial also for the
development of the self-system: “exchanges among peers, in the contexts of
cooperation, competition, conflict, and friendly discussion, allowed the child to gain
an understanding of the self as both subject and object (the notion of ‘looking glass
self’)” (Coplan et al., 2015:99).25
Sullivan (1953) proposed that experiences within the peer group are essential for
the development of skills of cooperation, compromise, empathy, and altruism and for
the acquisition and maintenance of important social skills of the adult’s life. Recent
research perspectives focus on the development of children who rarely engage others
in social play (Göncü & Gaskins, 2011).
There are marked differences among children in their willingness to engage in
social play and in the degree to which they are motivated to take part in peer play.
Individual differences are influenced by increasing age, but also by “dispositional
characteristics (e.g., temperament, sex), social motivations, social competence”
(Coplan et al., 2015:100) and by culture and parental influence.
The influence of a good, supportive, and loving family environment is vital for
play to appear in a child’s life: Spitz’s studies on orphanages (1945) showed that
contexts lacking meaningful relationships, care, and emotional support caused
serious deprivations in children, even in play. Caring parents know immediately that
their child feels pleasure in being stimulated, so they propose the game of ‘Cuckoo’;
they throw him or her in the air; they surprise him or her with unexpected playful
gestures; later they inspire him or her to play, so that he or she can learn; they offer
him or her suitable objects, new, different in shape and colour (Petrie, 1987); they also

24 According to him, four possible conditions can be drawn when only two children are together:
the non-social game (both can work together to mend a broken toy); the non-game non-social (one or
both of them may independently examine an object); playing non-social (one or both can engage in
imaginative activity independently); the social game (both are mutually engaged in a shared activity).
25 The reference here is to C. H. Cooley’s notion of ‘looking glass self’ as reported in Mead, G. H.
(1934). Mind, Self and Society. Chicago: University of Chicago Press.
 Fundamentals of Play   23

present them as animating characters; thus, providing an opportunity for starting the
pretend play.
Many studies (Schaffer, 1977) led to the belief that children learn to play,
especially “by playing with an adult who shows to share the play and the inherent
pleasure” (Bondioli, 2002:105). Adults, mothers in the first place, convey to the child
the idea that actions can be carried out in many ways, including the pretend one, that
objects can represent something else, and that it is possible to do something just to
take pleasure in doing it together.
The child’s first play activities, ritualised and repetitive, are common in many
cultures (playing to hide parts of one’s face or objects, performing a series of rhythmic
actions on the child’s body up to a fast closing and full of excitement, capturing the
child’s interest and increasing his or her attention time, and so on).
If, at first, the adult is the protagonist and the child the spectator, the roles are
reversed quite quickly;26 this process takes place, thanks to the gradual withdrawal
of the adults from their preeminent role, while in the meantime, the child becomes
able to promote the ludic activity. Then finally, the adult acts as a mediator of a ludic
contact with other children, suggesting and facilitating connections among peers in
play.
One of the areas in which the role of the adult as a prompter in play that has
been studied in the literature, is role-playing,27 which is founded and managed on the
transmission of scripts; according to Garvey (1982), the required skills in social role-
playing are suggested following a modelling procedure that takes place in the home
environment: children “in this way should have the occasion to learn: conventional
sounds associated with certain gestures of ‘pretend play’, personification and
animation of dolls, specific communication techniques to indicate the make-believe,
a processing in a non-literal perspective of roles, scripts and ludic plots” (Bondioli,
2002:111). Also, in this case, the adult gradually disengages from play, becoming just
a spectator and intervening if anything to provide new scripts and to introduce more
complex ideas (e.g., a state of health of the doll, an unexpected event).
Haight carried out an interesting study on the direct and indirect influence of
adults on child’s play, and pretend play in particular. Her literature analysis on this
theme makes it possible to assert that “parent-child pretend play is a potentially rich
context for the socialization and acquisition of cultural meaning” (Haight, 1998:262);
parents follow different ways to support their children’s play: they can teach them

26 Sutton-Smith (1979) indicated the following: 1) routine of exchange, the adult imitates the child
and vice versa; 2) the central person’s routine: the adult acts, the child serves as co-actor and routine
in unison, the actions happen together; 3) the child does something on adult who pretends to with-
draw offended, surprised, or scared.
27 Role-playing is an expression that can correspond to different meanings and techniques. In the
case of children’s play, make-believe can be considered a kind of role playing, whereas they adopt a
role—a teacher, a doctor, and so on—and act out as characters in this role.
24   The Need for Play for the Sake of Play

how to pretend, introduce the pretend mode, elaborate “upon their toddlers early
forays into the non-literal”; they also used to encourage children to be enthusiastic
about pretend play. However, she also found significant cultural differences, so she
concludes: “before advocating parent-child play, practitioners must consider the
cultural appropriateness of adult-child play, adults’ own preferences for interaction
with children, as well as other play and nonplay contexts that may promote similar
developmental outcomes” (ibidem).
The research of O’Connell and Bretherton (1984) indicates that children’s play is
less repetitive, more advanced, and less fragmented initially when they play with an
adult rather than with a peer; furthermore, in this case, play can be enriched as to its
variety, level, and duration.
In particular, it is interesting to note that though mothers cannot tailor their
proposals to the child’s potential, they naturally offer a range of possibilities from
which the child draws freely, according to his or her wishes and possibilities.
Indispensible elements to support the child’s play seems to be emotional support,
encouragement, effective participation in recreational settings; furthermore, the
interaction style must maintain a delicate balance between stimulation and non-
interference.
The last, but really not the least, characteristic of play considered here concerns
the fact that its capacity to evolve in childhood; the child’s play modalities, the
proposals he or she advances or to whom he or she is able to answer, the areas of
interest he or she develops, and in correlation, the ludic activities he or she does,
change over time, from birth to 18 years.28 The study of this evolution has involved all
scholars in the field, who have proposed different classifications, identifying types
and categories of play in correlation with the respective epistemological frameworks
of reference.
A careful and detailed examination of proposed classifications of play is presented
in this text, Chapter 3, which should be consulted for a more in-depth analysis.
Therefore, the development of play is still considered a useful indicator of a
child’s development, and to such a degree that it is also used as a diagnostic tool in
some cases to identify growth-related problems.
What is worth noting here is the contrast between two main approaches: on the
one hand, that of the successive stages of play—of which the Piagetian one is certainly
the best known—which proposes a hierarchical alternation between the stages of
play; each stage develops and grows in complexity, then exhausts its developmental
function for the individual and is replaced by the following one, which in turn

28 The theme of the relationship between the concepts of play and the concepts of time was dis-
cussed in an original way by Henricks (2009). According to this approach, we are undoubtedly refer-
ring here to the concept of ‘play as progress’. A detailed examination of studies about the evolution of
play is presented in Chapter 3.
 Fundamentals of Play   25

maintains with the previous one more or less direct and recognisable relationship;
and on the other hand, there is the approach inspired by cultural psychology and
then by constructivism, that while identifying an evolution—not rigidly hierarchical—
in characteristics, types, and degrees of complexity of children’s play, enhances the
value of inter-individual variability, avoids the correlation between type of play, and
predefined chronological ages of the child and does not support the idea of a linear
progression between stages (Rubin et al., 1983). Moreover, it points out the influence
of many concomitant factors, and not only of the cognitive ones: desires, volitions,
emotions, experiences, and social contexts of life.29
In the first case, play is connected to an epistemology which provides “invariant
and qualitative different stages of development; such stages are typically cumulative,
in that later ones build off earlier levels. Furthermore, later stages are thought to be
more complex, rationally controlled and abstract. Indeed, human development itself
is sometimes equated to the creation and maintenance of personal schemas that
feature increasing degrees of integration and control” (Henricks, 2009:16).
Play develops and proceeds from stage to stage, according to Piaget, substantially
thanks to intellectual development, with which it is considered closely related, since
its inception.
The practice play of infancy becomes “more sophisticated as the child’s ability
to act intelligently develops. When children’s sensory-motor schemes become
sufficiently coordinated to construct the concept of object permanence, the ability
to represent absent realities becomes possible” (De Lisi, 2015:235). During growth,
“intellectual development from early to late childhood includes an increasing ability
to mentally coordinate concepts that are needed to adapt to the natural, physical and
social worlds. These changes have an effect on children’s symbolic play. As children
come to understand the importance of reciprocity in relationships (especially as
experienced in peer relationships), they develop a deeper understanding of the
necessity to conform to social rules and conventions, including following the rules in
games” (ibidem).
The second case can be found typically in Vygotskij’s original interpretation. His
core idea is that “the history of human development is a complex interplay between
the processes of natural development that are determined biologically and the
processes of cultural development brought about by the interaction of the growing
individual with other people” (Bodrova & Leong, 2015:204).
Vygotskij explains exactly this way the birth and development of high mental
functions, in his view poorly studied by earlier theories: they appear and are built
first within social relations in which the child is immersed, and secondly, they
become psychological and biological functions of the individual. To put it directly in

29 An interesting analysis of the concept of ‘stage’ in the constructivist epistemology can be found
in Marshall (2009).
26   The Need for Play for the Sake of Play

his own words: “Every function in the cultural development of the child appears on
the stage twice, in two planes, first, the social, then the psychological, first between
people as an ‘inter’ mental category, then within the child as ‘intra’ mental category.
This pertains equally to voluntary attention, to logical memory, to the formation of
concepts and to the development of will” (Vygotskij, 1997:136).
It is exactly the role played by the social context and relationships that belong
to it that allows Vygotskij to lay the foundations for one of the most famous and
compelling concepts of his entire theoretical framework: “the Zone of Proximal
Development (ZPD) [which is] the distance between the level of independent
performance and the level of assisted performance” (Bodrova & Leong, 2015:206).
Vygotskij’s idea is that play creates the ZPD of a child, and that play is the leading
activity for children of preschool and kindergarten age.30 Within the ZPD, the entire
child’s development takes place, and in this sense, it is possible to state that it is play
that creates development.
The study of the evolutionary nature of play and the analysis of its effective
evolution in subsequent stages have always attracted scholars in the field. The
three typologies proposed by Piaget have formed an essential basis for everyone,
to break it away and articulate it, making it more comprehensive and complex. The
classifications of the types of play, whether or not included in the frameworks of child
development, are now numerous, and are treated in more detail in Chapter 3.
The flourishing of these proposals appears to be due to a latent dissatisfaction
with the completeness of the existing classifications; thanks to the careful observation
of children’s play lasting decades, radical ruptures between one stage (or type) and
another cannot be acceptable, because they seem rather to merge, each feeding the
other, to resurrect in different forms, in different times of life; and yet educators,
psychologists, and experts in general in the play field feel the need to have, know,
and distinguish them.
Some examples may be useful to highlight these aspects.
The baby’s body is certainly one of the first objects with which he or she plays
(Garner & Bergen, 2015), during the stage of practice play: his or her own feet, his
or her own hands assume for him or her a special interest, because they can act, set
in motion, and provoke interesting feelings; this play becomes more complex in the
following months, as the body comes in contact with the world that must be explored,
crossed. But later, much later, the body itself will become a symbol, when it will be
used to imitate the actions of the adults at a distance, or even later when it is masked
or brought on a stage, moving towards a more frankly symbolic phase.

30 “This laid the foundation of the theories of play developed by the so-called post-Vygotskian schol-
ars. […] all these theories put emphasis on play not as a reflection of past experiences but rather as the
activity essential for the development of a ‘future child’” (Bodrova & Leong, 2015:207).
 Fundamentals of Play   27

The constructive game, from Smilansky on (1968), has acquired—despite some

controversy—the dignity of a special type of play, creeping in between practice
play and symbolic play: it requires complex psychomotor skills—both for precisely
managing small elements to be assembled as in the case of Lego bricks, and for
giving life to toys and real worlds, for example, a rudimentary canoe, a platform on
a tree—which cannot be included within the group of the approximate abilities of
practice play; and it also, very often, requires an ability to hypothesise work plans,
monitor their implementation, if necessary, undo and redo again. In the case of
creating worlds with their own characters and stories, constructive play intertwines
with symbolic play and adopts the peculiarities of this play type, becoming, perhaps,
something else.
Another possible example is exercise, exploratory and gym play with the abilities
of the body that the child demonstrates on the playground: this can only be classified
as practice play, because new psychomotor skills are continuously refined during
actions and in relationship with objects of different shapes and nature; yet, it engages
children of all ages, sometimes it even becomes an enticement for adults. When it
assumes the form of a race or a competition, it also makes use of rules that can be
agreed upon or the result of mediation.
Moreover, most of the video games, and some so-called ‘educational games’
for early childhood, are merely practice play applied to a task: to perfectly carry out
coordinated fine, sometimes minimal movements; from the cognitive point of view,
they propose the endless repetition of the solution to the same problem.31 In some
cases, these over-specialised psychomotor skills can be used to play video games with
rules and strategies.
Caillois’ proposal (1958) can be considered, at least partially, consonant
with the need not to consider the types of play as rigidly determined; certainly
it stands out among other proposals for its originality and impressive reach. His
well-known taxonomy does not concern the types of play, but rather the player’s
disposition. The four identified dimensions are not mutually exclusive, but rather
can be present together and aspire to exhaust all possible types of play: agon, or
competition (the play done by two or more participants, where there is someone
who wins and someone who loses: running, playing ball, wrestling, billiards,
chess); alea, or chance (again, play involving a number of persons, but based on
the role of chance: to see who is going to be ‘it’, bingo, lottery, gambling); mimos,
or imitation, simulacrum (pretending, masks, theatre); ilinx, or vertigo, vortex (the
swing, dancing, mountain climbing). These four dimensions are moving, however,

31 This is the case of toys like ‘Sapientino’, which awards the association between the same pairs—for
example, of images—but also of many electronic games and the so-called educational software based
merely on the relationship between cause and effect (push a button, turn a lever, select an area of the
monitor to achieve a given and known scope).
28   The Need for Play for the Sake of Play

along two fundamental and different levels of tension, to ‘being in the play’: they are
paidia—a ‘first, primary freedom’, the unrestrained imagination typical of younger
children, but existing in varying degrees in any recreational activity—and ludus—
rule-based play, more related to adulthood; however, the two levels are placed at
opposite ends of a continuum, and all play activities will include different grades of
these dimensions, mixing them.
The proposal of Caillois offers a series of elements that can be combined in various
sizes and degrees of intensity of the personal involvement. But it does not take into
account directly and specifically the issue of play development, of the changes it
undergoes during the individual’s life.
The identification of different types of play, their emergence in different periods
of the individual’s development, together with their growing complexities and
intertwining over time are matters of specific interest for those wishing to explore play
as a specific topic of interest in the field of education—and in case of children with
disabilities, also of rehabilitation. A deeper awareness on the play development, in
fact, gives the educators and the adults in general the opportunity to knowingly extend
the proposals of play activities, as to the settings, the mediators, the relationships,
and of course, the type and the complexity.
Summarising here the strengths of the existing proposals and the analysed
criticisms, one might conclude that a model of interpretation and classification
organised in stages, while having the advantage of identifying types, with perspicuity,
that are now consolidated in the literature, also introduces a rigidity in the analysis of
the phenomenon—for example, the clearly defined stages associated with a specific
chronological age, stable and unique over time—for which it is not possible to really
understand it and to use it effectively.
It seems more effective and productive to adopt a model that, based on the four
main types today—in principle—shared in the field,32 makes it possible to respect and
safeguard the following data: a) in case of regular conditions of development, and
environmental or socio-cultural contexts, each type has a peculiar onset in a precise
developmental age; b) there is a characteristic progression between the types of play,
during development; c) environmental contexts or other technological innovations
may give rise to new types of play, which are an amalgam between those already
known, with varying degrees of involvement of their characteristics, or different
degrees of use of the related skills; d) the types of play can coexist in different
stages of life; e) each type of play can be reactivated, reveal itself anew, in different
developmental stages, remodelled and recontextualised or simply reproduced by
pure ludic spirit.
Play requires, claims, and builds up different competences and abilities during
development; it manifests immediately, co-evolves with the child, benefits from new

32 The framework adopted by LUDI is presented in Chapter 3.

 Functions of Play   29

skills becoming more and more complex, offering increasingly greater challenges,
and stimulating the construction of new—cognitive and social—skills.
It is for this reason that the play classifications ‘in separate stages’ do not work.
They never prove there is a real separation of competences and activities between
stages because a new play stage involves the competences of the previous one without
exhausting them: on the contrary, it re-elaborates and readjusts them at a new level.
At that point, those competences are no longer the same; they are contaminated,
more complex, and new.33
A graphical representation of this proposed model would probably not be a
continuum of a unidirectional timeline, but rather a spiral line, showing the different
periods of onset, the progression of the types, their possible coexistence in time, but
also the possible contaminations between them and even the somewhat reworked
reactivations of some of them, in other periods.

1.4 Functions of Play

But why do people play? To which needs does this activity respond? Which adaptive
functions does it support, being so deeply rooted—in time and in space—stable but
also changing, transmitted, known?
Scholars have always wondered about the meaning and purpose of this activity,
and have advanced explanations on its ultimate meaning, particularly on its role in
child’s development, where it seems to take precedence and have special meaning.
The ludic activity has been mainly studied not “’as such’, but as a ‘symptom’ or a sign
of the peculiarity of the infant psyche or mind; play is a paradigmatic phenomenon
that sheds light into the world of childhood” (Bondioli, 2009:19).
From time to time, according to an essentially reductionist approach,34 various
functions of play have been highlighted (and will be shortly presented in this
paragraph): the biological-adaptive, the cognitive, and the socio-relational, the
psycho-emotional.
Some functions of play will now be described and analysed: understanding the
possible reasons of play, perceiving the functions it performs in human development,

33 A reference to the representational redescription proposed by Karmiloff Smith (1992) can be
found in this description of the evolution of play, as in other expressions of human development, it
is possible here to recognise the role played by this process: an alternation between the acquisition
of competences, their representative metabolisation and their re-use with a new awareness and new
effectiveness.
34 According to Bondioli, the assumption of play within the theories of development meets the cri-
ticism of reductionism; in fact, some aspects of the phenomenon are emphasised and used so as to
show or prove, following an analogical procedure, some aspects of the epistemological and interpre-
tative models that the different authors would adopt (Bondioli, 2009:19).
30   The Need for Play for the Sake of Play

can provide support and nourishment to the educational field, including the area of
disability.
Almost all researchers mention that the ludic activity does not belong only to
human beings, and that some classes of animals35 devote part of their time, especially
puppies, to play in pairs or in groups, with adults and peers. Often these kinds of
play involve the carrying out—but in a less precise, less powerful, and less realistic
manner—of the animals’ daily life movements and actions: fighting, taking care of
their puppies, and so on.
These considerations suggested to many authors the idea that play should have
a useful role in ontogenesis, and also in phylogeny; for Kant, it would serve to train
the child in activities that ensure preservation of the organism; for Claparède, it
is a sort of preparatory exercise; for Groos, an activity able to test skills useful for
environmental adaptation; for Fröbel, the expression of the innate creative attitude of
human beings—thus almost already a job—and for Carr, a complementary exercise to
maintain useful habits that otherwise would disappear.
According to Lorenz, play has an adaptive function to explore new situations in
new environments, looking for optimal solutions. Miller, in a more systematic way,
comes to a similar conclusion: starting from the study of baboons, he claims that play
serves to provide a flexible substrate to the individual’s cognitive system: “a general
ability to produce the novel, an ability that is surely as important to survival as the
ability to produce the expected”. When people spend their time immersed in a game,
“they are creating novelty, however unimposing it might be […]. It is the habit of
occasionally creating novelty, rather than specific preparation, that makes us seem
intelligent when, confronted with a new problem, a new contingency in ‘reality’,
we have more than a random chance of marshalling the means at our disposal in a
hitherto useless but now adaptive way” (Miller, 1973:96). It cannot be overlooked that
Sutton-Smith (1997) argues that “as a form of mental feedback, play might nullify
the rigidity that sets in after successful adaption, thus reinforcing animal and human
variability”.
Also, Huizinga (1938) starts his discourse from the animal experience, noting,
however, that play goes beyond the limits of biological experience, as it is a function
that contains a meaning; it characterises the homo ludens, as a cultural animal: culture
itself rises in a playful shape, culture is first played. Play would have the original
function of being a creator of culture; it opens up the possibility, exquisitely human,

35 Today, ethologists claim that only in the classes of mammals and birds, it is possible to find play as
such. Social play is the most common among animals (grapple fights, chases, forms of sexual behavi-
ours, rearing offspring, and so on). Individual play consists exploration and manipulation of objects,
motor acrobatics, and pursuits of preys (real and fictional). Apes, if raised in contact with human
beings, play in an unusual manner, such as making funny faces in front of a mirror, walking while co-
vering their eyes with a hand to make it more difficult to walk on suspended logs, and doing complex
play activities with objects.
 Functions of Play   31

to attribute meanings, to comment, making it possible to develop art, science, history,

humour. “Not so much rules, behaviour and social roles would be learned through
play, but rather the fact that any behaviour has its own context, that it is culturally
determined” (Bondioli, 2002:56).
This cultural context, seen, however, exactly as a frame of roles and behaviours,
is the interpretation proposed by Bateson: what the child learns from play is not how
to behave according to certain rules or roles, but rather that there are types of roles
and categories of rules. The child acquires knowledge about the possible roles and
styles of behaviour and acquires flexibility regarding the ability to choose and adopt
different styles in relation to different frameworks or contexts of behaviour.
The function of play to support sensorimotor development has been emphasised
since the earliest field studies: the exploration and use of objects—including one’s
own body—typical of the practice play stage, allow the child to refine sensorimotor
coordination and its control, through feedback, hence stabilising processes that
gradually become automatic; manipulation and construction of objects become
gradually more and more linked to the achievement of objectives and to the action
on the surrounding world, thus promoting the use of mental patterns of planning,
while manual coordination becomes refined and precise, quickly opening the road
to constructive play. Exploration and action on objects create a new mobility of
knowledge patterns, which is of great importance for psychological growth.
In these activities, the child always tends to reach greater skills in using objects
that attract his or her attention and interest, and for this purpose, he or she constantly
alternates tireless repetition of the same gestures and voluntary introduction of
constraints, obstacles, and new ways to do things, thus checking the possible changes
in the gestures themselves.
Play has also been seen as an engine for cognitive development, in all its facets.
Symbolic play carries out, in this regard, an important function, because it is the
evidence of the birth of thought, which detaches from the concrete and the real to
start imagination and fancy; it forms the substrate for the development of higher
symbolic functions: language, graphical representation, narrative ability.
An interesting aspect of symbolic play—highlighted by Vygotskij—is the fact that
it is already sensitive to the effects of rules: players adhere to the constraints of the
‘pretend’, enter in a scheme that is ‘other’ than reality: and this requires the control
of two different contexts—reality and pretending—with their respective differences
in roles and behavioural patterns; “pretending or not pretending is an experiential
duality; [...] these pretend ludic worlds will educate the players in the semantics of
the subjective-objective duality destined to occupy their minds forever afterwards”
(Sutton-Smith, 2008:119).
Important consequences derive from the symbolic transformation of the real; in
particular, the nature and function of play conventions can be learned or reinvented:
rule-based play becomes gradually, among the other types of play, the more complex
and abstract one, with regard to the cognitive domain; play turns into games, until it
32   The Need for Play for the Sake of Play

is possible to manage entire systems of rules, including strategy and planning games.
Moreover, according to Bruner (1986), while teaching, conventions play can teach
skills useful for growth and becoming an adult.
However, symbolic play and rule-based play also highlight another fundamental
aspect of play, the development of social skills. More than the others, these types of
play, in fact, open up to social relationships, dual or in group, thus to the ability to
share, mediate, recognise, and adhere to social conventions; at this stage, social
adaptation is also accompanied by a greater ability to control impulses and a sense
of reality.
But play is certainly not just reasoning, social life, real life. Play also belongs,
and not for a small part, to the individual’s intrapsychic world; indeed, most of the
scholars at the beginning of the last century focused on this influence of play on the
child’s psychological and emotional development, and has rekindled the interest of
researchers in recent years.36
While many authors have seen in play the natural outburst of an overload of
emotions carried by the child, for Vygotskij, on the contrary, it gives the child exactly
an opportunity to act and experiment the ability to control emotions; imagination
itself arises when it is time to ask the child to delay the achievement of immediate
pleasure. Again, rules and constraints become extraordinarily important in this case:
the pleasure associated with play, in fact, is exactly due to the restrictions voluntarily
imposed on the ludic activity. “Play would represent the ideal of Spinoza’s ‘inner rule’,
or, to quote Piaget, a rule of self-restraint and self-determination” (Bondioli, 2002:36).
Far removed from these interpretations of the function of play, in relation to
the individual’s intrapsychic development, comes from the psychoanalytic line of
research. Fear, anger, desire, love, ambition, conflict, rivalry are, according to the
psychoanalytic theory, the dynamic elements of play, without which it would have
no reason to exist. The symbolic act is a substitution act; when the young child sucks
his or her thumb even if not hungry, he or she shows one of the primitive phenomena
of transient symbolisation, which creates a bridge between the child and the mother
when their separation starts. The transitional object—a blanket, a small toy, an object
of real life—according to Winnicott’s well-known analysis, ‘stands for’ the mother
without being her: it is the first symbol in the child’s life, who perceives it at the same
time as part of him or her or self, and as separate from him or her or self, independent;
by acting on and with the object the separation process starts and proceeds.

36 Fein, for example, offers a synthesis between approaches to play oriented towards cognitive deve-
lopment and emotional development; in her opinion, around 3 years of age, a representative system
in two layers has begun developing, one for practical knowledge and the other for affective know-
ledge, which “makes it possible for the individual to become aware of his/her own inner life and to
acquire control on the way to express it” (Fein, 1987:287).
 Play and Education: the Need for Play for the Sake of Play   33

Many other scholars faced this issue, which could be called the relationship
between ‘identification’ and ‘separation’; for them, play is not interesting as a form, or as
a function, rather its contents should be the subject of interest and study, because they
consist of feelings and emotions: “play is a theatre, an enactment, in which an attempt
to integrate the emotional experience, thus the self and the world, is implemented.
[...] It is a way to cope, to control, to give meaning to the process of growth, seen as
dramatically uneven and painful” (Bondioli, 2002:77). These feelings and emotions
help the child to adapt to reality and deal with the problems that he or she encounters in
real life: “This is an experience that allows the child to check his/her phantasmal events
and vicissitudes, on a manipulated and controlled reality, in an illusory dimension (and
real together), which favours both an examination of reality and the exercise of concrete
skills with a focus on adaptation” (Fornari, 1988:138).
Winnicott describes this path, which develops through the exploration, the knowledge
and the use of objects, but above all, through transactional objects, as a passage from
“a state of total fusion with the mother to one in which the child begins to be aware of
his/her individuality; [...] from a state of primary integration, in which everything that
will became later an ‘I’ is a set of fragmented and disconnected sensations, to a state of
integration, characterized by the perception of having an ‘inside’ and an ‘outside’; [...]
from a state of absolute dependence (viewed nonetheless as omnipotence) to a state
of independence (which involves awareness of limits and dependence). It is a journey
which, while leading to the construction and the discovery of the self, also enables the
discovery and the construction of the Other from many points of view: social (the one/s
with whom it is possible to relate), intellectual (the object of knowledge), affective (the
source of pleasure or displeasure)” (Bondioli, 2002:67).
It was Sutton-Smith to push this interpretation—in his usual ‘irreverent’ style—
up to reflecting on the consequences that the ludic activity may have in building
the individual’s feeling of independence; by playing, perhaps, the children “are
protecting themselves against varying hegemonic physical and human realities by
making fun of them with these relatively obnoxious representations. There is a kind of
courageous parody here”, to come to watch play “as at heart a kind of transcendence”
(Sutton-Smith, 2008:96).

1.5 Play and Education: the Need for Play for the Sake of Play

Play is a pedagogical topos and an explanation of childhood. The time a child devotes
to it, the intensity of his or her concentration while playing, the absoluteness of
the emotions that this activity visibly stimulates, the flexibility it demonstrates in
changing according to the variation in ages, environmental conditions, companions
and constraints, the stability with which it occurs in every geographical area, in every
era and every culture, all these features have given play a special status in this unique
period of human life called childhood.
34   The Need for Play for the Sake of Play

1.5.1 A Short Historical Overview37

Children and adults of all periods have played and have made toys. Egyptians made
dolls from cloth or majolica, as well as wooden or stone toys, while Romans made
sweets in the form of letters and invented games involving imitation and comparison.
Play was used by the Greeks and Romans as a prize following educational activities,
and the close link between school and play is also etymologically demonstrated by
the two words skholé (‘fun’, ‘leisure time’ but also ‘school’ for the Greeks) and ludus
(‘fun’ but also ‘school’—ludus schola—for the Romans).
According to Plato, to be educational, play involving children had to: favour
movement, be done in a group—in a place consecrated to the gods—mix males and
females and be supervised by nursemaids to moderate the liveliness. Furthermore,
it also must have a set of fixed rules, which make it possible to test and specify the
socialisation processes. This is a very modern attitude, and within the experimentation
of these mutual relationships among play participants lies the possibility of moral
growth.
Basically, however, in ancient times, educational attention on play focused
mainly on the development of gymnastic and sport skills and to prepare for war.38
In the Middle Ages, it was the Church that provided a strong orientation
regarding the area of play, that was considered an activity to be controlled, since it
was a possible source of moral promiscuity and some games may be dangerous for
moral development;39 play was kept under control: if on one hand, it was necessary
to educate, on the other, it was necessary to allow to vent itself because—as Fénelon
asserts—children have their own innate ‘great heat’.
Locke’s idea of play can be considered a precursor of modern pedagogy; according
to him, toys must not be purchased, but made by the children themselves: “little
stones, a pack of cards, a mother’s keys, and other similar items that they can’t hurt
themselves with are fun for children just as much as those things that are bought at
such a dear price in stores and that go bad or break in a very short time” (Locke, 1918,
orig. ed. 1693). Study should be just as fun as play, and if a child wants to continue

37 This paragraph is largely inspired by Besio (2008).

38 In more modern times, motor play has been studied mainly by Parlebas (1990), who emphasised
its relationship with specific cultural models, including rules (e.g., the game of tag). It combines af-
fectivity and the fantasies of the child and not only the motor coordination abilities, and is capable
of reaching conscious and unconscious levels. Comparative studies have been developed between
different types of games, such as football and baseball, about how they are structured from a motor
viewpoint, the role that they identify, the type of relationships that they suggest and create, and not
only because of their rules.
39 Around the 1400s, distinguishing features were making headway within the general attitude of
condemnation: there was a focus on ludus licitus, ludus tolerabilis, ludus indifferens, ludus ricreati-
on, up to ludus laudabilis that consists of the holy representations of the life of saints.
 Play and Education: the Need for Play for the Sake of Play   35

to play, it’s a sign that he or she is not yet ready to study. There is a pedagogical
advantage in the efforts children make while playing: “I thus thought that if games
were invented with a certain contrivance it would be possible to find many ways to
teach kids to read in a way that would seem almost like playing to them” (Locke, cit.).
For Fénelon (cit.), play can be functional to the needs of education, making
study more pleasurable—”let’s hide study behind the appearance of freedom and
pleasure”—then from games, we must remove everything that can make children
overly excited, or that permits the simultaneous presence of males and females: in
other words, play can make you lose your head or can be a source of sinful thoughts.40
The era of Illuminism represents the great turning point in the European
history regarding education, because pedagogy put the focus on creating citizens
and disseminating social values. The educational process must move towards the
illuminist project of citizens, who must not only understand and adapt to laws, but be
possibly capable of developing new ones.
The educational utility of play is clearer at this point: Basedow (1914, orig. ed.
1768) was the first to knowingly link play with educational activity, for example,
inventing school competitions—and many linguistic ones—in which children could
try to beat the other peers in the group and with which they could have a lot of fun;
and fun—conceived in this case mainly as a joke—was an integral part of the education
project through play.
However, it is only with Fröbel (1967, orig. ed. 1826) that play acquires its full
educational value: it stimulates the imagination and allows the child to relate with
himself or herself and with the world. To carry out these functions, play cannot be
solitary, but with a group, and must allow children to practice skills and roles that
they can adopt and do as adults. As known, Fröbel invented the mechanism of ‘gifts’
to offer to children to favour their growth that is seen as total, of body and mind
(“the body and its parts must be made capable of obeying the spirit at any time”),
growth that must take place at the same pace, following the same path (Provenzo,
2009). Thus, recreational education requires particular attention: movement and
play must be developed together and gradually at different ages. Physical strength
and moral and spiritual determination exist in a direct relationship that, through
play, can be taught. He encouraged children to engage in self-directed manipulations
of the material world, so that they can join scientific knowledge with an aesthetic
experience (Henricks, 2014).
Fröbel’s educational project is based on some fundamental features that are still
quite interesting: a) play is a planned part of the school day; the adult must not act

40 Piaget himself was interested in play as the source of moral thought, because it leads to awareness
of moral relationships in society: :The individual by himself remains egocentric. The solution lies in
a comparison among children, in their playing and working together, in the negotiation of meanings
and rules and in cooperation” (Piaget, 1980, orig. ed. 1932).
36   The Need for Play for the Sake of Play

in an authoritative manner; b) the use of structured educational materials that carry

out the explicit function of teachings; c) play must be correlated to the environment
in which it is carried out and be open to contact with nature; d) the creative and
cognitive aspects present in play must be safeguarded and nurtured at the same time;
e) the link between play and life is explicit; the recreational behaviour can become a
social behaviour.
Since Fröbel opened history’s first kindergarten in 1837 and wrote that play is
the highest phase of child development, incorporating play into early childhood
programmes has almost been synonymous with the pedagogy of the field. The
progressive school educator of the first quarter of the 20th century then built upon
Fröbel’s emphasis on the importance of play.
Then, Maria Montessori’s (1936; 1949) famous method encourages children to
play with elements that have implications for adult life, such as toy hammers, dishes,
and ovens. According to her, children desire self-guided activity with culturally
valued items instead of fantasy-based role play; they also enjoy the social validation
that comes from sharing their activities with peers. The entire educational system of
Montessori is based on the seriousness of adult work. The play impulse in children is
really a work impulse; its two main characteristics—the tendency to be active and the
tendency to be experimental—can be assets of education.
For Dewey (1910), the relationship with materials is of great importance: materials
are seen as real tools, if the situation is governed by playful spirit, which commits
them to the inherent value of what they are doing and excites their creativity. The
value of play was greatly emphasised, as something that builds the person, through
experiences but also by habits of self-directed enquiry: “In short, the grounds for
assigning play a definite place in the curriculum are intellectual and social not
matters of temporary expediency and momentary agreeableness. Without something
of the kind, it is not possible to secure the normal estate of effective learning; namely,
that knowledge-getting be an outgrowth of activities having their own end instead of
a school task” (1944:195).
Also, to Piaget, play is a way to engage children in the learning process: “This is
why play is such a powerful lever in the learning process of very young children and
to such an extent that whenever anyone can succeed in transforming their first steps
in reading, arithmetic or spelling into a game, you will see they become passionately
absorbed in these occupations which are ordinarily presented as dreary chores”
(Piaget, 1972:155).
The consequences of adopting play in the educational process are, for Vygotskij,
not so subservient to fragmented aspects of learning, but rather related to the child’s
development ‘per se’, as play is a leading factor in development: “Children’s great
achievements are possible in play, achievements that tomorrow will become their
basic level of real action and morality” (Vygotskij, 1978:100).
 Play and Education: the Need for Play for the Sake of Play   37

1.5.2 The Difficult Relationship Between Play and Education: Controlling Play41

Where does the relationship between infant play activity and learning begin? Is it
possible to have fun while learning? Can teaching be made fun? And, is it beneficial
to make learning fun? What is the difference between play in other contexts and play
in educational contexts? Is it possible to teach how to play, without having in mind
teaching something other than play?
In what follows, an attempt is made to track the most important steps of the
relationship between play and education, which has been more controversial than
what might be expected; and it is still in this way.
Generally speaking, the scholastic context can take advantage of the instructional-
educational values shared with play: in fact, it has the ability to positively interfere
with the child’s growth factors identified as always as pedagogic objectives.
–– Cognitive development a) increases the mental reprocessing of reality (abstraction,
imagination, fantasy); b) favours the exploration of the world of possibilities
and hypotheses; c) develops creative and inventive skills and decentralisation
capacities through symbolic play; d) requires the adoption and experimentation
of planning and problem-solving strategies.
–– Emotive-affective development permits and develops: a) the expression and
control of emotions; b) a realistic awareness of self; c) personal independence.
–– Socio-relational skills favour: a) respect for the rules; b) ability to cooperate; c)
ability to mediate and negotiate.
–– Socio-cognitive development (Ashman & Conway, 1989; Bandura, 2001) influences
structuring and consolidation of a) motivation; b) self-efficiency; c) self-esteem;
d) prosociality; e) agentivity.

As seen in the previous paragraph, ‘historic’ pedagogy has focused on the value and
role of play in education and considers it as a learning mediator, even when it was
bestowed the role of a protagonist; it is since the first years of the 1900s that play
became a significant part of the early childhood school curriculum.
In the contemporary literature of the field, there is a greater awareness, which
corresponds to an important amount of studies, about the role of play as the main

41 The study of the role that play has taken in time in the pedagogical field, and above all, that it has
now in education, forms the basis for reflecting on the role that play has for the education of children
with disabilities. It should not be forgotten anyway that children with disabilities spend most of their
time in rehabilitation activities and settings. The relationship between education and the rehabilita-
tion frameworks has not been addressed clearly until now; what is clear enough is that both—edu-
cation and rehabilitation—aim for the same goal: give the child an opportunity to make positive and
useful experiences, for training new effective abilities, so positively influencing the structure of the
brain and consolidating new learning. This possibility is recently supported and deepened by neuros-
cience studies (Sandman & Kemp, 2007).
38   The Need for Play for the Sake of Play

activity of the developing child, as well as a more clear consciousness about the
different types of educational settings—formal, informal, non-formal42—with which
the child comes into contact. Moreover, one could say that for each of the different
functions of play highlighted by scholars, there is an educational-didactic or
rehabilitative-therapeutical application: so, play can become a tool to foster learning,
the privileged means to encourage socialisation, and to promote the expression of
feelings as well as their control, while in some cases, it becomes the main road to get
into the child’s inner world, providing an instrument for cure and assessment.

1.5.2.1 Play and Play-like Activities

Inevitably, however, all these interpretations and uses of play are, to some extent,
dominated by the objective for which the play activity is proposed and programmed;
while play has extraordinary educational value and can be used as an incomparable
educational ‘hook’, it undoubtedly loses some of its play features: for example,
freedom, pure ludic spirit, transgression, autonomous initiative, and autotelism.
It was the Italian pedagogist Aldo Visalberghi (1958) who systematised these
issues clearly, in a way that is still productive today for a critical reading of the existing
research in the field and for future directions. Indeed, according to him, the play
activity has the following characteristics: a) it is demanding, it requires a complete
commitment by the player;43 b) it is continuative, it develops continuously in a child’s
life;44 c) it is progressive, because it can become gradually and increasingly complex;
no play activity is exclusively repetitive and equal to itself;45 d) it envisages the end of
an activity, not requiring a continuation once the game has ended.46
Many activities carried out in schools or in educational contexts that include
learning objectives can have the appearance and even the structure of play activities
and can, of course, have amusing and fun characteristics. For these activities and
programmes, Visalberghi proposes the expression play-like. They have the same

42 According to OECD (2010): a) formal learning is always organised and structured, and has learning
objectives; from the learner’s standpoint, it is always intentional; b) informal learning is never orga-
nised, has no set objective in terms of learning outcomes, and is never intentional from the learner’s
standpoint; often it is referred to as learning by experience or just as experience; c) non-formal lear-
ning is rather organised and can have learning objectives. Such learning may occur at the initiative
of the individual, but also happens as a byproduct of more organised activities, whether or not the
activities themselves have learning objectives.
43 This point can be considered in analogy with the characteristics of commitment, intrinsic motivation,
and intensity, but also with the fundamental of doing, which creates and requires continuous challenges.
44 This theme can be connected with the evolutivity of play and with its characteristic of freedom
that permeates it entirely.
45 This aspect can be seen in relation to the fundamental of evolutivity of play and with its charac-
teristic of flexibility.
46 This argument is directly associated with ‘being in play’, the in-lusio and the framework of Bateson.
 Play and Education: the Need for Play for the Sake of Play   39

first three characteristics as the play activities, but not the fourth one, since they
do not end in themselves, but have educational objectives and a final scope, that
of learning.
Play-like activities and educational games are an integral part of the educational
life and process, which start from nursery school, and according to Scurati, can be
found also in the play-like games of pre-adolescence, which must be understood as an
authentically autotelic event (or as a phenomenon that has in itself its own scope) and
“as a mere hetero-formative device, understood as a kind of sophisticated adultistic
camouflage, a trick device” (Scurati, 2000, cited in Besio, 2008:23). In fact, in this
case, the intentionality of giving cultural contents would be so open as to impede
the real involvement of the learner, preventing him or her from getting into the play
atmosphere.
Useful signals indicating that one is in a context of ‘controlled playfulness’ or
‘goal-oriented playfulness’ are given by: well-structured relational rapports, presence
of expressed rules, and a stable guide provided by adults or educators who, in fact,
are familiar with and declare the end of the activity, and thus define its times and
procedures.
In these cases, the adult or educator can also act as a mediator between the
relationships of children to modulate the complexity of the game so that it will match
the varying level of capacities of each person, to guide the movement of the activity if
necessary by referring to the defined rules, and so on. Examples of play-like activities
and programmes can be:
a) Activities intentionally created and materials expressly used to give a fun and
pleasant form to certain types of learning actions that are considered complex—
thus requiring special concentration and reasoning—or boring because of their
repetitive nature (e.g. games such as domino or bingo to learn multiplication tables;
nursery rhymes to learn automatic series such as the alphabet or the months of
the year; attractive and fun toys to support the accomplishment of psychomotor or
cognitive activities that would be difficult otherwise).
b) L earning contexts47 and programmes proposed to groups of children—but also to
individuals—informed in a playful manner, so that the educational objectives are
part of the play situation itself even if they remain extrinsic to play (e.g., symbolic
play sessions proposed to develop the pragmatic aspects of verbal language
or to monitor the concomitant development of other symbolic competences;
construction play planned to test the child’s memory span or competence in
operating the technical aspects of building with blocks—dimensions, weights, and
so on—practice play in the playground designed to verify and improve the child’s
psychomotor abilities or balance); in other words, the play situation becomes the
best way to convey and pursue the educational objective, in any field it belongs.

47 For different contexts of learning, see also Note 38.

40   The Need for Play for the Sake of Play

c) Learning contexts and programmes created for the purpose of giving the group of
children the possibility to explore and actively adopt co-operative approaches and
techniques in working and playing together; social competence is mainly addressed
in this case for creating worthy societies: “play is inquiry into the challenges and
responsibilities of social living” (Henricks, 2015:4).

Today, the commitment to play can be found in early childhood programmes in many
different countries (Wood & Artfield, 2005). “Many programs today organize the space,
materials and time of the curriculum around a focus on children’s play (Frost et al.,
2005; Sluss, 2005). The space of the modern classroom is divided and arranged into
activity areas or centres, defining the type of play that will occur within the particular
space of the classroom. These areas or centres are then stocked with the materials
needed to support the type of play that is to occur. The typical daily schedule of early
childhood programs now also provides a designated amount of time for play, often
labelled free play time, activity time or choice time. In most cases, this is a time of the
day during which children are free to choose the area or centre in which they want to
play, and once there they are free to choose what they do with the materials available
for them in that area” (Kuschner, 2015:288-289).
Adopting Visalberghi’s systematisation, we could say that on the one hand, play-
like activities and contexts have taken the field and spread at least in the young child’s
education, while the space of play as such has been transferred and included into the
denomination ‘free play’: during free play time, the child is left free to do what he or
she wants, but this somehow weakens the play’s educational value, because it is only
considered as a free outburst (Bredekamp, 2004).48

48 An examination of the contemporary relationship between play and early childhood education
reveals, however, a paradoxical tension: “On the one hand, children’s play has long been regar-
ded as strengthening the fabric of early childhood education at child-care centers, nursery schools,
preschools, kindergartens, and the first three grades of elementary schools. Yet on the other hand,
educators of children between the ages of three to seven have sharply contested how to weave play
into classroom practice. And further, many schools now shrink from play” (Kuschner, 2015:287). The
disagreements and tensions concerning play and early childhood education are still with us today,
especially in Northern European countries; it has been noted that “in recent years, children’s play has
come under serious attack. Many preschools and elementary schools have reduced or even eliminated
playtime from their schedules” (Zigler & Bishop-Joseph, 2004:1). It seems that didactic instruction
and testing are pushing play out of the kindergarten; most forms of schooling or education are “less
interested in what comes out of the child than they are in what can be put into or transmitted to the
child” (Kuschner, 2015:287). Thus, as children play is “not just in response to external stimuli but also
in accord with internal ideas” (Berk, 1994:32), they become less curious about play. Kindergartens
are now under intense pressure to meet inappropriate expectations, including academic standards.
These expectations and policies that result from them have greatly reduced, and in some cases, obli-
terated opportunities for imaginative child initiated play in kindergarten.
 Play and Education: the Need for Play for the Sake of Play   41

1.5.2.2 The Role of Adults in Supporting a Child’s Play

Two aspects of the play-curriculum relationship have been addressed within the
research on play in the context of early childhood education. Within these studies,
play is primarily viewed as a means to foster child development in disciplinary
domains. They also gave rise to practical suggestions on “how to create math- or
literacy-rich play environments and on how to incorporate math, science or literacy
language into children’s play (Van Oers & Wardekker, 1999)” (Bodrova & Leong,
2010:2).49
Another line of play research has been done in naturalistic settings with
children engaged in free play with little or no adult guidance; it focusses on the
multiple forms that play might assume (e.g., social, pretend, or object), stressing
the fact that it is like a child-initiated activity; “these contributions are associated
with the development of broader competencies such as theory of mind (Berk et al.,
2006), symbolic representation (Rogers & Evans: 2007), and self-regulation (Miller
& Almon, 2009) that not only affect child development in early years but have a
long-lasting effect in the school years and beyond” (Bodrova & Leong, 2010:2).
Recommendations for the curriculum coming from these studies emphasise
both “the provision of adequate physical spaces and props to support play” and
“the need to allow ample time for children’s free play in the preschool daily schedule
and preserve or increase recess time for kindergartners and children in the primary
grades (Farran & Son-Yarbrough, 2001; Smirnova & Gudareva, 2004)” (Bodrova &
Leong 2010:2).
This clear separation between the study of play in educational settings and
for educational goals from one hand and the study of free play and of its possible
developmental consequences on the other is also affected by what Wood (2008)
calls “ideological commitment to free play and free choice”.
This has, however, largely lost sight of the substantial role of the adult within the
playful situations; in field studies, “while there is substantial evidence on learning
through play, there is less evidence on teaching through play” (Wood, 2009:27). The
focus should, on the contrary, shift to better understanding the distinctive purposes
and nature of play in educational settings and the role of adults in planning for play
and playfulness in child-initiated or teacher-directed activities.
The pedagogy of play “is defined broadly as the ways in which early childhood
professionals make provision for play and playful approaches to learning and

49 “One set of researchers look into the use of play elements, play environments, or play motivation
as a way to enhance instruction in core subjects such as literacy (Saracho & Spodek, 2006; Ginsburg,
2006), mathematics (Fleer, 2009; Uren & Stagnitti, 2009) or science (Dickinson, 2001), or as a way to
promote specific areas of development such as the development of children’s social-emotional com-
petencies (Connor et al., 2006), oral language (Pellegrini 2009; Pullen & Justice 2003) or gross and
fine motor skills (Lillard, 2001), etc.” (Bodrova & Leong 2010:1).
42   The Need for Play for the Sake of Play

teaching, how they design play/learning environments, and all the pedagogical
decisions, techniques and strategies they use to support or enhance learning and
teaching through play” (Wood, 2009:27).
However, the importance of home-based pedagogies of play and the ways in
which children teach themselves how to play during their self-initiated activities
should not be underestimated. According to an English large-scale longitudinal
study,50 which explored the specific pedagogical actions linking play with
positive learning outcomes (Sylva et  al., 2007), it is necessary to distinguish
between “pedagogical interactions (specific behaviours on the part of adults) and
pedagogical framing (the behind-the-scenes aspects of pedagogy which include
planning resources and routines)” (Wood, 2009:29). According to the Effective
Provision of Pre-School Education (EPPE) scholars, “the most effective (excellent)
settings provide both and achieve a balance between the opportunities provided
for children to benefit from teacher-initiated group work and the provision of freely
chosen yet potentially instructive play activities” (EPPE, 2002:43).
“Indicators of effective pedagogy include opportunities for co-construction
between children and adults, including ‘sustained shared thinking’, joint
involvement in child and adult-initiated activities and informed interactions
in children’s self-initiated and free-play activities. The practitioner’s role is
conceptualized as proactive in creating play/learning environments, as well as
responsive to children’s choices, interests and patterns of learning” (Wood, 2009:29).
This means that learning through play should not be left to improvisation nor
to incident; pedagogical models should be developed and adopted for sustaining
‘complex and reciprocal relationships’ and organising ‘socially constructed and
mediated’ activities; play should be ‘endorsed within integrated pedagogical
approaches’, but the current situation is not homogeneous all over the world.
While in the UK, for example, achieving good-quality play in practice remains a
considerable challenge, as teachers face competing demands for accountability,
performance and achievement, the experience of the Reggio Children school model
in Italy has been acclaimed worldwide for being significant. Teachers and children
are here engaged, together with families, in applying and developing an educational
model based on participation, observation, mediation, and discussion, according
to the constructivist approach. “The physical environment (the ‘amiable’ school)
receives much attention and supports exchange and relationships through physical
qualities of transparency, reflectiveness, openness, harmony, softness, and light
(Ceppi & Zini, 1998; Gandini, 1993). A classroom atmosphere of playfulness and
joy pervades. The school and surrounding community welcome the children into

50 The study, conducted in the UK in 2004 and named EPPE (Effective Provision for Preschool Educa-
tion; www.ioe.ac.uk/RB_Final_Report_3-7.pdf) “has provided detailed evidence of the impact of pre-
school education and family background on children’s development” (Wood, 2009:28).
 Play and Education: the Need for Play for the Sake of Play   43

their culture and toward democratic participation” (Pope Edwards, 2002:9). Play
is here considered a source of identity, imagination, freedom; this “makes the idea
of play as freedom a natural assumption in the Reggio experience. The will of an
individual, if fully nourished and multilaterally expressed within a community, is
regarded as a positive and creative force. With the folk memory of totalitarianism
lingering in the Reggio consciousness, this makes the ‘right to play’ more than just
a fashionable assertion” (Kane, 2004:282-283).

1.5.2.3 Need for Clarity: Roles, Terminology, Activities

These reflections help to understand the level of awareness the debate on play and
education reached, though with some contrasts, in recent decades.
The use of play for educational purposes—or rather, the organisation of ludic
activities and programmes that directly influence the educational and developmental
levels—made it possible to state useful considerations about the role of the adults
in play, on how their collaboration can be less directive, more collaborative, more
available to listen to the child’s playful initiative, which is instead usually left to
a phase of free play, for which the adults decide not to participate. Furthermore,
the convincing results of ad hoc research projects made it possible to contrast that
‘ideological commitment’ that wanted to preserve a certain idea of ‘freedom’ in play,
according to which its introduction in educational settings, or even the participation
of adults, eventually pollute its natural evolution and inherent creativity, even
influencing a child’s development.
According to a research by Bennet et  al. (1997), “where children follow their
own interests and agendas the teachers realize the need to understand the meaning
of play in children’s own terms, rather than in relation to predetermined learning
objectives. [...] In particular, they realized that children need more time to develop
sustained bouts of play, and to return to their own themes and ongoing interests”
(Wood, 2009:30).
“Miller and Almon (2009) recommend that neither laissez-faire free play nor
didactic highly structured classrooms are the answer, but rather classrooms that are
rich in child-initiated play and activities initiated playfully by teachers. They believe
that young children need a balance of child-initiated play and more structured and
focused experiential learning activities, all occurring in the presence of skilled and
engaged teachers” (Kuschner, 2015:289).
“However, the lack of a common definition of play makes it hard to provide
specific recommendations for curriculum designers and to advocate for preserving
play in early childhood classrooms in the face of increasing demands for a focus
on academic skills. One way to solve this dilemma is to use more specific terms
like ‘playful learning’ to make a distinction between child initiated play and adult-
initiated activities that make use of play elements in one form or another. This may
help to avoid confusions that lead to certain curricula to be labelled as ‘play-based’
44   The Need for Play for the Sake of Play

when in reality they leave no time for children to initiate play on their own. However,
the distinction between play and playful learning has to be made clear both in the
description of their objectives and the specific pedagogies associated with each of
them. In addition, this also calls for more in-depth analysis of how exactly play
elements are used in instruction and whether their use is perceived as ‘playful’ by
children themselves or only by the teachers” (Bodrova & Leong, 2009:3).
So, interesting and promising studies and researches are starting, aimed at
achieving greater pedagogical awareness in educators, practitioners, if possible
in adults ‘tout court’, about specific modes of interaction and cooperation to be
adopted within the play framework and activity, in order to promote the child’s
development in certain areas.
Among these, some proposals try to establish connections between the children
and their teachers, with regard to their attitude about play. In support of the idea
that the dichotomy between learning and play is a false one, researchers of NAEYC51
argue that both direct instruction and play have roles in high-quality early childhood
education. Some studies compared children’s behaviour when provided with direct
instruction (of a sort) about how to activate a novel toy, and when allowed to explore
the toy without explicit instruction (a sort of free-play condition). Both children
given direct instruction and children in the free play mode learnt the intended use
of the toy, but the latter also discovered additional uses of the toy or its pieces; only
this group of children showed creativity and problem-solving skills not necessary in
the direct instruction condition (Hirsh-Paseck et al., 2009). After the publication of
these studies, Snow (2011) proposed that a new strategy to find “the middle ground
between play and direct instruction is to view instruction and play as two ways of
defining activity in classrooms” (Figure 1.1.). In it, the degrees of child activity and
teacher activity are mapped onto each other. The resulting four quadrants show the
overlap between teacher instructional strategies (as more or less actively directing)
and child play activities. Both of these approaches challenge us to think about the
roles of teacher and child, and of play and instruction, in more complex and more
intentional ways.

51 It is the acronym of the US National Association for the Education of Young Children, www.
naeyc.org.
 Play and Education: the Need for Play for the Sake of Play   45

Figure 1.1. Instructed and free play: relationships between teachers and children (Snow, 2011)

1.5.2.4 Play for the Sake of Play

It must be said, however, that these considerations are mainly related, rather than to
play itself, to play-like activities and contexts: activities and contexts of play based on
programmatically clear educational goals, demanding not only precise planning, but
also a different and more complex, participation of the adult.
There is an additional area of reflection and analysis that until now has been
overlooked, and is the subject of the development of play as such, for the purpose
and objectives of the play itself: what in this section has been called ‘play for the sake
of play’.
Play, as we have seen, cannot have extrinsic preordained goals—it lives, arises,
develops, and stops, only for itself; it is free, but not without limits, and indeed seeks
out and constructs by itself the constraint to become more exciting, compelling, and
challenging. It resorts to the use of routines and requires rapid changes, evolving
towards new and more promising types, and then intertwining the new types with
the previous ones, that are already known.
It definitely ‘produces’ learning on a large scale and in many areas of the
individual’s development, but it never patently pursues such a purpose. While
playing with adults, a child shows play levels of greater complexity and appears more
concentrated; this also happens in the case of play with more experienced peers—
even if to a different extent and in different ways. These play relationships activate the
proximal zone of development.
46   The Need for Play for the Sake of Play

Play for the sake of play can also be learnt. An educator or a practitioner can
enter the child’s play to improve, increase, and develop it. not for reaching external
goals, not to turn it into a play-like activity, but only to pursue objectives inherent
to the play itself.
This awareness is not yet clearly shared in the field sciences: it’s about learning
to enter play, to play with children, with full awareness of one’s own adulthood
and educational competence, but maintaining and respecting the constraints and
limitations of play itself and taking action to consolidate it, change it, and increase
its complexity and flexibility as play, not as a means of learning or development.
Bondioli noted already some years ago: “the child is the ‘teacher’ of play and the
adult who plays with the child should not have other intention than play itself,
neither to instruct, nor to train. It is a ‘negative’ role which becomes a positive
behaviour [...]. The scope of this ludic action is neither therapeutic nor strictly
‘educational’, but simply ludic: happy sharing is simultaneously its meaning and
its purpose” (Bondioli, 2002:86).
The adult who plays with a child shares his or her own ludic experience with
that child, and this interaction will become more advantageous the more the adult’s
infancy has been richly, extensively, and broadly playful. Playing with a child also
means losing the typical adult/child asymmetry, becoming immersed in reciprocity
and sharing. It is also a form of sentimental education as it paves the way to listening
to the infant’s innerness, sharing the emotional reality that appears in play.
This can only be achieved if the adult has in mind a clear developmental
model of play, to sustain the child’s action, and to ‘work with and through play’: its
characteristics, its mechanisms, its rhythms, its times and needs. In other words,
the adult would greatly benefit of having in mind the evolutionary spiral on which
any type of play is grafted, as well as the need to indulge both unpredictability and
rigorousness.
It is not a simple goal to achieve, and probably, specific training will be
needed. In fact, “teachers and practitioners strive to constrain and manage the
unpredictability of play that is truly free and aim instead to engineer children’s
play choices and behaviours in ways that promote educational outcomes. And, if
play is to be purposeful, then whose purposes are privileged, and whose purposes
are being served: those of the child, the practitioners or the curriculum?” (Wood,
2009:32).
Practitioners need to understand better and more deeply the meaning of
children’s play activities, and they should know and adopt the appropriate
scaffolding strategies to support the interactions between children and between
the child and the adult. They should also become more aware of how to plan the
educational curricula in order to combine activities that are directed by themselves
and those that are initiated by the children. “These integrated approaches require
high levels of pedagogical knowledge and skills, flexibility in curriculum planning
assessment and evaluation” (Wood, 2009:33).
References   47

According to Wood, “further conceptual advances can be facilitated through

socio-cultural and activity theories which propose that play is a social practice and
is situated in communities of practice” (ibidem). If learning is socially mediated
and constructed within an everyday ‘real world’ mixed with the ‘play world’,
“play activities may facilitate the transfer of knowledge across different contexts,
with the distinction that play occurs in imagined situations. Players become
part of a discourse community in which meanings, intentions and activities are
communicated through mediating means: imagined situations, tools, symbolic
actions, scripts, roles and rules” (ibidem).
In this sense, play also becomes the privileged means for creating inclusive
contexts and adopting inclusive styles, with respect to any kind of differences,
including those related to the possible impairments and to human functioning.

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Keith Towler
2 Children’s Right to Play, Whoever They Are,
Wherever They Are. The Play Rights of Children and
Young People with Disabilities
This chapter outlines the importance of the United Nations Convention on the Rights
of the Child (UNCRC), and in particular, Article 31 and General Comment No. 17, when
we consider the play rights of children and young people with disabilities. First,
the International Play Association (IPA) was delighted and honoured to be asked to
present at the LUDI Conference on this important topic. The IPA is an international
non-governmental organisation founded in 1961, which now has members in more
than 50 countries worldwide. IPA’s purpose is to protect, preserve, and promote
child’s right to play as a fundamental human right.1
It is, perhaps, worth outlining upfront what Article 31 of the UNCRC says: “That
every child has the right to rest and leisure, to engage in play and recreational
activities appropriate to the age of the child and to participate freely in cultural life
and the arts. That member governments shall respect and promote the right of the
child to participate fully in cultural and artistic life and shall encourage the provision
of appropriate and equal opportunities for cultural, artistic, recreational and leisure
activity”.
So, it is worth stating that the UNCRC applies to all children across the world;
all children, whoever they are and wherever they are, have the right to play. This
right applies equally to children with disabilities. Why then, given that very clear
commitment, do so many children with disabilities find that right is denied? This
chapter aims to outline how the barriers to play impact on children with disabilities
and puts forward the case for change as supported by the UN General Comment on
Article 31.2

2.1 The UNCRC

UNICEF3 reminds us that: “25 years ago, the world made a promise to children: that
we would do everything in our power to protect and promote their rights to survive and
thrive, to learn and grow, to make their voices heard and to reach their full potential.

1 For International Play Association (IPA) information and resources, please visit http://www.ipa-
world.com.
2 Committee on the Rights of the Child (2013) General Comment No.17 (2013) on the right of the child
to rest, leisure, play, recreational activities, cultural life and the arts (Art. 31).
3 www.unicef.org.

© 2017 Keith Towler

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License.
54   Children’s Right to Play, Whoever They Are

In spite of the overall gains, there are many children who have fallen even further
behind. Old challenges have combined with new problems to deprive many children
of their rights and the benefits of development”.
The UNCRC outlines all the human, social, and economic rights of all children
(under 18) throughout the world. It was created in 1989, and nations across all UN
member states except for the United States have ratified the Convention (Somalia is in
the process of finalising ratification of the Convention). There are 54 ‘articles’ or rights
in the Convention. Articles 1–42 outline the rights specific to children, and Articles
43–54 outline the obligations of State Parties and other ‘duty bearers’.

2.2 Barriers, Voice, and Play Practice

The UNCRC:
–– informs and guides our professional practice, values, experience, and reflections
–– provides all practitioners, leaders, and services with a common platform to
working with, and for, children and young people (Hanson, 2014)
–– enables us to place children and young people at the heart of everything we do
(Trodd & Chivers, 2011)
–– enables us to navigate professional complexities and to work towards securing
what is in the best interests of children and young people – to do the right thing

Until recently (2008–February 2015), I was the Children’s Commissioner for Wales,
and in that role, I became acutely aware of how important play is to children. In fact,
there were two main things that children of primary school age wanted to talk to me
about. The first is how important it is to feel safe, and the second is play. Very often,
these two things go hand in hand. Feeling safe in school and learning through play
is one example, and playing outdoors, maybe on our streets, without being worried
about by disapproving adults is another.
There are a number of specific barriers that impact negatively on the ability of
children with disabilities to enjoy their right to play. They include (and this is not
an exhaustive list) physical barriers that prevent children using wheelchairs or
walking aids from accessing play spaces; poor public transport (a particular issue
in rural and semi-rural locations); poverty impacting on the ability to pay for and
access some organised play and recreation opportunities; isolation within the
family and within the community; and poor or limited assistive technologies, which
reduce opportunities for participation by children with disabilities. One of the major
barriers that exists is the attitude of professionals and others within the community
towards disability. Negative stereotypes hurt and impact on children’s lives, reduce
opportunities to participate, and increase emotional stress and poor mental health.
We know that play is fundamental (not optional) to children’s physical, social,
mental, and emotional development. Of course, play can and should happen all the
 Article 31 and General Comment No. 17   55

time, and children’s innate desire to play must be encouraged and allowed to develop
at the child’s direction. We also know that this extends to all children, regardless of
ability, and so, children with disabilities have an absolute right to enjoy their Article
31 rights.
An area that sometimes causes confusion is where rehabilitation and therapy
for children with disabilities fits with their right to play. Some of those therapeutic
and rehabilitative programmes can and do have playful qualities within them. It is
important to recognise, however, that these must never be seen as a substitute for
play, as described in the General Comment.
Article 12 of the UNCRC also reminds us that all children have the right to have
their voice heard in any matter that affects their lives. Voice is important, and in our
play practice, we must place listening and acting on the concerns and issues that
children raise as central to our work with, and for, them. Children with disabilities
can and do share their experiences, hopes, feelings, and wishes.
–– “I love it when it snows”, child aged 6.
–– “…no way for me to join in”, child aged 9.
–– “I can never go on my own… but sometimes they can’t take me and I feel sad”,
boy aged 15.
–– “It can be scary to play outside”, girl aged 8.
–– “People have spit at me. I don’t like that”, boy aged 9.
–– “I love playing with my mum”, girl aged 10.
–– “Playing is so good, we need more time to play, playing anywhere is just brilliant”,
boy aged 9.
–– “Computers are good but outdoors is the best”, girl aged 12.
–– “I’m so happy when I’m playing. It makes me feel like sunshine inside”, boy aged 6.

All of these quotes come from my meetings with children with disabilities in Wales.
They are so powerful and illustrate why we must develop our play practice to meet the
concerns they outline. Perhaps, we should all work to make sure that every child with
a disability feels like they have sunshine within them.

2.3 Article 31 and General Comment No. 17

The UN Committee on the Rights of the Child is concerned about the poor recognition
given by governments to Article 31 rights. Rising urban populations, violence in
all its forms, the commercialisation of play provision, child labour, and increasing
educational demands are all affecting children’s opportunities to enjoy their Article
31 rights. In general, where investment is made, it is in the provision of structured
and organised activities, but equally important is the need to create time and space
for children to engage in spontaneous play, recreation, and creativity, and to promote
societal attitudes that support and encourage such activity.
56   Children’s Right to Play, Whoever They Are

To address these concerns, the Committee produced a General Comment, which

it adopted at its 62nd session (14 January–1 February 2013). The General Comment has
three core objectives:
1. To enhance understanding of the importance of Article 31 for children’s wellbeing
and development
2. To ensure respect for and strengthen the application of the rights under Article 31,
as well as other rights in the Convention
3. To highlight the implications for the determination of obligations of governments,
the roles and responsibilities of the private sector, and guidelines for all
individuals working with children

Within the General Comment, the Committee outlines those children who require
particular attention to realise their Article 31 rights. They include girls, children
living in poverty, children from indigenous and minority communities, children in
situations of conflict, humanitarian and natural disasters, children in institutions,
and children with disabilities.
With regard to children with disabilities, the General Comment refers to multiple
barriers, including those I highlighted earlier. They point out that children with
disabilities may find themselves excluded from school, and informal and social arenas
where friendships are formed and where play and recreation take place. While adults
sometimes overlook its importance, the opportunity to make friends and simply play
together with peers is crucial to our experience of childhood and a sense of being
fully part of society. Article 23 of the Convention highlights disabled children’s rights
to fullest participation in the community, and IPA believes that the right to play is
fundamental to realisation of that right.
The General Comment highlights the problems of isolation at home, cultural
attitudes, and negative stereotypes, which are hostile to and rejecting of children
with disabilities; and physical inaccessibility of many environments. Lack of assistive
technologies can also impede children with disabilities access to media.
Of course, many children with disabilities live in institutions, and the General
Comment says that children living in residential homes and schools, hospitals,
detention centres, remand homes, and refugee centres often have limited, or are
denied, opportunities for play, recreation, and participation in cultural and artistic
life.
The General Comment also outlines government obligations. These include
governments adopting specific measures aimed at respecting and realising every
child’s Article 31 rights, including support for caregivers and awareness raising to
challenge widespread poor cultural attitudes. Governments are also required to
protect and fulfil Article 31 rights through, for example, legislation, regulation, child
protection measures, professional codes, independent complaints mechanisms,
data collection, and appropriate budget and resource allocations. It points out the
importance of Universal Design to promote and protect children’s play, municipal
Conclusion   57

planning, improvement of school and community environments, and training and

capacity building for all professionals working with or for children, or whose work
impacts on children.

2.4 Conclusion

We need to build a worldwide campaign on Article 31. The publication of the General
Comment provides an ideal opportunity to further raise awareness of the importance
of Article 31 with state parties, government departments, civil society, and the general
public across the world.
The case to make sure that children with disabilities have a right to play is
surely beyond question. The link with their health, wellbeing, and development
makes children’s play fundamental, not optional. The responsibility to ensure this
happens rests with family members, caregivers, professionals, policy makers, and
governments.
If we managed to implement the vision set in the General Comment on Article 31,
we would have happy children, learning through play and realising their individual
potential whoever they are and wherever they live.

References
Hanson, K. (2014). ‘Killed by Charity’. Towards Interdisciplinary children’s rights studies. Childhood,
21(4), 441-446.
Trodd, L., & Chivers, L. (2011). Interprofessional Working in Practice. Learning and working together
for children and families. New York, NY: Mc Graw Hill, Open University Press.
Daniela Bulgarelli and Nicole Bianquin
3 Conceptual Review of Play

3.1 Definition of Play

LUDI adopted the definition of play proposed by Garvey (1990), as it has been
considered the most representative one for the purposes of the project: “Play is a range
of voluntary, intrinsically motivated activities normally associated with recreational
pleasure and enjoyment”. This definition shows interesting features: it can include
all kinds of activities performed with ludic intention and takes into consideration
three important and typical dimensions of the infant play: pleasure, self-direction,
and intrinsic drive. On the contrary, all the activities made in ludic contexts and/or in
a ludic mood, with ludic tools (toys, games, etc.), but driven by an extrinsic goal (i.e.,
educational, rehabilitative) are defined as ‘play-like’ activities, and are not the core of
the LUDI research activity.
The International Classification of Functioning, Disability and Health – Children
and Youth Version (ICF-CY, WHO, 2007) includes play – that is not considered in the
version for adult – thus underlying the great importance it has in childhood. Defined
as a component of the domain ‘Activities and Participation’, play is placed both in
Chapter 1 ‘Learning and applying knowledge’ and in Chapter 8 ‘Major life areas’. In
the first case, play is seen as an engine for the child’s development, in particular,
for learning: in the item ‘Learning through actions with objects’ (d131), the ICF-CY
includes learning through actions with single, two or more objects, and also through
symbolic play (actions relating objects, toys, or materials symbolically) as well as
pretend play (actions involving pretence, substituting an object, body part, or body
movement to enact a situation or event). In the second case, play is interpreted as
‘Engagement in play’ (d880), that is “Purposeful, sustained engagement in activities
with objects, toys, materials or games, occupying oneself or with other” (2007:184).
This second definition is more adherent to the aims of our project and is then inserted
as a further definition of play adopted by LUDI. The item ‘Engagement in play’ is
subdivided into: play (d8800), onlooker play (d8801), parallel play (d8802), shared
cooperative play (8803); these categories will be better illustrated in the following
paragraph. In relation to the objectives of LUDI, it is worth mentioning the fact that
play is also treated within the domain of Environmental Factors in Chapter 1, ‘Product
and technology’: in fact, this chapter considers the following items: ‘Equipment,
products and technologies used in structured or unstructured play by an individual or
group’ (2007:192) and ‘Products and technology used for play’ (d1152). Both adapted
and non-adapted toys, or specially designed technologies to assist play can be
described.

© 2017 Daniela Bulgarelli and Nicole Bianquin

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License.
 Classifications of Types of Play   59

3.2 Classifications of Types of Play

The definition of play that LUDI adopted underlined the fundamental characteristics
that were reported in Chapter 1. Taking those key characteristics for granted to define
an activity as ‘play’, children’s play could be performed and described at different
levels of cognitive complexity or of social engagement, independently from some
kinds of impairment.
Both pedagogy and psychology have a long tradition in the study of play, and
have developed many classifications of play, that can be clustered around two main
dimensions: the first concerns the cognitive complexity implied by the different types
of play and the second concerns the degree and type of social interaction in which
the child is involved while playing. In some cases, these classifications described the
different types also as developmental stages, and related them to the general cognitive
and/or social child development; in other cases, these types could be considered as
coexisting and overlapping, at least partially.
Piaget’s original cognitive classification of play was organised in stages
characterised by growing complexity, and it has been partly changed by other scholars
who developed substages – or subtypes – to better catch different qualities of play, or
inserted new stages or types to include the interactional dimension (Rubin et al., 1976;
Santrock, 2006; Smilansky, 1945; Stagnitti & Unsworth, 2000, 2009; Takata, 1974). The
social classification of play has been originally proposed by Parten in the early 1930s,
and it still remains the main reference in this area of studies. This classification was
organised in stages of growing complexity as well. Garvey’s proposal differed from
the others, as the author did not adopt the dimensions, cognitive or social, but chose
to single out and describe broad types of play behaviours; furthermore, they were not
hierarchically organised. A further group of classifications of play strictly relates to
the type of toys used while playing (ESAR System, 2002; Kudrowitz & Wallace, 2009;
U.S. Consumer Product Safety Commission). Table 3.1 summarises the types of play
described in the considered classifications, the principal developmental dimension
that describes them, and whether they are hierarchically organised.
In what follows, some more information about the definitions of the types of play
according to the various authors are reported.
a. Piaget (1945) – the following categories are hierarchically ordered:
– Practice play: listening, visual, and tactile experimentation of objects, sounds, words,
expressions.
– Symbolic play: pretend play; make-believe activities (symbolic use of objects as they
were something else); use of absent objects.
– Play with rules: games with a specific code and rules accepted and followed by
the players.
60   Conceptual Review of Play

Table 3.1. Classification of types of play

Author(s) Year Dimension Stages Types

a Piaget 1945 Cognitive Yes Practice play; Symbolic play; Play with rules

b Smilansky 1968 Cognitive Yes Functional play; Constructive play; Symbolic

play; Games with rules

c Takata 1974 Cognitive Yes Sensorimotor play; Symbolic and simple

constructive play; Dramatic and complex
constructive play; Games with rules; Recreational
and competitive play

d Rubin et al. 1976 Cognitive Yes Sensorimotor play; Simulation; Simulation

1983 with objects; Simulation with substitution;
Sociodramatic; Role-playing; Games with rules

e Garvey 1990 Behavioural No Play with motion and interaction; Play with
objects; Play with language; Play with social
materials

f Santrock 2006 Cognitive and Yes Sensorimotor play; Pretend/Symbolic play;

social Social play; Constructive play

g Stagnitti & 2000 Cognitive (only Yes Symbolic play; Sociodramatic play; Role play;
Unsworth 2009 pretend play) Fantastic play

h Garon et al. 1982 Cognitive Yes Exercise play; Symbolic play; Assembly
(ESAR) 2002 (=construction); Games with rules

i U.S. National N.A. Cognitive and Yes Attunement play; Body play; Object play; Social
Institute of Play social play; Imaginative and pretend play; Storytelling
play; Creative play

j Parten & 1932 Social Yes Solitary play; Parallel play; Associative play;
Mildred Cooperative play

k ICF-CY 2007 Social N.A. Solitary play; Onlooker play; Parallel play;
Shared cooperative play

l Smith 2002 Cognitive Yes, Early exploratory/Practice Play; Construction

within Play; Pretend & Role Play; Game & Activity
each Play; Sport & Recreational Play; Media Play;
stage Educational & Academic Play

m Kudrowitz & 2009 Toys N.A. Construction; Fantasy; Sensory; Challenge

Wallace

n Goodson & 1997 Toys N.A. Active Play; Manipulative Play; Make-believe
Bronson Play; Creative Play; Learning Play
 Classifications of Types of Play   61

b. Smilansky (1968) developed Piaget’s categories and splitted the first play stage into
two ones.
–F  unctional play: simple body movements or actions with objects.
– Constructive play: doing something with objects (i.e., building a tower of small cubes).
–S  ymbolic play (Piaget’s examples).

c. Games with rules (Piaget’s examples). Takata (1974), based on a review of literature,
proposed an age-based classification of play:
–S ensorimotor play (0-2 years).
–S ymbolic and simple constructive play (2-4 years).
–D ramatic and complex constructive play (4-7 years).
–G ames with rules (7-12 years).
–R ecreational and competitive play (12-16 years).

d. Rubin et  al. (1976, 1983) developed Piaget’s symbolic stage into five stages with
growing complexity:
–S  ensorimotor play: it is similar to Piaget’s practice play.
–S  imulation of actions by the child; in this stage, only the body is involved.
–S  imulation with objects (with dolls or other toys).
–S  imulation with substitution, in which the objects become other than what they are.
–S  ociodramatic play, where children act out roles in life scenes.
– Role-playing, in which the child takes the next step of assigning roles to others and
planning scenes.
–G  ames with rules (Piaget’s definition).

e. G arvey’s proposal (1990) describes broad types of play behaviours:

– Play with motion and interaction: it reflects exuberance; running, jumping, skipping,
shrieking, and laughing are expressions of this type of play.
– Play with objects: children can explore objects with their senses, can manipulate
them, practice and use the objects as they are meant to, and repeat these behaviours
several times.
– Play with language can be expressed in four different forms: play with sounds and
noises; play with linguistic systems, such as those involving word meanings or
grammatical constructions; play with rhymes and words; play with the conventions
of speech.
– Play with social materials: this type of play is centred on the social world and consists
in make-believe and pretending.

f. Santrock (2006) reclaimed Piaget’s classification and added social and constructive
play:
– Sensorimotor play: exploratory and playful visual and motor transactions; exploration
of objects and their functioning; exploring causes and effects.
62   Conceptual Review of Play

– Pretend/symbolic play: transforming objects, substituting them for other objects, and
acting towards them as if they were these other objects.
– Social play: play that involves interactions with peers.
– Constructive play: combines sensorimotor/practice repetitive play with symbolic
representation of ideas: children engage in self-regulated creation or construction of
a product or a problem solution.

g. S
 tagnitti and Unsworth (2000, 2009) proposed four types of play:
– Symbolic play: children playing ‘as if’ and using an imaginary approach to play.
– Sociodramatic play.
– Role play.
– Fantastic play.

h. The ESAR system has been proposed by Garon et al. (2002) and is at the basis of the
‘Guide to Play and Toys’ developed by the Instituto Tecnològico del Juguete (AIJU)
developed in Spain to classify toys; the acronym is related to the four categories of
play identified by Smilansky:
– Exercise play: sensory and motor exercise play.
– Symbolic play: play that allows imitating objects, persons, or roles, which allows
creating scenarios and representing reality through images or symbols.
– Assembly (= construction): play to gather, combine, arrange, and fit more elements to
form a whole, and achieve a specific goal.
– Games with rules (Piaget’s definition).

i. The U.S. National Institute of Play classified patterns of play:

– Attunment play: joint attention interactions between infant and mother.
– Body play: exploratory body movements, rhythmic early speech (moving vocal cords),
locomotor, and rotational activity.
– Object play: activities involving objects.
– Social play: activities carried out with parents, pets, peers.
– Imaginative and pretend play: make-believe activities.
– Storytelling play: activities related to listening and telling stories.
– Creative play: activities that give the possibility to access fantasy-play, to transcend
the reality of our ordinary lives, and in the process, germinate new ideas and shape
and re-shape them.

j. Parten (1932) was the first scholar to consider and describe different types of the infant
play under its social aspect:
– Solitary play: the child plays alone and independently even if surrounded by other
children.
– Parallel play: the child plays independently at the same activity, at the same time, and
at the same place.
 Classifications of Types of Play   63

– Associative play: the child is still focused on a separate activity, but there is a
considerable amount of sharing, lending, taking turns, and attending to the activities
of one’s peers.
– Cooperative play: children can organise their play and/or activity cooperatively with
a common goal and are able differentiate and assign roles.

k. The International Classification of Functioning, Disability and Health Children and

Youth Version (2007) describes four categories of play in Activities and Participation
in the item of Engagement of play (d880):
– Solitary play: occupying oneself in purposeful, sustained engagement in activities
with objects, toys, materials, or games.
– Onlooker play: occupying oneself by purposeful observation of the activities of others
with objects, toys, materials, or games, but not joining in their activities.
– Parallel play: engaging in purposeful, sustained activities with objects, toys, materials,
or games in the presence of other persons also engaged in play, but not joining in their
activities.
– Shared cooperative play: joining others in sustained engagement in activities with
objects, toys, materials, or games with a shared goal or purpose.

l. Smith (2002) produced a study for the U.S. Consumer Product Safety Commission in
which the following play stages are described:
– Early exploratory/practice play: includes all the first stages of the child’s manipulative
and exploratory play, such as mirrors, mobiles, pull and push toys.
– Construction play: play activities with blocks and interlocking building materials.
– Pretend and role play: all the activities that imply symbolic and/or narrative
competence, such as dolls and stuffed toys, play scenes and puppets, dress-up
materials, small vehicles, and so on.
– Game and activity play: toys belonging to this type can be puzzles, card, floor, board,
and table games; computer and video games.
– Sport and recreational play: ride-on toys, recreational and sport equipment belong to
this type of play.
– Media play: in this category, Smith includes arts and crafts, audio-visual equipment,
musical instruments.
– Educational and academic play: books, learning toys, smart toys, and educational
software.
As underlined before, there are also classifications based on toys. In many cases, these
classifications do not belong to a scientific framework and have been developed through
a bottom-up strategy, that is, by considering mainly the characteristics of use suggested
by the toys themselves. Consequently, generally speaking, such classifications are
difficult to compare with others. Furthermore, as different toys can be suggested for
different age ranges, it is also difficult to identify whether these classifications refer to
stages or not.
64   Conceptual Review of Play

m. Kudrowitz and Wallace (2009) proposed four features to describe the values of play
and/or toys:
– Construction: this play is about creating and not simply creativity.
– Fantasy: this play is about role-playing or it has a level of pretence.
– Sensory: this play involves aesthetics and entertaining the senses.
– Challenge: this can be physical or mental; physical challenges include both fine and
gross motor skill development.

n. Goodson and Bronson – U.S. Consumer Product Safety Commission – proposed

another classification of toys (1997) from which Smith’s work was then developed:
– Active play: push and pull, ride-on toys; outdoor and gym, sports equipment.
– Manipulative play: construction toys, pattern making, dressing, lacing, stringing,
sand and water play toys.
– Make-believe play: dolls, puppets, stuffed toys, place scenes, transportation toys.
– Creative play: musical instruments, art and craft materials, audio-visual equipment.
– Learning play: games, books, specific skill-development toys.

3.3 LUDI Classification of Types of Play

LUDI aims at proposing a classification of types of play to create a common language

among practitioners and scholars, who daily work in the field of play of children
with disabilities. A shared and nuanced understanding of play is important to better
support the right to play. In fact, reasoning in terms of typologies of play could be
crucial for several purposes: for instance, to better understand how to support, for
the sake of play, a specific kind of play of children with their specific characteristics
and abilities; or to design accessible toys that can allow activities at different play
levels according to the children’s abilities. This will also be the classification used in
the following chapters.
Starting from the analysis of the existing classifications, their contents and
different types of play they include and describe, a new classification has been
developed for LUDI according to two main scopes:
–– It should be exhaustive; thus, including most of the types of play identified by
scholars over the years.
–– It should be consistent and effective, for the purposes of the project.

Furthermore, the LUDI Classification should maintain the two main clusters around
which the types of play have been grouped, corresponding to the main dimensions
the researchers decided to underline. The LUDI Classification – as it is possible to see
in Table 3.2 – is strongly inspired for the cognitive dimension by the Piaget/Smilansky
classifications, and for the social dimension by that of Parten.
 LUDI Classification of Types of Play   65

Table 3.2. LUDI Classification of play

Dimension Type of play

Cognitive Practice
Symbolic
Constructive
Play with rules (including video games)

Social Solitary
Parallel
Associative
Cooperative

Anyway, in the LUDI Classification, each type of play should be considered as a

more comprehensive category than the types of play reported in the literature: in
fact, each LUDI type of play includes types and definitions that other researchers
have singled out. In Table 3.3, a first attempt is made to group these types around
the LUDI types.

Table 3.3. Play theoretical references

Cognitive dimension

Practice play (Piaget); Functional play (Smilansky); Sensorimotor play (Takata;

Practice
Rubin et al.; Santrock); Play with motion and interaction, Play with objects
(Garvey); Attunement play, Body play, Object play (U.S. Institute of Play);
Exercise play (ESAR); Early exploratory/Practice Play (Smith)

Symbolic play (Piaget, Smilansky); Symbolic and simple constructive play,

Symbolic
Dramatic and complex constructive play (Takata); Simulation, Simulation with
objects, Simulation with substitution, Sociodramatic, Role-playing (Rubin
et al.); Play with language, Play with social materials (Garvey); Pretend/
symbolic play (Santrock); Symbolic play, Sociodramatic play, Role play,
Fantastic play (Stagnitti); Symbolic play, Imaginative and pretend play (U.S.
Institute of Play); Symbolic play (ESAR); Pretend and Role Play (Smith)

Constructive play (Smilansky, Santrock); Symbolic and simple constructive

Constructive
play, Dramatic and complex constructive play (Takata); Object play (U.S.
Institute of Play); Assembly play (ESAR); Construction play (Smith)

Play with rules (Piaget); Games with rules (Smilansky; Takata; Rubin et al.;
Games with
ESAR); Game and Activity play (Smith)
rules

The description of each type of play adopted in the LUDI Classification, for
what concerns the cognitive dimension, has been built upon the definition from the
literature reported earlier, and is better described in what follows.
66   Conceptual Review of Play

a. Practice play – cognitive dimension

This type of play refers to two main aspects:
– simple body actions or experimentation of body (movements with hands, arms,
legs, head and face, vocalisations, etc.);
– visual and tactile experimentation of objects (children can explore objects with
their senses, can manipulate them, practice and use the objects as they are meant
to). Moreover, children explore causes and effects (i.e., drop an object and listen to
the sound it produces).
Typically, in this type of play, movements and experimentations are repeated several
times. This type of play is typical in the first and second year of life.

b. Symbolic play – cognitive dimension

This type of play implies giving new signification to objects, persons, actions, or
events: thus, children symbolically use objects as they were something else, produce
pretend play, and make-believe activities.
There are several levels of symbolic play with growing complexity:
– simulation of actions by the child; in this stage, only the body is involved
– simulation with objects
– simulation with substitution, in which the objects become other than what they are
– use of absent objects
Role-playing or sociodramatic play is another type of symbolic play, where children
act out roles in life scenes; they assign roles to others and plan scenes. It involves
narrative competence.
The more simple expressions of this type of play typically emerge at the end of the
second year of life.

c. Constructive play – cognitive dimension

This play consists in gathering, combining, arranging, and fitting more elements to
form a whole, and achieve a specific goal. It usually involves blocks and interlocking
building materials (i.e., building a tower of small cubes). In this type of play, the
child combines sensorimotor/practice repetitive play with symbolic representation
of ideas: children engage in self-regulated creation or construction of a product or a
problem solution.

d. Rule play – cognitive dimension

This play consists of games with a specific code and rules accepted and followed by
the players. This type of play is usually combined with the other three types: practice,
symbolic, and constructive.
The four types of cognitive play emerged in specific period of the life of the typically
developing children, as the cognitive abilities develop and become stable: practice play
appears since the first weeks, because it basically involves sensory and motor competence
and requires less complex cognitive abilities. Usually, symbolic play appears between 18
 LUDI Classification of Types of Play   67

and 24 months, as the child’s representative ability emerges. Constructive play appears in
the second year as well, whereas first types of rule play emerge in the preschool age, from
three years, when the child is able to manage easy rules.
Each type of cognitive play appears in a simplest ‘version’ during the childhood
and develops and becomes more and more complex throughout lifetime. Early
examples of symbolic play usually involve the child pretending to do something
related to everyday routines: cooking and eating fake food, pretending to go sleeping,
etc. During infancy, symbolic play becomes more and more complex: children engage
in role-playing with peers, building very complex fantastic scenarios, with rules to
be followed by all the participants (e.g., pretending to be at school with teachers and
pupils or pretending to be fairies and wizards in a magical world).
The few examples reported here show that each kind of cognitive play is rarely
played independently, but very often intertwines with other types of play. Thus, the
symbolic play of pretending to be mom and dad with their kinds involves aspects of
rule play because each child will follow the social rules related to his or her character
(mom and dad will take care of the children and the house; the children will play and
disobey to some rules, etc.); aspects of constructive play (putting together different
elements in play); and aspects of practice play (the kids play with the ball during the
session of symbolic play).
As it has been synthesised in Table 3.2, play can be categorised accordingly to the
cognitive dimension or social dimension, the description of which has been strongly
influenced by Parten’s studies. The description that is proposed here is also derived
from the ICF-CY. In what follows, the social dimensions of play are described.
a. Solitary – social dimension
Occupying oneself in purposeful, sustained engagement in activities with objects,
toys, materials, or games. The child plays alone and independently even if surrounded
by other children.

b. Parallel – social dimension

Engaging in purposeful, sustained activities with objects, toys, materials, or games in
the presence of other persons also engaged in play, but not joining in their activities.
The child plays independently at the same activity, at the same time, and at the same
place.

c. Associative – social dimension

The child is still focused on a separate activity, but there is a considerable amount of
sharing, lending, taking turns, and attending to the activities of one’s peers.

d. Cooperative – social dimension

Joining others in sustained engagement in activities with objects, toys, materials, or
games with a shared goal or purpose. Children can organise their play and/or activity
cooperatively with a common goal and are able differentiate and assign roles.
68   Conceptual Review of Play

Each type of cognitive play can be played at a different social level: in solitary,
parallel, associative, and cooperative way. For instance, practice play involves two
persons in associative way in the case of the peek-a-boo game, or whenever children
play clapping their hands together, crossing hands fast. Again, the child can play
symbolically with dolls on his or her own (solitary), or he/she can play with other
children, each child doing the same activities with the dolls but independently
(parallel play), each child playing with his or her doll sharing the activities with the
peers (associative play), or the children taking along cooperative activities with the
doll (one child cleans the doll, while the other cooks some food for it).
Very often, the possibility to play with other persons allows the children to make
the play more complex, from a cognitive perspective as well, because each player
brings ideas and cues according to his or her ability, habits, and so on: this is the case
of the child playing with peers, older children, or adults.

3.4 Type of Play: Areas of Development and Child’s Abilities

Table 3.4 describes the children’s area of psychological and physical development
and the abilities that are necessary to display the types of play. For each play, the child
needs to possess the main area of development and at least some of the abilities.

Table 3.4. Areas of development prevailingly involved by type of play

Type of play Areas of development prevailingly involved Abilities

Practice Psychomotor Experimentation

Exploration
Cognitive (in the first year of life) Exercise
Cause/effect relationship Repetition
Permanence of the object Imitation

Sensorial Observation
Listening
Touching
Feeling (e.g., with mouth)

Symbolic Symbolic/representative Invention

Pretending (understand and use pretend and make- Imagination
believe) Interpretation (e.g., of
Representation roles)
Drawing (from scribble to extensive drawings) Imitation
Language (from wording to discourse)
References   69

Table 3.4. Areas of development prevailingly involved by type of play

continued

Type of play Areas of development prevailingly involved Abilities

Construction Fine and complex psychomotor Gathering

Assembling
Combining
Arranging
Fitting
Stringing
Plugging
Sticking
Use of tools (hammer,
screwdriver, spanner, and
so on)

Cognitive and meta-cognitive Invention

Goal-directed Imagination
Planning Hypothesis making
Problem solving Self-monitoring, self-
Spatial cognition evaluation
Self-regulation Identification and
correction of errors

Rule Cognitive and meta-cognitive Competition

Understanding and adhesion to conventions Collaboration
Understanding of and adhesion to rule systems Team work (participation,
Strategic thought organisation)
Risk-taking
Social and meta-social
Becoming and being part of groups and systems
(game teams, and so on)
Understanding and interpreting the others’ role

References
Garon, D., Chiasson, R., & Filion, R. (2002). Le système ESAR. Guide d’analyse, de classification et
d’organisation d’une collection de jeux et jouets. Paris, F: Electre.
Garvey, C. (1990). Play. Cambridge, MA: Harvard University Press.
Goodson, B. & Bronson, M. (1997). Which toy for which child. Technical Report, 285-286, U.S.
Consumer Product Safety Commission.
Kudrowitz, B. M., & Wallace, D. R. (2009). The play pyramid: A play classification and ideation tool
for toy design. International Journal of Arts and Technology, 3(1), 36-56.
Parten, M. B. & Mildred, J. (1932). Social play among preschool children. Journal of Abnormal and
Social Psychology, 27, 243–69.
Piaget, J. (1945). Play, dreams and imitation in childhood. London, UK: Taylor & Francis.
70   Conceptual Review of Play

Rubin, K. H., Fein, G., & Vanderberg, B. (1983). Free play behaviours in middle and lower class
pre-schoolers: Parten and Piaget revisited. Child Development, 47, 414-419.
Rubin, K. H., Fein, G., & Vanderberg B. (1983). Play. In: P. Mussen, & E. M. Hetherington (Eds.)
Handbook of Child Psychology, vol. 4., Socialization, personality, and social development (pp.
693-774). New York, NY: Wiley.
Smilansky, S. (1968). The effects of sociodramatic play on disadvantaged preschool children. New
York, NY: Wiley.
Smith, P. K., Takhvar, M., Gore, N., & Vollstedt, R. (1985). Play in young children: Problems of
definition, categorisation and measurement. Early Child Development and Care, 19, 25-41.
Stagnitti, K., & Unsworth, C. (2004). The importance of pretend play in child development: an
occupational therapy perspective. American Journal of Occupational Therapy, 63, 121-127.
Stagnitti, K. & Unsworth, C. (2000). The importance of pretend play in child development: An
occupational therapy perspective. British Journal of Occupational Therapy, 63(3), 121-127.
Takata, N. (1974). Play as a prescription. In: M. Reilly (Ed.), Play as exploratory learning (pp.
209-246). Beverly Hills, CA: Sage Publication.
World Health Organisation (2001). International Classification of Functioning Disability and Health.
Geneva, CH: WHO.
World Health Organisation (2007). International Classification of Functioning Disability and Health,
Children and Youth Version. Geneva, CH: WHO.
Nicole Bianquin and Daniela Bulgarelli
4 Conceptual Review of Disabilities

4.1 LUDI Definition of Disability

LUDI chose to adopt the definition of disability proposed by the International

Classification of Functioning, Disability and Health (WHO, 2001) as it fits the purposes
of the project.
Two definitions of disability that the ICF offers are outlined: both emphasise the
complex interconnection between the individual and the environment. The first one
puts greater emphasis on the environment and on how it can constitute a barrier or
a facilitator for the individual’s functioning. The second one explains the ways in
which disablement can manifest in relation to restrictions in participation. They are
presented as follows.
a) “
 Disability is characterized as the outcome or the result of a complex
relationship between an individual’s health condition1 and personal factors,2
and of the external factors3 that represent the circumstances in which the
individual lives. Because of this relationship, different environments may have
a very different impact on the same individual with a given health condition.
An environment with barriers,4 or without facilitators,5 will restrict the

1 “Health condition is an umbrella term for disease (acute or chronic), disorder, injury or trauma. A
health condition may also include other circumstances such as pregnancy, ageing, stress, congenital
anomaly or genetic predisposition” (WHO, 2001:228).
2 “Personal factors are contextual factors that relate to the individual, such as age, gender, social,
status, life experience and so on, which are not currently classified in ICF but which users may incor-
porate in their application of the classification” (WHO, 2001:229).
3 “Environmental factors constitute a component of ICF, and refer to all aspects of the external or
extrinsic world that form the context of an individual’s life and, as such, have an impact on that
person’s functioning. Environmental factors include the physical world and its features, the human-
made physical world, other people in different relationships and roles, attitudes and values, social
systems and services, and policies, rules and laws” (WHO, 2001:229).
4 “Barriers are factors in a person’s environment that, through their absence or presence, limit func-
tioning and create disability. These include aspects such as physical environment that is inaccessible,
lack of relevant assistive technology, and negative attitudes of people towards disability, as well as
services, systems and policies that are either nonexistent or that hinder the involvement of all people
with a health condition in all areas of life” (WHO, 2001:230).
5 “Facilitators are factors in a person’s environment that, through their absence or presence, im-
prove functioning and reduce disability. These include aspects such as a physical environment that is
accessible, the availability of relevant assistive technology, and positive attitudes of people towards
disability, as well as services, systems and policies that aim to increase the involvement of all people
with a health condition in all areas of life. Absence of a factor can also be facilitating, for example the
absence of stigma or negative attitudes” (WHO, 2001:229).

© 2017 Nicole Bianquin and Daniela Bulgarelli

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License.
72   Conceptual Review of Disabilities

individual’s performance;6 other environments that are more facilitating may

increase that performance. Society may hinder an individual’s performance
because either it creates barriers (e.g. inaccessible buildings) or it does not
provide facilitators (e.g. unavailability of assistive devices)” (WHO, 2001:15).

b) “Disability is an umbrella term for impairments,7 activity,8 limitations,9 and

participation10 restrictions.11 It denotes the negative aspects of the interaction
between an individual (with a health condition) and the individual’s contextual
factors12 (environmental and personal factors)” (WHO, 2001:228).

Moreover, these definitions are also evoked within the Convention on the Rights
of Persons with Disabilities (UN, 2006), which puts emphasis on the possibility
of participation for each individual: “[Recognizing that] disability is an evolving
concept […] [that] results from the interaction between persons with impairments
and attitudinal and environmental barriers that hinders their full and effective
participation in society on an equal basis with others” (Convention on the Rights of
Persons with Disabilities, Preamble, Art. e).
According to the biopsychosocial model adopted by the ICF, these definitions
highlight that disability is not a fixed concept. The condition of disability strictly
depends on the impairment on one hand and on contextual factors on the other:
the environmental characteristics (among them: social attitudes, architectural

6 “Performance is a construct that describes, as a qualifier, what individuals do in their current

environment, and so brings in the aspect of a person’s involvement in life situations. The current en-
vironment is also described using the Environmental Factors component” (WHO, 2001:230).
7 “Impairment is a loss or abnormality in body structure or physiological function (including men-
tal functions). Abnormally here is used strictly to refer to a significant variation from established
statistical norms (i.e. as a deviation from a population mean within measured standard norms) and
should be used only in this sense” (WHO, 2001:229)
8 “Activity is the execution of a task or action by an individual. It represents the individual perspec-
tive of functioning” (WHO, 2001:229).
9 “Activity limitations are difficulties an individual may have in executing activities. An activity li-
mitation may range from a slight to a severe deviation in terms of quality or quantity in executing the
activity in a manner or to the extent that is expected of people without the health condition” (WHO,
2001:229).
10 “Participation is a person’s involvement in a life situation. It represents the societal perspective of
functioning” (WHO, 2001:229).
11 “Participation restrictions are problems an individual may experience in involvement in life situ-
ations. The presence of a participation restriction is determined by comparing an individual’s partici-
pation to that which is expected of an individual without disability in that culture or society” (WHO,
2001:229).
12 “Contextual factors are the factors that together constitute the complete context of an individual’s
life, and, in particular, the background against which health states are classified in ICF. There are two
components of contextual factors: Environmental Factors and Personal Factors” (WHO, 2001:229).
 LUDI Categories of Childhood Disabilities   73

characteristics, social and legal structures) and the personal characteristics (among
them: gender, age, coping styles, social background, education, profession, past
and current experience, temperament). When this encounter between the person’s
functioning and the environment is not balanced, it can lead to limitation of activities
and restriction in participation. This can be the case of participation in play activities
of children with disabilities.

4.2 LUDI Categories of Childhood Disabilities

A classification of different types of disabilities is needed within LUDI because play,

play materials, and play contexts can have a strict relationship with the individual’s
impairments and his or her activity possibilities.
OECD’s (Organization for Economic Cooperation and Development) Centre for
Educational Research and Innovation (CERI) published an interesting document
‘Students with Disabilities, Learning Difficulties and Disadvantages: Policies,
Statistics and Indicators’ (2007, an updated version of a previous document published
in 2005), which contains a collection of data from many countries. The document
presents a comparison of data concerning the access to educational provisions by
students with special needs in a number of OECD countries. In order for policy-
relevant comparisons to emerge, a resource-based approach would require that the
pupils included under this definition would need to be subdivided into some forms
of straightforward classification scheme. Participating countries to the research
agreed on a tri-partite system, in which students are divided into three cross-national
categories: A, B, and C.
–– Disabilities (category A): Pupils with disabilities or impairments that are viewed
in medical terms as organic disorders attributable to organic pathologies (e.g., in
relation to sensory, motor, or neurological defects)
–– Difficulties (category B): Pupils with behavioural or emotional disorders, or
specific difficulties in learning
–– Disadvantages (category C): Pupils with disadvantages arising primarily from
socio-economic, cultural, and/or linguistic factors

As LUDI focusses on the play of children with disabilities, the target audience of the
project is related to category A. Table 4.1 shows the classifications used in the OECD
member countries only with respect to category A.
Table 4.1. Classifications of category A used in OECD member countries
74 

Country Physical Hearing Visual Mental Communication Multiple Autism Health Behaviour or Others
Emotion

Austria Physically Hearing Visually Severe mental - Speech impairment Ill students in
disabled impaired or impaired or disability - Moderate speech hospital
deaf blind problems

Belgium Pupils with Auditory Visual handicap- Minor Children suffering

(Flemish a physical handicap - Moderate or from protracted
community) handicap serious mental illness
handicap

Belgium (French Physical Hearing Visual - Mild Students suffering

community) deficiencies impairment deficiencies - Moderate from an illness
 Conceptual Review of Disabilities

or profound
mental
retardation

Canada (Alberta)- Severe - Deafness - Blindness - Severe - Severe - Severe

- Mild or - Mild or - Mild or - Mild - Mild or moderate - Mild or
moderate moderate moderate visual - Moderate communication moderate
physical hearing disability mental disability multiple
or medical disability disability disability
disability

Canada (British Physical Hearing - Visual Moderate Multiple Autism Severe

Columbia) disabilities or impairments impairment to severe to disabilities behaviour
chronic health - Deaf or profound disorders
impairments blindness intellectual
disabilities

Canada (New Physical Perceptual Intellectual Communicational Multiple

Brunswick)
 

continued
Table 4.1. Classifications of category A used in OECD member countries

Country Physical Hearing Visual Mental Communication Multiple Autism Health Behaviour or Others
Emotion

Canada (Saskat- Orthopaedic Deaf or hard of Visual Intellectual Multiple Autism Chronically ill Traumatic
chewan) impairments hearing impairments disabilities disabilities brain injury

Chile Motor deficit or Hearing deficit Visual deficit Mental Serious social and
disorder deficiency communication
impairments

Czech Republic Physical Hearing Sight handicapsMentally Speech handicaps Multiple Autistic - Students in Other
handicaps handicaps retarded handicaps hospital handicaps
- Children with poor
health (pre-primary
only)

Finland Physical Hearing Visual - Mild Dysphasia Autism and

and other impairment impairment - Moderate or Asperger’s
impairment severe mental syndrome
impairment

France Physical - Deaf - Blind - Severe Speech and languageMultiply Metabolic - Other neuro-
handicap - Partially - Partially - Moderate disorders handicapped disorders psychological
hearing sighted - Mild mental disorders
handicap - Other
deficiencies

Germany Physically Partially Partially Mentally Handicapped in Multiple Autism Sick

handicapped hearing or sighted or blind handicapped speaking handicaps
LUDI Categories of Childhood Disabilities 

deaf

Greece Physical Hearing Visual Mental Autism Other

 75

impairments impairments impairments impairments impairments

 Table 4.1. Classifications of category A used in OECD member countries
continued
76 

Country Physical Hearing Visual Mental Communication Multiple Autism Health Behaviour or Others
Emotion

Hungary Physical Hearing Visual Moderate Multiple Autism

disability disabilities disabilities degree disabilities
of mental
disability

Ireland Physically Hearing Visually - Mild Specific speech and Multiply

handicapped impaired impaired - Moderate language disorder handicapped
- Severely and
profoundly
mentally
 Conceptual Review of Disabilities

handicapped

Italy - Mild Hearing Visual - Moderate Multiple

- Severe impairment impairment - Severe mental handicap
physical handicap
handicap

Japan Physically Deaf and hard Blind and Intellectual Speech impaired Health impaired Emotionally
disabled of hearing partially disabilities disturbed
sighted

Korea Students Students Students Students Students with speech Students

with physical with hearing with visual with mental impairments with other
impairments impairments impairments retardation disabilities

Luxemburg Motor Sensory impairment Mental Emotionally

impairment impairment disturbed
children
 

Table 4.1. Classifications of category A used in OECD member countries

continued

Country Physical Hearing Visual Mental Communication Multiple Autism Health Behaviour or Others
Emotion

Mexico Motor disability - Auditory - Blindness Intellectual Multiple

or hearing - Partial visual disability disability
disability disability
- Deafness
or severe
auditory
disability

The Netherlands Physically - Deaf children Visual handicapMental Language and Multiply - Other health Behaviour
handicapped - Hard of handicaps communication handicapped impairment disabilities
or motor hearing disabilities - Chronic
impairment conditions
requiring paediatric
institutes

Poland Motion - Deaf - Blind - Light Multiple Autism Chronically ill

handicap - Partially - Partially - Moderate and handicap
hearing sighted severe
- Profound
mental
handicap

Slovak Republic Physical Hearing Visual - Mild Speech disorders Multiple Autism Ill and physically
disability impairment impairment - Moderate impairment weak children in
severe mental medical facilities
retardation
LUDI Categories of Childhood Disabilities 
 77
continued
Table 4.1. Classifications of category A used in OECD member countries
78 

Country Physical Hearing Visual Mental Communication Multiple Autism Health Behaviour or Others
Emotion

Spain Motor impaired Hearing Visual impaired Mental Multiple Serious Students in
impaired handicap impairment personality hospital or with
disorders, health problems
psychosis,
and autism

1
Sweden - Pupils with impaired hearing, vision and Students
physical disabilities with mental
- Students with impaired hearing and physical retardation
disabilities
 Conceptual Review of Disabilities

Switzerland Physical Deaf or hard Visual -Students Language disability: - Students Chronic conditions Behaviour
disabilities: hearing: handicap: with a mental special schools with a mental prolonged disorders:
special schools special special schools handicap handicap hospitalisation: special schools
schools or educable or multiply special schools
mental handicapped:
handicap: special schools
special schools - Multiple
- Students disabilities:
with a mental special schools
handicap
or trainable
mental
handicap:
special schools

1
This country is not included in the publication of 2007, but in the previous one only (2005).
 

continued
Table 4.1. Classifications of category A used in OECD member countries

Country Physical Hearing Visual Mental Communication Multiple Autism Health Behaviour or Others
Emotion

Turkey Orthopaedic Hearing Visual - Moderate Language and Autism Chronic illness Neurological
impairment impairment impairment - Severe speech difficulty injury
learning
disability
- Gifted or
talented

United Kingdom Children with statements (records) of special educational needs

(England)
United States Orthopaedic Hearing Visual Mental Speech or language - Multiple Autism Other health - Traumatic
impairments impairments impairments retardation impairment disabilities impairments brain injury
- Deaf or - Development
blindness delay
LUDI Categories of Childhood Disabilities 
 79
80   Conceptual Review of Disabilities

Starting from the analysis of these classifications, the LUDI Working Group 1 made
some choices with respect to the following criteria:
–– The need to adopt the most significant and useful categories for the project
purposes: this means categories related to impairments that prevent children
from playing freely
–– The appropriateness of the terminology
–– The need to avoid a proliferation of categories, rather to have broad categories
with the possibility to indicate the severity of the impairment

The proposal for the LUDI Classification of disabilities13 is reported in Table 4.2:

Table 4.2. LUDI Classification of disabilities

LUDI categories of disabilities

Mental or intellectual disability (mild, moderate, severe, profound)

Hearing impairments (partially hearing impaired – deaf)
Visual impairments (partially sighted – blind)
Communication disorders (language disorders)
Physical impairments (mild, moderate, severe)
Autism spectrum disorders
Multiple disabilities

4.3 Description of the LUDI Categories of Childhood Disabilities

The categories identified within the LUDI Classification of disabilities are described
and defined as follows, by referring to two main international sources: the WHO
International Statistical Classification of Diseases and Related Health Problems 10th
Revision (ICD-10, 2010) and the Diagnostic and Statistical Manual of Mental Disorders
5th edition, published by the American Psychiatric Association (2013). Whenever

13 The LUDI categories of disabilities may also consider ‘invisible disabilities’ for project purposes.
The term ‘invisible’ refers to disabilities that are less visible than other physical, sensory, or mobility
impairments, and that are prevalent but commonly under recognised (Gaines et al., 2008; Missiuna
et al., 2006). This category encompasses a heterogeneous group of major and minor neurodevelop-
mental disorders, attention deficit disorders, developmental coordination disorders, and specific
learning disorders that may compromise play participation. While these conditions are defined in the
Diagnostic and Statistical Manual of Mental Disorders 5th edition (APA, 2013), the affected children
may be more subject to misconceptions regarding the legitimacy of their play difficulties and need
of support to play. However, numerous researches have highlighted the need to be concerned by the
consequences of neurodevelopmental disorder on children’s playfulness and participation in play
(Kennedy-Behr et al., 2013; Leipold & Bundy, 2000; Poulsen & Ziviani, 2004; Unhjem et al., 2014).
 Description of the LUDI Categories of Childhood Disabilities   81

needed, reference will be also made to other sources and documents, because the two
main documents aforementioned were not exhaustive for a functional description of
all categories of childhood disabilities of LUDI.

4.3.1 Intellectual Disabilities

In the DSM-5, the neurodevelopmental disorders include three types of intellectual

disabilities: the intellectual disability, the global developmental delay, and the
unspecified intellectual disability. The intellectual disability should meet the
following three criteria:
a) Deficits in intellectual functions: reasoning, problem-solving, planning, abstract
thinking, judgement, academic learning, and experiential learning
b) Deficits in adaptive functioning involving three domains: conceptual, social,
and practical, so that ongoing support is needed to meet the developmental and
socio-cultural standards for personal independence and social responsibility;
limits are related to one or more daily life activities, such as social participation,
communication, independent living in several life contexts (home, school, work,
and recreation)
c) Onset of intellectual and adaptive deficits during the infancy and childhood

The intellectual functioning is conventionally estimated through standardised and

validated intelligence tests, and usually, a score lower than at least two standard
deviations from the average represents a cognitive delay. The adaptive functioning
is estimated by scales assessing social adaptation in a given environment. These
measures provide an approximate indication of the degree of intellectual impairment.
The diagnosis will also depend on the overall assessment of intellectual functioning
by a skilled diagnostician.
Intellectual abilities and social adaptation may change over time, and, however
poor, may improve as a result of training and rehabilitation. Diagnosis should be
based on the current levels of functioning.
The DSM-5 includes the following levels of severity of the intellectual disability:
–– Mild - Approximate IQ range of 55 to 70 (mental age from 8 to under 11 years).
Likely to result in some learning difficulties in school. During adulthood, persons
with mild intellectual impairment show social and occupational abilities that
allow them to live autonomously, although they may need some degree of support.
–– Moderate - Approximate IQ range of 40 to 55 (mental age from 4 to under 7 years).
Likely to result in marked developmental delays in childhood, but most persons
can learn to develop some degree of independence in self-care and acquire
adequate communication and academic skills.
–– Severe - Approximate IQ range of 25 to 40 (mental age from 18 months to under 4
years). Likely to result in continuous need of support.
82   Conceptual Review of Disabilities

–– Profound - IQ under 25 (mental age below 18 months). Likely to result in severe

limitation in self-care, continence, communication, and mobility.

4.3.2 Hearing Impairments

For the elaboration of the description in this category and the following – the visual
impairments – two separate sources found on the Web have been used; the first is a
document, the Kentucky’s Office for the Americans with Disabilities Act, produced by
the Kentucky Education and Workforce Development Cabinet14. The second source
is located within the WHO website, in the section dedicated to the Media Centre, in
particular in the ‘Fact Sheet’, in relation to the definition of deafness and hearing
loss15.
The hearing impairments are defined as a hearing loss that prevents a person
from totally receiving sounds through the ear. There are four types of hearing losses:
–– Conductive: Caused by diseases or obstructions in the outer or middle ear, which
usually affect all frequencies of hearing. A hearing aid generally helps a person
with a conductive hearing loss.
–– Sensorineural: Results from damage to the inner ear. This loss can range from
mild to profound, and often affects certain frequencies more than others. Sounds
are often distorted, even with a hearing aid.
–– Mixed: Occurs in both the inner and outer or middle ear.
–– Central: Results from damage to the central nervous system.

Hearing loss may be mild, moderate, severe, or profound. It can affect one ear or
both ears, and leads to difficulty in hearing conversational speech or loud sounds.
‘Hard of hearing’ refers to people with hearing loss ranging from mild to severe. They
usually communicate through spoken language and can benefit from hearing aids,
captioning, and assistive listening devices. People with more significant hearing
losses may benefit from cochlear implants. ‘Deaf’ people mostly have profound
hearing loss, which implies very little or no hearing.

4.3.3 Visual Impairments

Visual impairment is a functional limitation of the vision system, which cannot be

recovered by usual means (glasses, for instance). It leads to loss of visual acuity, loss
of visual field, visual distortion, or visual perception difficulties. Visual impairments

14 Retrieved from: http://www.ada.ky.gov/hearing_imp_def.htm.

15 Retrieved from: http://www.who.int/mediacentre/factsheets/fs300/en/.
 Description of the LUDI Categories of Childhood Disabilities   83

range from partial to total loss of sight. Visual impairment is defined as a best-
corrected visual acuity between 20/70 and 20/1200 (foot, accordingly to the Snellen
chart, 1862), and blindness is defined as a visual acuity worse than 20/1200 with the
best possible correction. There are four levels of visual impairments, according to the
ICD-10:
–– Mild visual impairment: Acuity equal to or better than 20/70.
–– Moderate visual impairment: Acuity worse than 20/70 or equal to 20/200.
–– Severe visual impairment: Acuity worse than 20/400 or equal to 20/1200.
–– Blindness: Acuity worse than 20/1200.

The definition of ‘legally blindness’ varies from country to country. The assistance
that a person with a visual impairment requires depends on the degree of sight loss
and when the loss occurred. A person who is visually impaired may use magnifying
glasses, enlarged print, or other strategies. A person who is legally blind relies more
on the other senses to perceive the world, but still can be completely independent.
This person may use a cane or a service dog, also called a ‘guide dog’.16

4.3.4 Communication Disorders

This category is presented in the DSM-5 in the chapter on neurodevelopmental

disorders, and includes deficits in language, speech, and communication. In
particular, with regard to play and the aims of the project, only one category within
communication disorders will be considered, that is the language disorder. The DSM-5
defines language as “the form, function, and use of a conventional system of symbols
(i.e., spoken words, sign language, written words, pictures) in a rule-governed manner
for communication” (2013: 41).
Language disorder is characterised by persistent difficulties in the acquisition
and use of spoken, written, or sign language; deficits in comprehension or production
include a reduced vocabulary, limited sentence structure, and impairments in
discourse. The disorder emerged in early age and is not due to hearing, sensory,
motor, or other neurological impairments. Language disorder affects communication,
social participation, and occupational performances.

4.3.5 Physical Impairments

A physical impairment is permanent and substantially limits physical ability or motor

skills. The physical capacity to move, coordinate actions, or perform physical activities

16 http://www.ada.ky.gov/vis_imp_def.htm.
84   Conceptual Review of Disabilities

is impaired, and the child faces challenges in one or more of the following areas:
physical and motor tasks. independent movement, performing basic life functions.
Physical impairment can be either congenital or acquired. Children with
congenital conditions are either born with physical difficulties or develop them
soon after birth. Acquired disabilities are those developed through injury or disease
while the child is developing normally. The age at which a condition develops often
determines its impact on the child. Physical impairments can also be progressive or
chronic. Physical impairments can be related to a problem to the performing system
(skeleton, neuromuscular system, joints) or to the directive system (central nervous
system), and in this last case, it can be specific or nonspecific.
Examples of impairments of the first type are muscular dystrophy, achondroplasia,
juvenile rheumatoid arthritis, and so on; examples of the second type are cerebral
palsy, ataxia, traumatic brain injury, neural tube defects, spinal cord injury, and so
on.
Possible subdivisions (mild, moderate, severe) can be related to the physical
extension of the impairment (i.e., number of limbs involved, presence of spasms or
other forms of dyskinesia, extension and level of the neurologic injury, and so on).
Unlike other categories and for intervention purposes, these subdivisions can be
related to the extension of the needed support: slight support (mild); substantial
support (moderate); very substantial support (severe).

4.3.6 Autism Spectrum Disorders

This category is included in the DSM-5 within the chapter on neurodevelopmental

disorders, and can be identified through two main criteria:
a. Persistent deficits in social communication and social interaction across multiple
contexts as manifested by the following: deficits in social-emotional reciprocity,
deficits in nonverbal communicative behaviours used for social interaction, and
deficits in developing, maintaining, and understanding relationships
b. Restricted, repetitive patterns of behaviour, interest, or activities as manifested by at
least two of the following: stereotyped or repetitive motor movement, use of objects
or speech; insistence on sameness; inflexible adherence to routines, or ritualised
patterns of verbal or nonverbal behaviour; highly restricted, fixated interest that
are abnormal in intensity or focus; and hyper or hyporeactivity to sensory input or
unusual interest in sensory aspects of the environment

The severity specifiers may be used to describe the child’s symptomatology with
the recognition that severity may vary by context and fluctuate over time. Severity
of social communication difficulties and restricted, repetitive behaviours should be
separately rated.
 Description of the LUDI Categories of Childhood Disabilities   85

Level 1 – Requiring support

–– Social communication: Without support in place, deficits cause noticeable
impairments: difficulty initiating social interactions, and clear examples of
atypical or unsuccessful responses to social overtures of others are present; the
child may appear to have decreased interest in social interactions.
–– Restricted, repetitive behaviours: Inflexibility of behaviour causes insignificant
interference with functioning in one or more contexts; difficulty in switching
between activities. Problems of organisation and planning hamper
independence.

Level 2 - Requiring substantial support

–– Social communication: Marked deficits in verbal and nonverbal social
communication skills; social impairments apparent even with supports in
place; limited initiation of social interactions; reduced or abnormal responses
to social overtures from others.
–– Restricted, repetitive behaviours: Inflexibility of behaviour, difficulty coping
with change, or other restricted or repetitive behaviours appear frequently
enough to be obvious to the casual observer and interfere with functioning in a
variety of contexts; distress and/or difficulty changing focus or action.

Level 3 - Requiring very substantial support

–– Social communication: Severe deficits in verbal and nonverbal social
communication skills cause severe impairments in functioning, very limited
initiation of social interactions, and minimal response to social overtures from
others.
–– Restricted, repetitive behaviours: Inflexibility of behaviour, extreme difficulty
coping with change, or other restricted or repetitive behaviours markedly
interfere with functioning in all spheres; great distress and/or difficulty
changing focus or action.

4.3.7 Multiple Disabilities

In literature, there is not an international consensus about the definition of

multiple disabilities, because children with multiple disabilities show combination
of concomitant impairments at physical, motor, intellectual, sensory, or
communicative level.
The World Health Organisation defines a child with multiple impairments
as a child with a significant physical disability combined with a sensory and/or
cognitive disability (WHO, 1996:4). According to the Individuals with Disabilities
Education Act (IDEA, U.S. Congress; 1975, 2004), a law by the U.S. Department of
Education, the combination of multiple disabilities “causes such severe educational
86   Conceptual Review of Disabilities

needs that cannot be accommodated in special education programs solely for one
of the impairments”. Thus, each child with multiple impairment shows a specific
condition that can dramatically vary in respect to general intelligence, gross and
fine motor skills, language, and social adaptation. Comorbidity with behavioural or
psychological problems is common in children with multiple disabilities (Cadman
et al., 1987).
According to the LUDI goal, which is to foster and guarantee play for the sake
of play for disabled children, multiple disabilities are defined as a condition in
which a sensory impairment is associated with another of the six disabilities listed
before. In fact, the sensory channel is a fruitful mean to playfully interact with the
child with disability and its damage brings additional challenges that need to be
addressed and overcome.

References
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(DSM-5®). Arlington, VA: American Psychiatric Association Publishing.
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predictors of language development in children born with and without family risk for
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http://www.parentcenterhub.org/repository/idea/.
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United Nations (2006). Convention on the Rights of Persons with Disabilities. Retrieved from:
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Health. Geneva, CH: WHO.
Daniela Bulgarelli and Vaska Stancheva-Popkostadinova
5 Play in Children with Intellectual Disabilities
Intellectual disability (ID) is characterised by significantly below-average intellectual
functioning and limitations in two or more areas of adaptive skills: communication,
self-direction, social skills, self-care, personal independence at home or in community
settings, school or work functioning, and maintenance of personal safety (Shalock
et al., 2010).
Children with ID do not form a homogenous group (Brodin & Stancheva-
Popkostadinova, 2009). The differences are based on the severity of intellectual
disability (mild, moderate, severe, and profound) and comorbidity. The limitations
in some adaptive skills often coexist with the strengths in other skills.
The biggest part of the children with ID face challenges in communication,
emotion regulation, language, rapid processing of information, attention, executive
functioning, and are more likely to show internalising and externalising problems.

5.1 Play in Children with ID

“The studies about medical and physical effects of different kinds of disability are
predominant, and until the end of last century very little attention has been given
to the way the nature of children’s play is changed by a disability” (Webb, 2003:15).
Play in children with ID is studied from different perspectives: in comparison
with children without ID (Blasco et  al., 1993; Lieber, 1993; Malone, 2006); home
settings versus school settings (Malone, 2009); correlations between specific
psychological characteristics and particular types of play (Cunningham et al., 1985;
Elias & Berk, 2002; Nader-Grosbois & Vieillevoye, 2012); role of parents in parent–
child play interaction (Hauser-Cram & Howell, 2003; Roarch et al., 1998); parents’
perceptions of children’s play (Malone & Landers, 2001).
The severity of ID influences the nature and characteristics of children’s play.
Allen (1980) reported that play in children with ID may not emerge so naturally
and informally as it does with other children, and may need to be encouraged.
Comparing atypically and typically developing (TD) children, Hughes (2009)
stressed that children with ID were more interested in the physical characteristics
of play materials than in their representational possibilities; they were more
likely to simply manipulate and handle play materials; they were more repetitive
and less varied in toy play (Lender et  al., 1988); finally, children were delayed
in the emergence of symbolic play and were less likely to reach higher levels of
sophistication.
In contrast with the previous positions, some studies by Malone et al. pointed
out that the patterns of play in children with and without ID within the same context

© 2017 Daniela Bulgarelli and Vaska Stancheva-Popkostadinova

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License.
 Cognitive Play   89

were similar: in fact, both groups of children spent nearly equal time in functional,
constructive, and pretend play during home-based independent play situation
(Malone, 2009; Malone & Stoneman, 1990). Moreover, Linn, Goodman, and Lender
(2000) stated that despite the frequencies of passivity and repletion, children with
ID spent the majority of their time engaging in spontaneous, nonrepetitive play.
This picture also emerged in a study in which mothers’ were requested to describe
play in their children with ID (Malone & Landers, 2001).

5.2 Cognitive Play

With respect to the cognitive dimension of play, the development of play in children
with ID proceeds similarly as for TD children; it is related to the child’s level of
cognitive functioning; thus, delays are usually present and symbolic play appears
later (Beeghly, 1998; Cicchetti & Ganiban, 1990; Fewell et  al., 1997; Gowen et  al.,
1992; Hill & McCune-Nicolich, 1981; Hughes, 2009; Libby et  al., 1997; Motti et  al.,
1983; Turner & Small, 1985). Play of children with ID appears to be more repetitive
than TD play because of distractibility and impairment in motivation, perception,
learning (Lender et al., 1998; Morgenstern, 1968).
Messier, Ferland, and Majnemer (2008) reported that in a group of children
with ID between 6 and 8 years of age, play age was about 2.5 years. Their practice
play, involving gross and fine motor skills, their interest in sensory elements of
play, and their interest in exploration were well-established, whereas all aspects
related to imitation, imagination, and dramatisation abilities were delayed. Singh,
Iacono, and Gray (2014) found that 12 two- to five-year-old children with Down
Syndrome mainly performed functional play and less complex symbolic play. Thus,
symbolic play typically appears later in children with ID (Hughes, 2009). Children
with ID between 8 and 12 years of age displayed level of symbolic play similarly to
TD children of similar mental age (3-6 years; Beeghly et al., 1989; Hill & McCune-
Nicholic, 1981; Motti et al., 1983; Nader-Grosbois & Vieillevoye, 2012). When involved
in structured situation, in which, for instance, play objectives are defined by adults,
children with ID showed higher pretend play level (Nader-Grosbois & Vieillevoye,
2012). In terms of their play with objects, children with ID seem to prefer structured
materials, such as puzzles and jacks, while typical children of the same mental age
prefer open-ended materials (e.g., art supplies) that allow them to be creative and
imaginative.
In literature, studies on practice and symbolic play in children with ID are
present, mainly because these are intended as indicators of cognitive development.
On the other hand, studies about constructive and rule play in this population are
uncommon because of children with IDs’ difficulty in cognitive reasoning, planning
of strategies and goals, and so on. In general, children with ID are less likely than
other children to combine objects appropriately in play (Hughes, 2009).
90   Play in Children with Intellectual Disabilities

It is worth noticing that children with IDs ludic attitude, consisting curiosity,
initiative, pleasure, spontaneity, and participation, were found to not being related
to the IQ level and cognitive functioning (Linn et al., 2000; Luttropp & Granlund,
2010; Messier et al., 2008).

5.3 Social Play

With respect to the social dimension of play, compared to the TD children, children
with ID show higher proportion of solitary play (Guralnick et al., 1996b; Guralnick &
Groom, 1987a; 1987b; Kopp et al., 1992), interact less with peers, and exhibit lower
levels of complexity in engagement (Guralnick et  al., 2006; Luttropp & Granlund,
2010). Moreover, they have specific problems in ludic interactions, above all, with
peers. In general, social interactions are more restricted than those of comparable
groups of children (Guralnick, 1997), and children with ID are less likely to initiate
play with peers and have difficulties with cooperation (Luttropp & Granlund, 2010;
Messier et al., 2008).
In fact, playing with peers is a high-demanding activity from a linguistic, cognitive,
and social point of view: it implies self-regulatory strategies, achieving interpersonal
goals, sustaining and coordinating play sequences, resolving conflicts, processing
complex social information, and so on (Guralnick 1999a; Luttropp & Granlund, 2010;
Vieillevoye & Nader-Grosbois, 2008). Consequently, with difficulties in complex
interactions, children with ID have been found to be more socially included during
structured activities in kindergartens (Luttropp & Granlund, 2010).
Because of these difficulties, during ludic interaction, children with ID also spent
more time in passivity, or disengagement from activity than TD children (Krakow &
Kopp, 1982, 1983; Lender et  al., 1998; Linn et  al., 2000). In these children, passive
behaviours increased according to the amount of time spent in playing. Moreover,
while TD children can quickly coordinate and alternate play and social interaction
with the partner, children with ID need to stop playing to interact with the partner,
thus reducing the total amount of ludic interactions (Linn et al., 2000).
Children with ID have smaller social networks than TD children and rarely have
best friends to play with frequently. Thus, they spend higher percentage of their social
activities (including play) with adults (parents, teachers, educators) or siblings, who
are more likely to adapt themselves to the cognitive and interactional level of the
children with ID and can better understand their communication (de Falco et al., 2008;
Luttropp & Granlund, 2010; Moyson & Roeyers, 2012; Solish et al., 2010). Moreover,
it could be difficult for TD children to understand and anticipate the reaction of
children with ID, because of their difficulties in complex social interactions and in
self-regulation (Ytterhus, 2003), whereas siblings, for instance, can better interpret
children with ID communication and behaviour (Moyson & Roeyers, 2012).
Conclusion   91

IDs influence others’ behaviours and specifically parental support during play
sessions. For instance, mothers of children with ID tend to be more directive and
supportive than mothers of TD children (Hauser-Cram & Howell, 2003; Roarch et al.,
1998). This style was functional to support children’s play: in fact, it was associated
with more object play and vocalisation by children with ID (Roarch et al., 1998). It is
worth noticing that among children with ID, great individual differences emerged:
degree and type of disability were not strongly correlated with the child’s social
competence and participation (Luttropp & Granlund, 2010).

5.4 Conclusion

The literature about play in children with ID covered more than 45 years of research
and still this topic is of current interest. Some studies compared play in children with
and without disabilities, others presented specific aspects of play, or play in specific
disability groups.
Even if there are some controversial results, majority of the studies showed that
there are more similarities than differences in play of children with ID and without
ID. Despite some individual differences, both the cognitive and social complexities
of play displayed by children with ID are mostly related to the development of their
cognitive and social competences. Thus, supportive environments and supportive
partners are important to give children with ID a chance to play for the sake of play.

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Anna Andreeva, Pietro Celo, Nicole Vian
6 Play in Children with Hearing Impairments
According to the World Health Organisation (WHO, 2015), 32 million children
worldwide have hearing loss. The degree of hearing loss is classified into four
subgroups: mild (26–40 dB), moderate (41–60 dB), severe (61–80 dB), and profound
(over 80 dB) (WHO, 2015). The presence of hearing loss in childhood puts a child at
risk for language, social, and academic difficulties. It can negatively affect the quality
of life, even if the hearing loss is mild (Burkey, 2006). Language development and
modalities of communication are strictly related to the emergence of play skills and
influence the relationship with other children in mutual play situations.
Many factors affect the communication skills, as well as the cognitive and also the
play development of children with hearing loss. They include: the degree of hearing
loss, its etiology, the audiometric configuration, the age of onset, the age at which the
child’s hearing impairment is identified, the adequacy and the type of programme in
the rehabilitation intervention, the presence of other impairments, the consistency
of the adopted amplification mode (hearing aid, cochlear implant, bone-anchored
hearing aid), the family and environmental influences and the attitudes of the other
children and their parents (Spencer & Marschark, 2010; Sininger et al., 2010; Paul &
Whitelaw, 2011; Harris, 2014; Mills et al., 2014).

6.1 Play and Language Development in Children with Hearing

Impairments

Young children explore the surrounding world through play: it is very important for a
child’s development. Play has been recognised by the United Nations High Commission
for Human Rights as a right of every child. Play is crucial for communication, cognitive,
physical, social, and emotional development of young children (Ginsburg, 2007).
Many studies have explored play in groups of children with hearing impairment. A
hearing-impaired child can be as competent as a typically developing one. Individuals
with hearing loss necessarily play, think, learn, or behave exactly like their hearing
peers. Some research compared play behaviour of children with and without hearing
impairment; part of the studies found similarities, but others ascertained differences
that were strongly associated with language levels (Higginbotham & Baker, 1981 in
Schirmer, 1989; Spencer & Marschark, 2010).
Hearing-impaired children and their families have a variety of opportunities to
choose the communication methods as well as the rehabilitation methodology that
will support learning. Usually, parents of children with mild or moderate hearing loss
choose oral approaches (i.e., listening and spoken language), whereas for children
with more severe hearing losses, parents may opt for a sign language. Other functional

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This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License.
 Play and Language Development in Children with Hearing Impairments   95

outcomes, such as later socialisation, academic achievement, and self-esteem, are

also considered by parents when deciding on the communication mode (Harris, 2014).
The interval between birth and auditory rehabilitation is not always negatively
correlated with the neural development (Kral, 2013), as well as play, perceptual,
linguistic, and cognitive abilities (Geers et  al., 2007; Pisoni et  al., 2008; Peterson
et  al., 2010; Havy et  al., 2013). In cases of early identification of hearing loss, the
communicative functions and play are not compromised in deaf children as well
as in those children exposed to deaf sign language or in situations of bilingualism
(Grosjean, 2015). Evidently, if detected language skills are related to oral skills, most
of the deaf children will be out of compliance with the standard. In fact, bilingual
children in inclusive school showed cognitive levels and language skills in sign
language similar to hearing children (Tommasuolo, 2006).
It is worth noticing that the condition of a deaf child born in a family of deaf
parents and then genetically close to them is different from that of many deaf children
born to hearing parents. Congenital or acquired hearing impairment puts the child
in a situation of diversity about their family, and this determines the approach to
rehabilitation methods. In case one or both parents of the child are deaf and use the
sign language, they usually find it very natural to adopt the sign language for the
communication exchanges with their child.
What is important about language and play development is not the degree of
hearing loss, but sharing the same condition and the same way of being in the world.
Indeed, any communication delay does not seem to be given by deafness as such, but
by the failure of early communicative interaction between adults and the deaf child
(Malfatti, 2009). The lack of a real communicative relationship affects play more than
the type of hearing impairment or the type of family.
White and White (1987) studied a group of young children with severe to profound
hearing loss. They explored the relation between the child’s age at the beginning
of intervention, the hearing status of the family (deaf versus hearing parents), and
the outcomes in language development. Children born in families with deaf parents
were identified rather early because of routine hearing screening for infants. This
situation gave the chance for these infants to begin early with the intervention and
rehabilitation. This study found that the early identification and intervention could
be a predictor of better spoken language in these children (Sininger et al., 2010), and
correspondingly, of better play development. Today newborn hearing screening and
cochlear implants give the opportunity for more children to rely on spoken language
from an early age. When the level of verbal communication in children with hearing
impairment is similar to their hearing peers, they have equal abilities to interact in
play.
96   Play in Children with Hearing Impairments

6.2 Play between Parents and Children with Hearing Impairments

Parents are the first playmates of children, because of their response to the playful
infant behaviour. Infants naturally engage in different forms of play activities. During
the years they grow up and have more experiences, thanks to interactions with adults
and peers. It is their play with objects and people that stimulates brain development,
and subsequently, cognitive growth (Piaget, 1962). One of the earliest forms of infant
play is the repetitive motor activity. Infants also play by making sounds. They find
these vocalisations pleasurable, and also draw attention and provoke playful response
from caregivers (Wellhousen, 2002). Children with hearing impairment naturally
produce rhythmic motor play through vocalisations, but this production decreases
because they cannot hear themselves and cannot feel pleasure in listening to their
own babbling. But, in case of consistent use of proper amplification (hearing aid,
cochlear implant, bone-anchored hearing aid), the hearing abilities are stimulated,
and respectively, they have a positive effect on the child–parent interaction and play
behaviour.
Joint attention between a parent and a child develops during the first three
years of life. This developmental process facilitates the acquisition of new words
through interpersonal interactions and play. Joint attention subsequently forms
representational skills and use of symbols in play. Cejas et al. (2014) found that young
deaf children of hearing parents, compared to hearing counterparts, have deficits in
joint engagement, which are related to oral language. In the youngest age groups, deaf
children spend more time in unengaged states and less time in symbol states (e.g.,
parent and child are taking turns pretending to feed a doll). Clearly, the focus of their
research is on oral relation and does not take into account shared communication in
sign language. These results contrast with those from a study done by Spencer and
Waxman (1995), which showed no differences in engagement states in play between
deaf and hearing children aged 9 to 18 months.

6.3 Pretend Play in Children with Hearing Impairments

Researches about pretend play reported no significant differences comparing children

with typical development and hearing-impaired children (Lyon, 1997; Spencer &
Deyo, 1993; Spencer, 1996 in Brown et al., 2001). In 1990, Spencer, Deyo and Grindstaff
showed that deaf children with deaf parents, who use sign language as their first
language to communicate, spent equivalent amount of time in pretend play and
produced the same amount and level of pretend play as their hearing counterparts.
Another research by Brown et al. (2001) reported about pretend play and language
production in children with hearing loss (between 3 and 6 years). The study showed
that deaf children who have significant spoken language delay engaged in pretend
play less often than their hearing peers (Higginbotham & Baker, 1981; Schirmer, 1989;
 Symbolic Play in Children with Hearing Impairments   97

Cornelius & Hornett, 1990; Brown et al., 1997; Selmi & Rueda, 1998: in Brown et al.,
2001). The scores for each one of the structures underpinning pretend play were lower
in children with hearing loss. Children with hearing loss between 12 and 30 months
of age in oral programmes produced lesser imaginative play than their hearing peers.
Differences between the experimental and control groups were found in the language
domain, but not in the cognitive domain (Brown et al., 2001). Verbal communication
of hearing-impaired children is affected, but the nonverbal communication and time
spent in pretend play are similar to typically developing children.

6.4 Symbolic Play in Children with Hearing Impairments

Humans use a wide variety of symbolic systems—spoken language, reading and

writing, numbers, painting, drawing, music, and so on. Children develop these
systems during the first five years of life by learning during play. Normally, play
with language starts under the age of one, playing with sounds of the language or
languages children are hearing around them. This is a very active process and quickly
develops into making up new words, playing with rhymes. In case of hearing loss at
an early age, it would result in oral language delay and the symbolic play would be
affected.
Slade (1994) quotes a longitudinal study of play in six deaf children aged 1–3 by
Gregory and Mogford (1983) who found that children with hearing impairment clearly
demonstrated the capacity to use objects symbolically. But, comparing to the hearing
counterparts of the same age, deaf children did not enact sequences of similar length
and complexity (Slade & Wolf, 1994).

6.5 Free Play in Children with Hearing Impairments

Play provides a context in which children are motivated to communicate, and the
availability of playmates increases the frequency and range of opportunities for
language practice. Initiating, mediating, and sustaining a joint, playful activity
requires children to use language in innovative ways and challenge them to
communicate more clearly in social exchanges. Mills et al.’s (2014) findings in a study
are supported by Odom et al. (1993). They observed that verbal interactions between
peers were more likely to occur during play than during any other classroom activity.
Barton and Wolery (2008) found that providing an intervention to increase play skills
led to increased vocalisations, even though language was not a direct target of the
intervention (Mills et al., 2014). It seems that free play supports language development
of young children.
Play could be an effective medium for developing the necessary relationship to
foster appropriate interaction (e.g., play turn-taking, sharing), and ultimately social
98   Play in Children with Hearing Impairments

communicative growth (e.g., vocal/verbal initiations, responding, and turn-taking)

between children with and without hearing loss (Bat-Chava & Deignan, 2001). The
magnitude of language skills essential for spontaneous play is considerable.
De Luzio and Girolametto (2011) evaluated the types of initiations and responses
during play between children with normal hearing and children with severe to
profound hearing loss. They found no significant difference between the two groups
in terms of their initiation efforts. Both deaf and hearing preschoolers frequently used
vocalisations, smiles, and object-related acts as strategies to initiate play (Vandell &
George, 1981). Hearing-impaired children used similar initiation strategies as their
hearing peers. They include nonverbal initiation, invitation to play, offering an object,
or imitating the behaviour of other children (Weisel et al., 2005).
Play behaviour in preschoolers with and without hearing loss was described
in several research articles. Harris (2014) quotes a study by Lederberg et  al. (1987)
about free play, in which researchers documented the duration, the number, and the
complexity of children’s interactions. The conclusion of the study was that, during
free play, both hearing and hearing-impaired children interacted more frequently
with peers with similar hearing abilities (Harris, 2014).

6.6 Social Play in Children with Hearing Impairments

A study of play in nursery school by Schvarfman (1977) found differences in quality

and nature of play between hearing-impaired and typically developing children. Deaf
children spent more of their time as onlookers and in solitary play. They engaged in
less parallel play and in less cooperative and dramatic play with their hearing peers
(Slade, 1994).
Qayyum, Khan, and Rais (2015) observed play behaviour during leisure time
of children with hearing impairment in special schools. They found that the most
frequent play behaviour was social play (group play) followed by non-play behaviour
(active conversation) and the last was cognitive play (games with rules). The cognitive
functional play was the least because these games require better understanding of
rules through listening. Qayyum et  al. found that games, which require listening
to rules before start of play, were not understood well by the children with hearing
impairment. Pupils played better games that only require visual cues (Qayyum et al.,
2015).
Xie (2013) quotes a research by Anita and Dittillo (1998) focused on social play of
children with hearing impairment and hearing children during inside play in a small
group. They found that children with hearing impairment engaged in significantly
less associative or cooperative play than children with normal hearing, but they
engaged equally in non-play and social play.
Conclusion   99

6.7 Conclusion

Many researchers explore play in hearing-impaired children. They found a strong

relationship between play and language development. Play and language are indirectly
influenced by the hearing status and the modality of communication (sign language
or spoken language). Less optimal early experiences, such as deprivation of linguistic
stimuli by the caregiver, lack of exposure to sign language, linguistics re-education
delay, could impede normal cognitive and linguistic development of hearing-
impaired children. Better language development in both sign language and spoken
language is a predictor of better play behaviour. Children with hearing impairment
think, learn, play, and behave exactly like their hearing peers. Deaf children could
need more visual signs, cues, or speech reading and those need more time in turn-
taking exchanges. However, more time in the exchanges does not mean worse quality
of play interaction, especially when this is made with suitable communication mode
for each child with hearing impairment. If the children with hearing loss are provided
with supportive communication from early stage of their life, they develop and play
like typically developing children.

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Mira Tzvetkova-Arsova and Tamara Zappaterra
7 Play in Children with Visual Impairments

7.1 Basic Issues on Play in Children with Visual Impairments

As mentioned in Chapter 1, “play is a range of voluntary, intrinsically motivated

activities normally associated with recreational pleasure and enjoyment” (Garvey,
1990). Play is also the child’s main ‘job’. It is often associated mainly with its visual
aspects–looking at the toys, and thus, playing with them, seeing the play-partners,
and initiating a game together, or in other words, engaging in the play activity through
establishing a visual control, visual collaboration, and visual participation.
Many researches have been dedicated to play in children with visual impairments;
within these studies, comparison are often offered, with respect to play, among the
groups of blind, low-vision, and sighted children. Most of them conclude that visually
impaired children, in general, experience major challenges and delays in many
developmental areas, including play. According to Lowenfeld (1948), for instance, the
limits of blind children are situated in the following three main areas:
a. I n the control of the environment and the self in relation to it.
b. I n the ability to get about.
c. In the range and variety of concepts.

Other researchers (Rowland, 1985) report that the delays and limitations experienced
by visually impaired children and adults may include:
a. S ensory delay.
b. S ocial delay (difficulties in the quality and quantity of social relations).
c. Political delay (limits in the political and social awareness that their condition must
be protected with egalitarian rights).

On the other hand, studies revealed that visually impaired children and sighted
children have equal levels of development in many other areas, such as:
– Language development (Kirk & Gallaghar, 1979)
– Cognitive development and the intellectual abilities (Bateman, 1963; Litvak, 1985).
– School achievements (Gomulicki, 1961).

The famous blind Italian educator Augusto Romagnoli indicates that the blind child
acquires through play the awareness of self, of the others and of their otherness,
experiences solidarity and cooperation. So, play must be pursued as a principle of
maximum socialisation (Romagnoli, 1924).
Based on these findings, one may expect that play is also delayed or compromised
in blind and low-vision children. Different studies confirm this assumption. For

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 Basic Issues on Play in Children with Visual Impairments   103

instance, a Nordic study about five-year-old children in kindergartens identified four

separate behaviour patterns (Sommer, 2003):
a) Social interactive behaviour. The child:
– is able to focus his or her attention on and follow the intentions of other children;
– is able to mark and follow his or her intentions, ideas, and desires – but is also able
to adapt them to the interests of other children;
– is able to interpret and size up the intentions and enterprises of other children;
– is able to act in order to facilitate that his or her intentions and enterprises are
carried out;
– is often able to leave his or her mark on the mutual interaction in the group in a
positive way through his or her intentions, initiatives, and enterprises;
– is characterised as well integrated in the group of children.
b) Self-marking behaviour. The child:
is characterised by a strong motivation for being ‘seen and heard’;
tries to catch the attention and interest of others to show himself or herself off;
shows individuality and competes noticeably with others to claim the social scene.
c) Adaptation-ready. The child:
– is able to contribute to the execution of activities in the group thanks to his or her
great attention to the intentions of others and good social ‘ear’;
– is seldom a soloist;
– is able to follow others’ proposals and agenda–through social acts, not in the form
of passive submission;
– only marks his or her intentions weakly and to a modest extent;
– is able to follow an agenda determined by others–but has minimal influence on the
group’s agendas; he or she seldom opposes other children’s agendas;
– often experiences that his or her proposals are ignored by others who are more
dominant and better at applying various instruments of power–often he or she
experiences talking without anyone paying attention;
– often leaves it up to others, adults, and children, to choose his or her social contacts,
others making contact to other children on his or her behalf.
d) Socially isolated behaviour. The child:
– generally has only sporadic interactions with others;
– receives few and weak initiations of contact from other children. As a consequence,
the child is often ignored or overlooked by others;
– uses more active strategies to avoid or break a social contact;
– experiences lack of success in making contact with others, and this results in minor
attention to the other children’s intentions as well as in reduced ability to follow
these intentions;
– withdraws from interactions with other children and withdraws to inner fantasy
world;
– sometimes may turn into a socially excluded child, if the isolation is severe and
consistent.
104   Play in Children with Visual Impairments

Blind children often have difficulty in becoming or showing socially competent in

interactions on their own with sighted friends. They may use self-marking behaviour
as a necessity in order to be acknowledged–heard and seen–by the others. However,
positive self-marking behaviour may often develop into negative behaviour, because
self-marking behaviour is only positive if it is adopted with moderation. Blind
children’s behaviour patterns may have some points of similarity with behaviour
patterns that are normally observed in adaptation-ready and socially isolated
children (Ingsholt, 2009). It is important to note that these differences in social
skills affect the play behaviour. Many studies have shown that children with visual
impairments show a high variability in social competence skills, a compromised
social interaction and show that this limits the play behaviour: in kindergarten they
are less enterprising, while only seldom they look for interactions with peers and
propose games and activities (Celeste, 2006; Parsons, 1986; Skellenger et al., 1997;
Zanandrea, 1998).
In addition, Schneekloth (1989) discovered that blind children spent playing
alone 56% of their play time, while low-vision children spent only 33% of this time
alone, compared to 14% in children without any visual impairment. The same
author also found out that sighted children spent most of their play time interacting
with their peers, while visually impaired spent 1/3 of their play time in interactions
with adults.
A comprehensive study of Fraiberg (1977) compared visually impaired and
sighted children in their play activities. She discovered that blind students had
significant delays in many play areas–for example, they did not perform imitative
play before 30-36 month. An earlier research of Fraiberg and Adelson (1973)
suggested that even the concept of self in blind and low-vision children was delayed
because of their poor and rare engagement in symbolic, pretend, and fantasy plays.
According to the authors this is due to the fact that sighted children started to
imitate the household life by taking care of a doll, for instance, at the age of 24
months, while blind children did not demonstrate this type of play before the age
of 36-42 months.
Later, a similar study was carried by Troster and Brambring (1994). The authors
concluded that sighted children engaged in more complex levels of play at an earlier
age than the blind children did; the blind children interacted less frequently with
their peers than the sighted children did; furthermore, the blind children preferred
tactile-auditory games and toys and rarely engaged in symbolic games.
Similarly, other studies (Parsons, 1986; Lewis et al., 2000; Tioli, 2006) confirm
a substantial difference in the playing capabilities of blind children, indicating
that the blind child has a delay in the onset of mental image that later gives rise to
the emergence of symbolic play. The blind child remains engaged for long in play
activities that include: exploration of own body, and undifferentiated manipulation
of an object, in a nonfunctional modality, without specific purposes. These are,
therefore, activities of repetitive and stereotyped solitary play. Not only the symbolic
 Basic Issues on Play in Children with Visual Impairments   105

play appears much later than in sighted children, that is in a span of time between
the second year of life and the end of preschool age, but also the constructive
play–where child learns to place objects in relation to each other (for example, to
build a tower with toy blocks or doing a puzzle)–is compromised due to manual
and bimanual coordination difficulties, less coordination and orientation abilities.
In 1995, the Bielefeld longitudinal study on early intervention and family
counselling for blind infants and preschoolers (Brambring et al., 1995) assessed all
areas of development, comparing the blind and sighted children’s performances.
In 2005, Brambring presented some results of the longitudinal studies held in the
University of Bielefeld, which included the findings on 107 skills analysed in a
comparative way between blind and sighted children, divided into four areas.
–– Manual and daily living skills
–– Gross motor skills
–– Social interaction
–– Language

Table 7.1. shows a few examples, where blind children experience serious delays in
different play activities.

Table 7.1. Play delays in blind children (Brambring, 2005)

Skill Sighted children Blind children

(age in months) (age in months)

Building a tower with three toy blocks 15 29

Finding two identical objects in a set of five objects 26 42

Beating a drum rhythmically with two drumsticks 11 37

One very comprehensive literature review on play in visually impaired children

was made by Rettig (1994). One of the findings in this research was that vision and
communication were both very important, especially in the case of social play with
peers, and in this regard, some forms of play may be difficult to perform by blind or
low-vision children. Furthermore, Rettig (cit.) adds that visually impaired children
have limited play experience in their play, and these are due to delays in different
developmental areas. This applies to a great extend to:
1. Practice play
2. Pretend or symbolic play
3. Social play
4. Play with rules
5. Creative play
6. Associative play
106   Play in Children with Visual Impairments

Visually impaired children demonstrate a delay in their symbolic play–at the age
of 25,9 months (Rogers & Puchalski, 1984). Fariberg (1977) even prolonged this
delay, stating that blind children do not participate in pretend and imitation play
before 30-36 months of age. Fraiberg and Adelson (1973) suggested that the delayed
acquisition of the concept of self in visually impaired children is associated with the
delay in their symbolic play.
This point of view is confirmed more recently by Brambing (2004) who described
the difficulty of the process of separation-individuation not only as a cause of limited
self-perception of the child with visual impairment, but also as the cause of his or
her late speech development, especially in regard to the late appearance of the first
person singular. This last–that is the initial delay in language development–is also
explained (Rowland, 1984; Hatwell, 2003) in relation to the lack of the prelinguistic
child/mother dialogue through facial expressions and proxemics.
Brambing (2004) also underlined that, when symbolic play appears in the blind child,
it is not based on the use of objects, rather on role-play games. This may be due to the fact
that for the blind child it is easier to understand and use the process of symbolisation
through acknowledging a similarity of reciprocal body movements and exchanges
between people than through a similitude of objects. This hypothesis confirms that during
the development of these children the emphasis is on the verbal aspects of their life, and
also demonstrates that the initial language delay can be perfectly compensated.
On the other hand, some forms of play may not be so difficult for children with
visual impairments, and they may feel engaged in them without great effort; as to
the possible kinds of play activities, it is the case of, for example: functional play,
constructive play play with language fantastic play, storytelling.

7.2 Strategies for Compensation of the Delays and Difficulties in

Play by Children with Visual Impairments

Rettig and Salm (1992) suggested five strategies for intervention in order to support
and to improve the play behaviours of young children with visual impairments:
1. Specific instructions for developing play skills
2. Use of toys
3. Adaptation of the environment
4. Including peers without disabilities
5. The role of adults

The first strategy includes actions as: a) providing the blind babies and infants with
as many real objects as possible; b) helping symbolic play; c) avoiding the stereotyped
behaviours and mannerisms and so on; d) enhancing sense of self to foster social
development (Rettig, 1994); e) encouraging intrinsic motivation, active engagement,
flexibility, spontaneity (Recchia, 1997).
Conclusion   107

The second strategy includes: a) demonstrating the child on how to use the
different toys he or she has at home; b) providing the blind child more tactile and/or
musical toys.
The third strategy suggests to help the visually impaired children to orient and
move effectively and autonomously in their play environment and to feel comfortable
and safe there. Schneekloth (1989) states that play environments that are appropriately
designed for children with visual impairments need to be “accessible, safe, exciting
and complex” (1989: 201). This strategy also includes to design ordinary learning
environments opportunities for play and to adapt learning environments to make
them accessible to the impaired child in inclusive contexts (Rogow, 1983; Staccioli,
2010).
The fourth strategy proposed to introduce gradually sighted playing companions
to the visually impaired child (at first only one). In addition, Rettig and Salm (1992)
suggested to provide some adult supervision when visually impaired and sighted
children play together in order to encourage any spontaneous interactions and to
avoid any discriminative behaviours. The interaction between the blind child and his
or her peers is important not only for access to associative and cooperative play in
view of his or her development and pleasure, but mostly to give them the opportunity
to fully exercise one of their rights: in fact, participation in recreational, play, leisure,
and sport activities, including those in the school system, is precisely cited in the UN
Convention on the Rights of Persons with Disabilities (2006, Art. 31), historically most
denied in case of sensory disability.
Lastly, the fifth strategy suggests different levels of participation of adults
(parents, early carers, and other professionals) in the visually impaired child’s play.
Rettig (1994) refers a gradual withdrawal of parents and other adults from playing
with the children with visual impairments. Tioli (2006) also advances that the role of
the adult becomes more and more insignificant during these children’s development.
On the contrary, the play of these children should be first led by the adult, who should
commensurate it to the child’s ability but also propose higher level of performance;
not too high, however, so that the child does not feel frustrated and the attempt
to increase the complexity of play does not fail. Only at that point, when the child
has successfully experienced some types of play and feels more confident with this
activity, a play free from adult intervention can be proposed.

7.3 Conclusion

Many authors underline the significance of play for the overall child development.
Experiences from the early periods of child’s life, when play is the main activity a child
is engaged in, form the basis for subsequent social development in adults (Sutton-
Smith, 2001; Ingsholt, 2009; Tzvetkova, 1994). Augusto Romagnoli was one the first
educators to indicate that the blind child acquires through play the awareness of self,
108   Play in Children with Visual Impairments

of others. and of their otherness, experiences solidarity and cooperation. So, play
must be pursued as a principle of maximum socialisation (Romagnoli, 1924).
However, visually impaired children are able to build their play skills similarly
to sighted children, with some difficulties or delays. As the Russian educator and
psychologist Vygotskij noted: “In the end there is no fundamental difference between
the sighted and the blind child [...] and the whole process of development is one and
the same for blind and sighted children” (1983:95).

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Natalia Amelina and Vardit Kindler
8 Play in Children with Communication Disorders
All mental processes during the childhood – perception, memory, attention,
imagination, thinking, purposeful behaviour – develop through direct engagement
with language.
Connected with consciousness in general, human language joins various
relationships with all mental processes. Being a mediated system of signs, language
reconstructs all mental processes of the person, reaching the level of volitional,
conscious functioning. It is clear that language and thinking are closely connected
with each other.
Clinical, medical, psychological, and pedagogical research, as well knowledge in
the professional fields of language, show that children with communication disorders
face specific challenges associated with mental processes: attention, perception,
memory, thinking (Hughes, 2010).
Not only the development of cognition suffers from the presence of communication
disorders, but, as it is immediately evident, the area of social development is affected
by the restriction of possibilities to exchange comments, ideas, proposals with their
peers that these children unavoidably experience. This fact has, in turn, consequences
on the overall child development, and in particular, on the language development
itself. Solutions should be found as soon as possible to substitute and/or to support
the communication of these children, exactly to the purpose of avoiding secondary
acquired limitations.
However, before characterising the play skills of these children, it is important
to identify the term ‘communication disorders’. Most of the existing studies identify
children with communication disorders as a heterogeneous group characterised by a
range of difficulties in speech and language.
Communication disorders due to language difficulties are often associated with
other kinds of disabilities, such as intellectual and physical impairments or autism
spectrum disorders;1 or, they can be present as the only or prevalent neurological
disorder, as in the case of dysphasia.
Language disorders are usually diagnosed by using tests of nonverbal intelligence
(Guralnick et  al., 2003; Catts et  al., 2002; Kelly & Sally, 1999). Other diagnosis
instruments aimed at evaluating the detailed characteristics of the impairment can be
used to study single levels, including those of phonology, morphosyntax, semantics,
pragmatics, and discourse (Leonard, 1998; Tager-Flusberg & Cooper, 1999; Tallal &
Benasich, 2002).

1 Further deepening is contained in the related chapters of this book.

© 2017 Natalia Amelina and Vardit Kindler

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License.
112   Play in Children with Communication Disorders

8.1 Some Characteristics of Mental Processes in Children with

Communication Disorders

Psychological research states that limitations in communication often result in

difficulties in some intellectual activities, such as to analyse purposefully the
conditions of an intellectual task, or to find its essential elements and to single out
the right correlations among them; to make comparisons; to generalise; to make
abstractions; and to implement control over intellectual activities. The main obstacle
for these children is the difficulty to plan their activities (and play is among them) as
a logical series of consecutive specific actions. At the same time, the performance of
separate operations usually does not cause difficulties to them.
The most critical limitation in the intellectual activity of these children is the
insufficient development of separate operations, while the whole plan of the activity
is comprehended and carried out by the child (Usanova, 1995). Lurija (1998) noted
that communication disorders result in cross-functional social and developmental
limitations.
All types of limitations in language and speech development, according to
various authors, decrease the volume of information that can be acquired by a child;
furthermore, the accuracy of the acquired information decreases and the processing
of language development slows down. In general, they have negative effects on a
child’s play.
Children with speech impairments due to visible damages to the effector
apparatus – for example, in the case of lip and/or palate cleft malformations2 – often
meet difficulties in interacting with their peers and experience emotional stress.
Stuttering3 in childhood is often related to the limitation of attention
concentration; according to some authors, they often show impulsivity that leads
them to try to reach a goal in a hurry, without the needed concentration. Also, in this
case, their relationships with peers can be restricted due to a reluctance induced by
their awareness of their verbal expression difficulties; they look shy and sometimes
isolated, do not trust their own abilities, are reluctant to take a central role in play and
prefer to observe or to adopt supporting roles.
Children with dysarthria4 have severe difficulties or limitations in developing
effective attention abilities (both sustaining and shifting) as their peers; they may find
it difficult to understand language and may need additional explanation or prompts

2 Cleft lip and palate malformations, also known as oro-facial cleft, is a group of congenital impair-
ment, that includes cleft lip and/or cleft palate.
3 Stuttering is a speech disorder in which the flow of speech is disrupted by involuntary repeti-
tions and prolongations of sounds, syllables, words, or phrases as well as involuntary silent pauses or
blocks in which the person is unable to produce sounds.
4 Dysarthria is a motor-speech disorder resulting from neurological injury of the motor component
of the motor-speech system.
 Play Activities of Children with Communication Disorders   113

when they are given verbal tasks or instructions. They also may show difficulties in
switching from one task to another, as well as a little interest in the results of the
performed activity.
According to Ippolitova and Mastyukova (1985), children with dysarthria might
find logical thinking challenging. Sometimes, they are not used to make connections
between subjects and phenomena of the world around – similarities and distinctions
– on the basis of usual and expected cues; for example, the classification of
subjects is carried out on the basis of the concrete situational environments of their
communication, while they find it difficult to make generalisations.
Developmental dysphasia,5 which is a total restriction in speech related to
language disorders, can radically influence the child’s social and psychological
development; it interrupts and affects the most important means and ways of
communication, thus causing a slow down of the cognitive development. Children
with developmental dysphasia may experience a slow rate in the information
reception and in the quality of language processing, which, in turn, also worsens
the communication abilities: for example, they may find it difficult to analyse tasks,
make comparisons, generalise, make abstractions. Attention stability and switching
attention can be also difficult. All these problems might cause them face possible
emotional and psychological challenges, such as irritability, emotional instability,
lack of initiative, and so on. A constant support to their motivation can be useful for
their involvement.

8.2 Play Activities of Children with Communication Disorders

Psychological research states that preschool children with speech and language
disorders, in comparison with their non-impaired peers, linger long in the
manipulation of objects expected in the stage of practice play; in addition, role-
playing games are mastered by them much more slowly, with quite repetitive and
elementary contents. If the child starts playing with his/her peers, he or she quickly
‘slides off’ the role assigned to him or her, thereby breaking the rules. This could be
a reason for these children often are excluded from play with their peers or they are
given only supporting roles in the play activities.
The negative factors influencing the play of children with communication
impairments are related to the fact that their language is considered poor by their
peers, or that their play companions do not correctly understand what they are
saying, due to their imperfect pronunciation of language or the adoption of unusual
morphosyntactic structures.

5 Developmental dysphasia is a severe impairment of the language system that is considered a re-
sult of cortical speech zones defect appearing in the preverbal period.
114   Play in Children with Communication Disorders

All these limitations may cause difficulties mainly to the symbolic play, where
the use of language is almost imperative, for pretending an object is something else
and agreeing on this fact with other children, for building up – alone or in group –
play situations, with roles, conversations, events, and so on, or even for using the
language as the core itself of play, for example, in narrations, in language jokes.
A number of researchers have, in fact, investigated the relationships between
language disorders and difficulties in symbolic play (Lewis et  al., 2000; Lyytinen
et al., 2001; McCune, 1995; Watt et al., 2006). Many authors, for instance, noted that
children with communication disorders face difficulties in handling peer conflict
(Hart et al., 2004; Horowitz et al., 2007); they are seldom capable of behaving in an
assertive way, get frustrated easily, and are more dependent on adults for assistance
than other children (McCabe & Marshall, 2006; Picone & McCabe, 2005). For all of the
aforementioned reasons, they are less likely than the typically developing child to
engage in cooperative make-believe play.
Preschool children with severe speech and language disorders often tend to play
with toys silently, in a solitary way; only sometimes, they may accompany their own
actions with sounds or emotional exclamations. While communicating with peers,
they tend to replace words with deictic words or gestures, or sometimes with single
words. The most frequent emotional aspect of the relationship of a child with a toy is
displayed in the form of exclamations, sounds, single words, onomatopoeias.
In the case that these children show also difficulties in understanding the
language and the situations in which they are, the core essence of the play and mainly
the game rules remain inaccessible for a long time; they tend to repeat their actions
and to imitate what has been already done in other similar situations.
Another type of play that is really compromised in the case of communication
disorders is the game with rules: in fact, in this case, not only the rules should be
deeply understood – and they are mainly shared verbally in the children’s group – but
they should then be adopted, sometimes with the need of negotiating with the peers
their right application.
All the play situations, within any type of play, in which a space is necessarily
devoted to negotiation, mediation, to presenting and explaining one’s own reasons
and ideas about the play development, can be challenging for these children. They
can, of course, take part in games and in collective play activities, but they rely mostly
on imitation and repetition, while as soon as the need for a dialogue is foreseen, they
would need support; otherwise, they will soon abandon the play activity itself.

8.3 Environmental Factors: Augmentative Alternative

Communication

A number of researches noted that the differences in the play activities between
children with communication disorders and the other children can be strongly related
 Environmental Factors: Augmentative Alternative Communication   115

to environmental factors and that the impairments can be widely reduced with the
right environmental supports, strategies, and tools.
The quality and quantity of interactions with peers, the adult’s ability to respond
to the child’s communication efforts, the accessibility of play areas for those facing
additional impairments (e.g., children with motor and/or visual impairments), and
the availability of adapted toys or assistive technologies for play and communication
are the factors that influence the child’s participation in play and leisure activities.
Due to its focus on participation, the adoption of Augmentative and Alternative
Communication (AAC) strategies is a variable influencing the child’s engagement in
play and his or her participation in social interactions with peers.
According to ISAAC, AAC is “a set of tools and strategies that an individual
uses to solve everyday communicative challenges”.6 AAC is an umbrella term that
encompasses the communication methods used to supplement or replace speech for
persons who experience impairments in the production or comprehension of spoken
or written language.
AAC is based on devoted intervention approaches (Glennen, 2000) that
combine the child’s natural communication abilities (including any existing speech
or vocalisations, gestures, manual signs, facial expressions) with aided forms
of communication, including the use of communication boards with symbols7
(pictures, photographs, line drawings, symbols, printed words) or the use of speech-
output communication devices.
AAC is a multimodal approach, permitting a child to use a wide range of modes to
communicate messages and ideas. As communication abilities may change over time,
although sometimes very slowly, the choice of the AAC system or code at one age is
not to be considered definitive, and it may be modified as a child grows and develops
(Beukelman & Mirenda, 2005).
The roles an AAC system plays will vary depending on an individual child’s
needs; they can augment the existing natural speech, provide a primary output
mode for communication, provide an input and an output mode for language and
communication, and serve as a language intervention strategy (Light & Drager, 2007).
If a child needs an AAC communication system, it is very important that it is
used during all his or her daily activities, to express his or her desires and ideas, to
comment about what happens. Of course, in these cases, the AAC system as well as its
low- or high-tech supports should be available in his or her contexts of life above all to
support the daily activities, first of all for playing. The most common and well-known

6 ISAAC is the International Society for Augmentative and Alternative Communication; www.isaac-
online.org.
7 The symbols and pictograms that are used can be created on purpose, on the basis of the single
child’s needs, or belong to internationally established codes, as in the case of PIC, PCS, Blissymbolics,
and so on.
116   Play in Children with Communication Disorders

role of the devices is to provide an output mode for communication. Technological

devices, in particular, offer children with communication impairments the access
to “the magic and the power of communication” (Light & Drager, 2007). It is also of
utmost importance, in fact, that the child is offered appropriate AAC systems as early
as possible, so that the communication mode becomes a substantial aspect of his or
her life. Thanks to the use of AAC, the child can grow, learn, develop under the social
and cognitive respect.
But, to reach these objectives, the related technological devices should respond
to some particular characteristics (Light & Drager, 2002): among the others, they
should be ‘appealing, capturing’; they must be easily integrated into all aspects of
daily living; they might ‘provide access to the magical power of communication’;
they should grow with children as they develop. The design of these tools is, thus,
extremely important (Light et al., 2004), possibly as similar as possible in its main
features to the children’s first toys, above all as they should be used in collective
spaces, where other children also live and play; they must be attractive also to the
peers of children with communication impairments, and become a usual and well-
known mean for communication and for playing together.
As it has been argued, the type of play that is mostly influenced by a
communication impairment is the symbolic play. By providing the impaired child
the right symbols he or she needs to fully participate, AAC can prove very useful to
support – without underestimating the evidence from practice that in some cases play
should be explicitly taught (Barton & Wolery, 2008) – all the symbolic play activities,
from the pretend play to the use of dolls and other toys able to create environments
and make-believe situations, or even role-playing.
AAC can, of course, also be adopted to tell stories, by substituting the written text
that usually accompanies the children’s book stories with symbols, and this option
gives a group of children the possibility to share the same activity; if they are very
young, symbols can be as the unique text, without the alphabetical one.
Furthermore, the possibility to manage a communication code gives the child
with communication impairments the opportunity to play different roles within the
group and also within the family: for example, he or she can tell a joke, pretend that
an object is a different one, give instructions to other persons – peers or adults – on
how they should act, or respond, and on the roles they should assume; if the device
has also a voice output, the child might also take part in nursery rhymes, can even
sing with the others.
If the communication impairment is not accompanied by other types of
impairments, the child should not experience difficulties in constructive play; thanks
to the AAC, he or she can be anyway supported in following the different steps of a
complex activity, such as building a home for puppets, using Lego bricks, cooking
biscuits, and so on, and this is much more true if a physical impairment is associated
and the child has severe limitations in fine movements.
Conclusion   117

As to the games with rules, AAC can be used as a support to explain the rules to
the child with communication impairments, in case this is needed, but it can also
be concretely used as a tool for mediating relationship with peers – for example, to
indicate the alternate turn, to score points, to interrupt the game if needed and makes
one’s arguments heard.
This short review can illustrate clearly that AAC is a very powerful tool for making
it possible and improving the play of children with communication impairments;
as it is easy to understand, communication being the most important way to be in
contact with the world around, these play activities should be patently supported to
enhance and empower their potential inclusive aspects. As soon as communication is
available, it is also possible to build up new worlds – real or invented – and to modify
them, to share ideas and projects, to discuss, to impose one’s own points of view, to
claim victory, or to admit defeat.
This not only favours but implies that inclusive contexts are offered to these
children, so that they can fully benefit of the related opportunities for communicating,
and for playing; on the other hand, the greater validity of the inclusive model has been
confirmed in the field research (Foreman, Arthur-Kelly & Pascoe, 2004): students
using AAC in general classrooms were involved in significantly higher levels and more
frequent communicative interaction than their peers in special classrooms.

8.4 Conclusion

The topic of play of children with communicational disorders has not been studied
in-depth until now and even the existing studies give only some suggestions about
the reasons that are at the basis of the differences existing in their play activities. Too
often, it has been assumed that children with communication disorders have inherent
limitations in play when, sometimes, differences in play skills might be explained
more easily by environmental variables.
However, it is important to take into consideration the possible reasons of play
differences, cited by a certain number of the aforementioned researches.
–– The cognitive activities of children with communication disorders are impacted
by difficulties in their attention, in particular, the attention focus, the ability to
switch, the attention stability, and so on.
–– There are difficulties in memory – acoustic, visual, verbal, and logical. These
limitations have an impact on the other mental processes, such as perception,
thinking, self-organisation of purposeful activity, and they make speech even
more difficult.
–– Speech and language disorders limit the social contacts and communication of
these children with their peers and/or with adults. This influences in a negative
way the development of the cognitive processes, and in turn, changes also the
nature of their play.
118   Play in Children with Communication Disorders

It is very important for adults to understand the verbal and nonverbal signals while
playing with the child. The aforementioned strategies and assistive technologies can
play a significant role of support to parents and educators.

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Serenella Besio and Natalia Amelina
9 Play in Children with Physical Impairment

9.1 Motricity and Mind

According to numerous researchers (Sechenov, 1952; Pavlov, 1937; Oliverio, 2007),

motor actions play an important role in the formation of mind; they affect learning
and are at the basis of language development. In fact, movements, motor schemes,
and physical relationships with the real world can cause a development in mental
logic, underpin logical construct, and are at the basis of the understanding of the
cause/effect relationships and of the chaining of sequences of thoughts.
Between motricity and mind, there is a complex interrelation, which could be
described as cyclic: a movement can exert some consequence on the surrounding
environment, and due to the perception of these consequences, new, modified
movements can be produced; this relationship appears very clearly in a newborn
(Barbeau, 1990). According to this approach, it is not the movement that satisfies
the mind’s needs, while it is the mind that performs the actions (Oliverio, 2007).
Some authors recently sustain that motor control resides in nervous system, body,
and environments “viewed as dynamical systems in continuous interaction” (Turvey,
2009:3).
The ontogeny seems to reproduce in this sense the phylogeny: some
neurophysiologists (Calvin, 1990) sustain, in fact, that the evolution of some motor
behaviours caused, historically, the creation of a ‘motor logic’ based on subsequent
steps, and this provoked—from the motor and the premotor cortex areas—a sort of
contamination towards the Broca area of language, to ‘inspire’ the generation of
sequences of syllables.
For Lurija (1973), the human brain is a sort of archive of complex motor schemes—
that he defined ‘kinetic melodies’ to refer to their fluidity and availability in different
moments of daily life. The techniques of brain imaging have then greatly contributed
to the knowledge of such schemes. The major achievement in these last decades is the
discovery of the role of the mirror neurons (Gallese et al., 1996) located in the premotor
areas: it has been demonstrated, in fact, that there is a parallelism between the brain
areas fired while acting a movement and in imagining it or viewing it performed by
another or even by a robot. Studies concerning these relationships are currently done
in the neuroscience field, within the framework of the so-called ‘embodied cognition’
(Wilson, 2002), and even if final conclusions have not been reached, the undergoing
experimentations about the relationships between some areas of cognition (language,
memory, visual perception, and so on) and the movement, obtain various results, they
always demonstrate interesting clues of secure interconnection (Tomasino & Rumiati,
2013; Tomasino et al., 2011).

© 2017 Serenella Besio and Natalia Amelina

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License.
 Children with Physical Impairments   121

The child’s motricity depends on a complex mixture of predispositions and

experiences, on the brain’s capability to record the motor actions perceived by sight,
and on the progressive acquisition of motor actions that are corrected and refined
through trials and errors; they are finally stored in a memory able to code them as
schemes and to make them available in a fluid and stereotyped form (Oliverio, cit.).

9.2 Children with Physical Impairments

As a consequence of what is discussed in the previous paragraph, it is possible that a

delay in the development of motor skills, or the presence of various degrees of motor
impairments, may have an adverse impact on the mental and cognitive development
of the child.
A physical impairment—both congenital and acquired—creates substantial
limitations to physical ability or motor skills; when it is related to a problem of the
central nervous system—as in the case of cerebral palsy (CP),1 ataxia, traumatic
brain injury—it may be accompanied, at different degrees, by intellectual and
neuropsychological impairments,2 language and speech disorders, sensory
disabilities, as well as emotional and social difficulties (Tingle, 1990). It could also
be related to a damage to the peripheral nervous system and/or to the effector organs
(muscles, joints, and bones); the functional situation of these children is often
severe—as in the case of some types of muscular dystrophy, and of spinal muscular
atrophy— with rapid worsening; and also when it is less dramatic—as in the case of
juvenile rheumatoid arthritis—it limits the movement possibilities of the children,
thus restricting their ability and also their willingness to be active and to participate.
In many cases, motor impairments can prevent the child from acting in an
autonomous way in his or her daily activities, and in its turn, these limitations cause
insufficient development of his or her sensory and perception capabilities, as well as
low self-esteem and self-efficacy.
Very often, these children need the adoption of various assistive devices and
supports for movement and for communication. Of course, this implies a special
organisation of their daily life, because they need to be trained to the use of these tools
for long periods, and in turn, this may create restrictions in social participation as
well as difficulties at the psychological level, mainly with respect to self-construction
and self-representation.

1 Cerebral Palsy affects 2% of the newborns in technologically advanced countries.

2 Some Italian researches have highlighted the high presence (the two-third) of an intellectual disa-
bility in children with CP with a mean lower performance of one standard deviation (Cioni et al., 1993).
122   Play in Children with Physical Impairment

In the case of CP, the possible association of intellectual and sensorial

impairments,3 as well as the possible absence or severe impairment of speech,4
may cause a very complicated overall functioning of these children and may make
challenging to support and to empower their play abilities.
Speech disorders may disadvantage their communication with peers, as it might
be difficult to understand them, or an alternative communication system should
be adopted. These aspects, together with the possible difficulties to the emotional
sphere reported in the clinic literature,5 can result in social participation restriction,
if appropriate inclusive contexts are not established.
The most recent interpretative model of CP highlights the spontaneous adaptive
effort of the affected children, by considering the symptoms as the result of this effort,
within a complex situation of functional and biological systems that are intertwined
but superordinate to the performance. Thus, the motor component is no more the only
variable to consider, but it should be analysed together with the others: perceptive,
attentional, motivational, cognitive, and emotional-affective. All these components
tend to reach the best possible balance, while facing the inner and outer needs of the
child; in infancy, play is without a doubt the ideal bridge between the external world
and the internal world of the child (Voltolin & Obino, 2011).
But, play is also a matter of social inclusion: within the framework offered
by the International Classification of Functioning (WHO, 2001), many studies—
conducted to single out the possible correlations between the physical impairment
and the level of participation of children (Wright et al., 2008)—concluded that they
are at risk of reduced participation, interpreted both as a subjective and an objective
experience (Law et  al., 2006). A comprehensive literature analysis found that they
“experience greater participation restriction than their peers without impairment and
the participation of children with CP or other neurological impairments was more
restricted than that of other disability groups” (Imms et al., 2008:363). Furthermore,
activities are more passive, mainly organised at home and lack variety (Shikako et al.,
2008). Other surveys (Majnemer et al., 2008; Orlin et al., 2010; Palisano et al., 2011)
sustain that the intensity of participation is influenced by some determinants of
the child and his or her family: higher participation is related to higher gross motor
function, higher enjoyment, younger age, and higher family orientation; moreover,

3 According to the clinical literature, slowness of the thought processes and inertness of thinking
are typical of children with CP. Insufficiency of the highest cortical functions can also be shown in a
delayed development of the representations of space and time, of the processes of phonemic analysis,
and synthesis and problems of astereognosis (Mastyukova & Ippolitova, 1985).
4 Speech development of children with CP is characterised by disorders on many components: le-
xical, grammatical, and phonetic or phonemic. Most frequently, they suffer from dysarthria or even
anarthria.
5 Emotional excitability or irritability, sometimes mental block, disinhibition. In some cases, low
motivation to activity and aspiration to restricted social contacts are referred.
 Technologies and Children with Physical Impairments   123

social supports and environmental services also play an important role in increasing
the degree of participation. Denmark, with its welfare system, has been singled out as
one of the European countries where participation is best sustained (Michelsen et al.,
2008); another direct correlation has been found with the type of school system,
even if in Italy—a country that can boast a ‘totally inclusive’ system—the level of
participation is not so satisfying for families.

9.3 Technologies and Children with Physical Impairments

The severity of the physical impairment of these children has been often considered
a scientific challenge to create solutions for supporting both their activities and
participation; more than in the case of children with other types of impairments,
technologies can become a significant part of their life, and their use as tools for
rehabilitation is highly represented in the field literature. In particular, the play of
children with physical impairment has been investigated: for this reason, in what
follows, a short presentation of the area in more general way is necessary to review, in
the next paragraphs, the existing literature with respect to the characteristics of the
various types of play.
A particular role can be played by Assistive Technologies (ATs)6 whose name
should not remind the idea of being passively ‘assisted’ rather the construct of ‘supports
for independence’: in fact, they are mainly addressed to support the autonomy of
the impaired persons, to let them reach their goals, and to decrease the workload
of assistants. Many AT products7 have been developed, classified at international
level according to their scope,8 and made available to the users according to national
regulations.
Also, mainstream technologies are often used as tools for rehabilitation,
enjoyment, and leisure time. Due to the extraordinary and rapid changes in the
technological field, it is quite natural to think that they could offer these children what
they need, provide experiences they might not do by themselves, and consequently,
improve the perception of their own capabilities, thus enhancing their self-efficacy
(Bandura, 1977). This has been the case, for example, of some proposals to use the
virtual reality (VR) environments (Reid & Campbell, 2006), which can provide these

6 “Any product or technology-based service that enables people of all ages with activity limitations
in their daily life, education, work or leisure” (AAATE, 2003; www.aaate.net). Other definitions have
been established by international bodies, such as ISO 9999.
7 WHO prefers the expression Assistive Health Products to underline their importance to support the
person’s health condition, that is, a status of complete well-being: physical, psychological, and social:
http://www.who.int/phi/implementation/assistive_technology/gate_full_final_report_july_2014.pdf.
8 The Standard ISO 9999:2011 classifies the assistive products for persons with disabilities accor-
ding to their function in three hierarchical levels: www.iso.org/obp/ui/#iso:std:iso:9999:ed-5:v1:en.
124   Play in Children with Physical Impairment

children a sense of mastery and self-efficacy. In effect, VR has proved to provoke fun
in children with physical impairment, also when it is used for rehabilitation purposes
(Bryanton et al., 2006).
Nowadays, AT and mainstream technology are often used together to create
original systems called ‘assistive solutions’,9 which can also assemble environmental
modifications and even some personal assistance. They are highly personalised, as the
solution found for one individual is usually different from the one that proved useful
for another individual (Andrich, 2013). In addition, the same AT products are not
useful to the same degree for different persons, and they can play different functions
according to the users’ needs; a single piece of technology cannot solve a situation,
rather it should be adapted to the type and context of use (Besio, 2007). For all these
reasons, the process of choice of AT should be managed by a multi-professional team
with the active participation of the child and also of his or her parents during the
decision phase.
Another important field in which technology is fast developing and experimenting
is robotics. Play has been adopted as a promising testing area:10 “the underlying
assumption is that providing tailored means to encourage play through a robotic
toy will break down barriers for development through play, fostering individual
development up to the persons full potential” (Kronreif, 2009:222). These researches
also intend to envisage a ‘new potential role for advanced robotics in society’, seen
as a possible contributor to enhance the following three aspects: quality of life, social
inclusion, learning, and therapy. A very promising area of development of this field
is the use of robots to reveal cognitive skills of children with disabilities, which is
particularly difficult in case of severe impairments (Cook et al., 2010).
Any AT—including robotic tools—that supports the motor actions of the child
“may enable development” (Cook & Polgar, 2008:67). Unfortunately, finding the
suitable assistive solution for children with severe physical impairment could be
difficult and challenging for them, and they should be supported and motivated to
gain the desired result: their major involvement can be, obtained, again, by recurring
to technologies that can be able to playfully engage them in the training activities
(Adams et al., 2013).
Bringing together a very broad discussion, we can say that products, technologies
in general, and AT solutions, which are all included within the ICF domain of
Environmental Factors, can become powerful facilitators—if correctly identified and

9 See also the ‘Position Paper’ of AAATE, 2012. http://aaate.net/wp-content/uploads/

sites/12/2016/02/ATServiceDelivery_PositionPaper.pdf.
10 Anyway, the application of robotics to disability, and in particular to physically impaired children
is mainly addressed to rehabilitation; experimentation results are frequently assessed with respect to
rehabilitation objectives, even when they are used for engaging and ludic activities (Rahman et al.,
2015).
 Play and Children with Physical Impairments   125

situated in a person’s daily life—for the activity of a person with disability and his
or her social participation. In the case of the child with a physical impairment, they
are used as a support for typical activities of the age, including play; they can, in
fact, offer occasions to experiment, to grow, to have fun, to become autonomous, to
increase participation and social inclusion.
But, products and technologies can also pose to be barriers for play: this could
happen in the case of toys and playgrounds that are not usable or accessible to the
child with physical impairment, for example, if they are not easy to grasp, to be
explored, manipulated, used.
The need to develop effective technologies to support these children’s play has
become a meaningful objective of the scholars in the field, while abilities to assess and
improve the usability and the accessibility of play tools, technologies, and contexts
are still to be implemented and widely disseminated.

9.4 Play and Children with Physical Impairments

The scientific interest towards the play activities of children with motor and/or
physical impairments has increased during the last 20 years. Playfulness has been
found significantly lower in children with CP than in typically developing ones
(Okimoto et al., 2000): in particular, their ‘play age’ is referred to their mental abilities
and not to their chronological age. Something similar was reported by Harkness and
Bundy (2001): their experimentation resulted in scores of ‘exuberance’ higher in
children with physical impairment—but without any intellectual impairment—than
in typically developing ones.
The presence of an intellectual impairment and its complex interrelation with
the physical impairment seems to be extremely relevant data; in particular, it can
determine the capacities, the possibilities, and the preferences of the motor-impaired
child when playing. Dallas et al. (1993a) found that children with CP showed a deficit
of assertiveness during play, while Brodin (1999) stresses passivity, lack of attention,
and concentration.
Howard (1996) hypothesised a possible correlation between these behavioural
data and the living habits of these children, often obliged to reduce drastically leisure
time and fun, due to the intense and frequent rhythms of physical rehabilitation.
The lack of initiative not only seems to be a consequence, but also a cause of
a reduction of the play occasions. This is true, for example, for physically impaired
children who show a significant delay in speech development and a consequent
reduction of communicative competence, or who depend on others for their movement.
In such cases, their social interactions decrease, and as a consequence, they acquire
a reduction in play initiative and in peer relationships (Harper & McCluskey, 2002).
The most recent research results put specific emphasis on the role of the
environmental competence and proposals; a wide inter-individual variety exists
126   Play in Children with Physical Impairment

among children, and child neurologists stress that differences should not always
considered pathological: it is important to observe, interpret, and exploit the
child’s adaptive capabilities, or, as Brazelton says, the ‘best performance’ within the
limitation (Bottos, 2003). As some severely impaired children can express their will
and ability to act and participate, any prognosis should be made with caution, taking
advantage of their desires as well as of the environmental proposals; and this is true
also—or mainly—for what concerns play (Mortenson & Harris, 2006).
Certainly, adaptability and modifiability can occur only within an environment
that is competent to welcome, interpret, and support the child’s needs and proposals
of interaction. On the one hand, the environment should be correctly structured and
oriented towards the cognitive development (Bronfenbrenner, 1975), and on the other
hand, the children’s activities should be facilitated, for example, by choosing the right
toys, which can be usable and contemporarily can offer the right level of challenge to
stimulate their motivation, their fun, and finally, their development (Brodin, 2005).
In what follows, the main aspects that the different types play reveal in the case
of children with physical impairment will be presented.

9.4.1 Practice Play

Through exploratory activities, the child becomes able to make inferences on the
surrounding reality, to integrate perceptive and motor schemes in a sort of elementary
interpretation of the world. The child with physical impairment is particularly
disadvantaged in such activities: the inferential processes seem to proceed from the
motor abilities, and particularly, from their use within the play activities.
In fact, there are physically impaired children who due to their functional
limitations cannot reach, manipulate, use the objects and are only onlookers of their
peers’ play activities; some of them do not know the special condition of tension
and density that can be related to play because they do not perceive themselves as
the owners of their own thoughts, or they cannot understand the rules, the peers’
proposals and suggestions.
Bruner (1968) sustained that the concrete motor act is not decisive to determine
the child’s development, while it is important the intention to make it, the capability
to formulate a hypothesis, and to plan the activity; this reflection could be interesting
to explain why in some cases children with severe motor impairment can show
typically developing intellectual abilities. But, this interpretation should not lead to
underestimate the possible consequences—for the child’s development—of a reduced
motor activity and particularly of a lack of practice play. To elicit play abilities, to
favour curiosity, and to increase relationships of the young motor-impaired children,
some solutions have been experimented (Butler, 1986) in trying to give them as
much mobility as possible, as early as possible; this brought to the development of
some robotic vehicles for children, such as PALMIBER (Ceres et al., 2005; Raya et al.,
 Play and Children with Physical Impairments   127

2013). These projects are based precisely on the need to offer these children proper
opportunities to explore and interact with space, 3D objects, and people around
them (Cook & Polgar, 2008). Therefore, to drive these vehicles, children should be
able to carry out purposeful actions, to interact with objects and use them as tools;
to make this possible for children with physical impairment, who cannot manipulate
objects directly, on-purpose adaptations and assistive solution systems have been
implemented, including switches or other devices (Cook et al., 2000). Verburg (1987)
found a decrease in parents’ protectiveness while the child is able to demonstrate
more confidence in mobility.
Another productive line of research and intervention is conducted in a less-strict
technological area, and it is aimed to increase awareness of teachers and professionals
in the field and to improve their knowledge and competence in assessing and choosing
products, toys, and technologies for the play of children with physical impairment:
in fact, these objects must be suitable for their functional needs and their further
development.

9.4.2 Symbolic Play

As already noted, in some children, especially in the case of CP, severe physical
impairment is accompanied by a deep impairment in language and/or speech
acquisition and use. The development of effective and competent symbolic functions
is also related to the integrity of the gross and fine motor functions: this means, the
ability to use objects for pretend play, but also to use language to create and ‘inhabit’
invented worlds. Anyway, some findings in literature (Martinoni & Scascighini, 1997)
describe cases of symbolic play in the absence of a completely developed speech
capability, mostly if strategies of alternative communication have been established.
If some researches indicate significant differences in play abilities between
children without and with developmental language difficulties, being lower in this
last case (Casby, 1997), other ones demonstrate that pretend play does not show a
stable correlation with the use of verbal language (Lyytinen, 1991) even if language
seems to have a pulling role for the development of the symbolic function as a whole.
Other studies underline the strong influence exerted on symbolic play by the
child’s socio-economical context and by the parents’ educational styles (Bornstein
et al., 1996).
Symbolic play can be greatly compromised in the case of children with physical
impairment due to motor difficulties—think, for example, to play with dolls that
should be manipulated in a fine manner; very often the play companion helps the
child in overcoming these difficulties “becoming the child’s hand” (Brizzolara et al.,
2005).
The developmental leap for this type of play is the ability to deal symbolically
with objects, and ATs can be of great help if they are designed accordingly to these
128   Play in Children with Physical Impairment

children’s possible needs: play activities can now be organised along sequential
steps—like within a narration—and, in case that their speech skills are poor, the
symbols of augmentative codes should be implemented on their toys and play objects.
Research demonstrates that the adoption of the suitable ATs to support symbolic play
can enable learning and associated development.
An interesting high-tech perspective in this sense is the ‘social robotics’, which
creates a direct interaction between the user and the robot; an example of this type
is IROMEC,11 which was tailored towards becoming a social mediator, to foster social
and cooperative play. More than having ‘symbolic’ features in itself, IROMEC has been
used as a mediator for building up symbolic play activities (thus also overcoming some
limits it demonstrated about its attractiveness as an enjoyable tool), as it happened
during experimentations: “Between the first and the last session, the adults try to
enhance the play situation. They try to enrich it, to build more stimuli and ideas to
make children’s attention more focused on the activity; in terms of play theory, it
could be said that they try to enhance the play scenarios available on the IROMEC,
that mainly belong to the sensorimotor level, by translating them to a symbolic and
imaginative level” (Besio et al., 2013:147).

9.4.3 Constructive Play

It was Smilansky who first stressed the need to separate, in the child’s development,
the acquisition of gestures from their use for doing things, creating, constructing.
This idea opened the possibility of separating the practice from the constructive play,
which includes in fact the growing child’s abilities of planning and realising ideas
that are in his or her mind and very quickly mingle with the newly acquired symbolic
abilities, in a developmental spiral of incremental complexity (Smilansky & Shefatya,
1990).
Smilansky’s approach is particularly productive and rich in new ideas for studying
the play of children with physical impairments because it has facilitated the raising
of research projects in the field of engineering and robotics. One interesting example
of this is given by the robot system Play ROB, designed as an assistive system to help
severely impaired children in playing with Lego bricks; in this case, the robot is not
the toy, but it helps to use the toy (Kronreif et al., 2005).
Some authors suggest that, for the cognitive development of children with motor
impairment, it is not essential to be able to act on the objects of the world around
them, rather to be able to make inferences on it and to represent these actions in their
minds. Anyway, this assertion has been somehow questioned by some case studies

11 It is the acronym of Interactive Robotic Social Mediators as Companions, IST-FP6-045356, Specific
Targeted Research or Innovation Project.
 Play and Children with Physical Impairments   129

that used educational and robotic technologies (Besio, 2004; Kronreif et al., 2005).
They put into evidence, in fact, a not complete effectiveness of these representational
mechanisms, as children, when asked to act concretely on objects according to
precise plans, showed weaknesses in planning exactly their actions and in verifying
the obtained results, as well as in correcting the actions that were wrong according
what they had in mind.
More recently, some contexts of ‘constructive play’ with commercial robots
have been used to study the cognitive skills of children with disabilities (Cook
et  al., 2010); the detailed analyses of the subsequent so-called ‘micro-behaviours’
needed to manage and control a robot within a constructive play activity as well as
the categorisation of the increasing cognitive skills implied by these play activities
are the basis to build up a theoretical framework for relating robot skills with child-
developing cognitive skills. This result will be unavoidable in the future to foster new
knowledge and develop new tools in the field.
Starting from this point, for example, the use of Lego Mindstorms robots as
ATs for giving children with physical disabilities the possibility to play through
manipulation has been tested for the purpose of measuring the possible effects on
playfulness (Rincon et al., 2013a); robots were used for play at home with the intention
of supporting free play of a child with CP. The results demonstrated that playfulness
increased with the introduction of a robotic intervention, and, even more interesting,
this happened thanks to the creation of play scenarios in which robots became
the mediator of symbolic activities with dolls, blankets, and ‘scenes’ to represent.
The results related to the previous study indicate that the child’s communicative
utterances increased as well as the mother’s responsiveness to the child’s initiative
(Rios et al., 2013b); this was interpreted as a consequence of a major engagement and
motivation in play of both.

9.4.4 Play with Rules

Children with physical impairments can approach this type of play in many cases by
recurring to the use of an IT tool; if the accessibility issue is correctly solved and the
suitable game is chosen in relation to their cognitive abilities, it is possible to offer
them a virtual environment that is adaptable and usable.
These kind of games have been already experimented successfully (Weiss et al.,
2003; Reid, 2004): for example, adolescents with CP showed appreciation and
enjoyment in using these tools, in strict correlation with the cognitive workload
requested by the game.
Reid and Campbell (2006) reported a successful use by children with CP (with
non-disabled peers) of a VR environment—managed by a video camera as a device
for capturing and tracking—for playing games of volleyball and snowboarding. They
130   Play in Children with Physical Impairment

perceived VR as an ‘equaliser’ of abilities with their peers, and this fostered feelings
of competence and acceptance by the others.
One of the main problems of mainstream videogames for these children is
their requirement of playing fast and being action-oriented. Hernandez et al. (2013)
created a specially designed videogame—called ‘exergame’—to avoid the need for
time-sensitive actions and to keep the game pace slow, which have been tested with
children with CP, both to achieve the right physical activity and fun.

9.5 Social Aspects of Play in Children with Physical Impairments

Since decades, we know that the mere exposition to toys is not sufficient either to
increase the number of play activities or to adopt new types of play, while the adult’s
mediation reveals much more importance in this respect, to model the child’s play
behaviour.
But, in case of children with disabilities, there is a risk that parents adopt a
‘diagnostic’ attitude (Brodin, 2005),12 focussed on recovery and rehabilitation of the
impairment, rather than on ‘unproductive’ activities such as play, which is considered
a ‘wasted time’. The same author proposes that parents should be trained to adopt
specific abilities, such as withstanding the slowness of gesture execution of their
children and their delayed comprehension of play situations, as well as acquiring
the needed competence to liven concentration on the task and to maintain it for long
time.
In some studies of the field, children with physical impairments have been
described as frustrated by their motor impairment and poorly trust in themselves as
players and play companions (Pollock et al., 1997); they have been also described as
snivelling and emotionally unstable, not very friendly (Sprinkle & Hammond, 1997).
Spencer-Cavaliere and Watkinson (2010) sustain that they feel ‘included’ in a physical
activity when they gain entry to play, feel like a legitimate participant, have friends.
According to Skär (2002), they improve their own perception if they use ATs that can
give them more autonomy in play activities, without recurring to the aid of an adult.
On the other hand, their limitation on activity and restriction in participation
causes a huge decrease in their possibility to make choices and may even produce
loss of awareness on their right to have control on their own lives; this is an important
loss because it is exactly the possibility to influence one’s own environment and
to interact with people that makes it possible to reduce the feeling of helplessness
(Weiss et al., 2003).
But, the real and most important infant social learning happens during play
activities with peers. Children with disabilities, mainly those with severe impairments

12 Not all the studies are in the same frame (Malone & Landers, 2001; Lane & Mistrett, 1996).
 Social Aspects of Play in Children with Physical Impairments   131

such as CP, tend, regardless of the chronological age, to adopt subaltern roles in the
group (Dallas et al., 1993a, 1993b); play dyads are, for this reason, more fruitful if the
impaired child is the youngest one, thus benefiting by control behaviours adopted by
the other (McGillicuddy-De Lisi, 1993).
Cooperative behaviours in siblings (one of them with CP) increase in time as
well as pro-social and care behaviours; time probably increases the awareness about
the reciprocal needs and supports in building a good relationship: the non-disabled
sibling becomes more and more competent in interpreting the sister or brother’s
wishes and in complying with them, maintaining attitudes of support and physical
proximity. This also results in increasing the impaired child’s participation and
attention to the play activities.
Therefore, children with CP find it difficult to start an interaction with their
siblings, and this causes less probabilities to be involved in play activities and a major
probability that the siblings take the control over the situation (Dallas et al., 1993a).
Specific characteristics related to the impairment can greatly influence the
acquisition of play competences. The linguistic abilities play a primary role: children
with good verbal competences are more likely to be involved in the peers’ play activities
(Stoneman et al., 1989; Harper & McCluskey, 2002); also, the cognitive competences
influence the associative and collaborative types of play, because sometimes these
activities prove to be too complex for an impaired child. Furthermore, children who
are not autonomous in their movements and need some support for moving tend to
rely on adults for entering the peers’ group.
An Italian research some years ago (Catullo, 1984) verified that children with
motor impairment but without any associated cognitive impairment were more
popular among their peers, unless children who showed behavioural problems and
difficulties to understand the rules or to comply with them, who were often left out. In
addition, only 6% of the drawings of peers depicting children with motor impairments
put into evidence signs of their impairments, for example, their technical aids. This
fact was interpreted as a positive demonstration that these children are not seen as
‘lacking’ something, no child seemed interested in the ‘disabling’ aspects. The same
experimental model has been reproduced in Italy (Besio, 2011), but different results
were found. In fact, it was confirmed that only 8% of the children depicted wheelchairs
or other technical aids of their peers, but these drawings were found in classes where
the inclusive process was well established and effective, in which impaired children
with disabilities obtained high preference scores in sociograms. This result seems to
lean towards the opposite conclusion of the previous experiment: more precisely,
it is possible that a positive experience and relationship with an impaired peer can
contribute to improve general attitudes towards disability in general and to the
perception of technical aids and other possible ‘strange objects’ as simply normal in
the school context, as if they belonged to the whole inclusive community.
This conclusion could be interpreted within a line of studies, which identifies a
direct correlation between the attitudes towards ATs and disability in general: negative
132   Play in Children with Physical Impairment

attitudes towards disability (seen as weakness and dependence) are associated to a

negative perception of AT (McMillen & Söderberg, 2002; Bender Pape et  al., 2002),
while in the meantime, positive attitudes towards disability also include a positive
conception of technologies that are considered as tools that make it possible or favour
the autonomy of a person.

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Sylvie Ray-Kaeser, Evelyne Thommen, Laetitia Baggioni,
and Miodrag Stanković

10 Play in Children with Autism Spectrum and Other

Neurodevelopmental Disorders
Autism spectrum disorder (ASD) is a complex mental condition manifested by a wide
range of cognitive, emotional, and neurobehavioural disabilities. ASD begins early
in childhood (before the age of three) and lasts throughout life. Core deficits cause
substantial impairments in social interaction and communication as well as the
presence of fixed, stereotyped patterns of behaviour and a lack of interest in peers
(APA, 2013). The first signs for the parents are that their child does not react to their
presence nor responds to his or her name (despite the fact that hearing is intact) or
is focusing on certain objects for a long time without initiating contact with people
(Baron-Cohen, 2004). Moreover, a change of setting does not modify the core features
of their behaviour, which differentiates ASD children from children with other
developmental disorders (Stanković et al., 2012).
From this point of view, as a neurodevelopmental disorder, ASD shares many
characteristics with those psychiatric conditions that typically manifest early in
development. Neurodevelopmental disorders are “characterized by developmental
deficits that produce impairments in personal, social, academic or occupational
functioning” (DSM-5; APA 2013:31). They include disorders such as intellectual
disability, specific learning disorders, communication disorders, attention-deficit
hyperactivity disorder, and motor disorders. Comorbidity has long been recognised in
children with neurodevelopmental disorders, which reflects some overlapping causes
and underlying neurological abnormality (Kaplan et al., 1998).

10.1 Play Skills of Children with ASD and Other

Neurodevelopmental Disorders

Multiple skills (cognitive, psychomotor, and relational) are required for playing,
especially playing with peers (Perrin, 2011), and difficulties in playing are part of the
core symptoms in ASD. Although many researchers describe the particularities of play
amongst children with ASD, there are still misunderstandings and confusions about their
actual ability to play. These children seem less playful than their peers, showing repetitive
behaviours with objects, and restricted play interests (Benson et al., 2006). The way they
play is characterised by certain fixations: they exhibit “preoccupations ranging from a
fascination with objects to an intense focus on arcane topics” (Wolfberg et al., 2012:57).
The described behaviours may occur as a result of a range of varying overlapping
difficulties. Sensory integration dysfunctions are frequently associated with ASD

© 2017 Sylvie Ray-Kaeser et al.

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License.
138   Play in Children with Autism Spectrum and Other Neurodevelopmental Disorders

(Rogers et  al., 2003; Watling et  al., 2001). Current estimates show that 45 to 96%
of the children with ASD have difficulty in processing sensory stimuli (Ben-Sasson
et  al., 2009; Lane et  al., 2010). A child’s difficulty in processing and integrating
sensory inputs affects participation in play activities (Schaaf & Mailloux, 2015).
Over-sensitivity to noise, light, smell, or touch, also called sensory defensiveness
(corresponding to a low threshold for response to stimuli), may manifest in play as
avoidance of movement and restricted play preferences (Schaaf et al., 2011). On the
contrary, sensory insensitivity or sensory seeking (high threshold) may manifest as
reduced social interaction and difficulties in functioning or excessive movement and
manipulative play in order to self-regulate the child’s sensitivity level. Inattention
may result from sensory-seeking behaviours, which makes the child switch from one
activity to another, so that it interferes with play (Lane et al., 2010).
Children with ASD have been found to show similar motor difficulties as
children with developmental coordination disorders (DCD) (Dewey et  al., 2006;
Green et al., 2009). Motor coordination difficulties, such as poor balance, eye-hand
coordination, and decreased ability to plan and execute motor tasks, create social
isolation and restrict participation in play (Cairney, 2015). Numerous researchers
have highlighted the need to feel concerned about the consequences of impairment
in motor coordination skills on children’s playfulness and participation in physical
play (Kennedy-Behr et  al., 2013; Poulsen & Ziviani, 2004). Preschool children with
coordination impairments show a lower developmental play age and engage less
frequently in play than their typical peers (Kennedy-Behr et al., 2013). School-aged
children with DCD avoid school playgrounds and engage less in physical and social
play (Smyth & Anderson, 2000).
Children with ASD have impaired joint attention, decreased imitation, and social
imagination, which are all skills necessary for symbolic play and pretend play
(Jarrold, 2003). Social interaction disturbance, which is the core symptom in ASD,
has very heavy consequences for social play (Nadel, 2002; Ten Eycke & Müller, 2015).
Moreover, reduced social play of children with ASD has been linked to particularities
in cognitive and emotional development (Jordan, 2003), while difficulties in verbal and
nonverbal communication limit the capacity of children with ASD to engage in play
with others (Wolfberg et al., 2012).
A theory of mind impairment is often discussed in ASD children to explain their
difficulties in symbolic play (e.g., dolls, tea parties) or ‘hide and seek play’ that
involves mental representations to imagine being another person or put oneself
in a playing partner’s shoes (Thommen et al., 2014). Executive functions disorder
is also available as an explanatory theory of ASD functioning and the difficulties
involved in planning series of actions to ‘create’ the play, be attentive, be able to
change the rules of play, and even inhibit a response when they have to take turns
(Thommen et al., 2014). However, due to the heterogeneity of the symptoms in ASD,
it is important to avoid asserting simply that all children with ASD have the same
difficulties in playing.
 Play Skills of Children with ASD and Other Neurodevelopmental Disorders   139

All these primary skills needed for a child with ASD to play have to be learnt. To do
so, individual play may initially be prioritised before group play, which will later ensure
the generalisation of learning. Social cognition may then become the main focus.
Different methods of individual intervention for children with ASD exist to develop
the skills needed for play. Even though they need more structured play and external
cues to develop their play skills (Tanta & Knox, 2015), the structural component of
the environment might be problematic for them. When it is very controlled, as in the
Applied Behavioural Analysis (ABA) method (Lovaas, 1987), it can lead to difficulties
in the generalisation of learning (Wood et al., 2013). Other methods of intervention
such as Pivotal Response Training (PRT) (Koegel & Kern Koegel, 2006), Treatment and
Education of Autistic and Communication Handicapped Children (TEACCH) (Schopler,
1997), or Early Start Denver Model (ESDM) (Rogers & Dawson, 2010), use the most
natural environment while being structured and encourage behaviour initiation in
order to facilitate the generalisation of learning. These interventions are the most
effective for developing play skills because they use the child’s strengths and seek
inner motivation through activity more than external rewards (Luckett et al., 2007).
Using the specific skills of children with ASD to increase their motivation in play
seems essential. Specific skills related to the characteristics of ASD, for example, the
ability to perceive details or even the restricted interests of a child, could then become
assets in some play situations.
Playing with others requires multiple skills, especially social skills. Through social
play, children with autism learn about social interaction. Therapeutic and educational
play settings should be designed to provide long-term learning processes. Before
they can correctly express emotions in daily life, children with ASD need to learn to
understand emotions and recognise them and their meaning. For this reason, emotional
recognition and theory of mind are frequently taught to these children before work can
begin to improve play for the sake of play (Thommen et al., 2010). Many social-cognition
training programmes exist; they can be computerised (Silver, 2000 and Baron-Cohen,
2004 cited in Nader-Grosbois, 2011; Glaser et al., 2012 cited in Wood et al., 2013) or not
(Howlin et al., 2010; Wellman et al., 2002). Social scenarios are also interesting tools for
learning social interactions (Gray, 1994). However, in play situations, the child will be
confronted with many different emotions and varied ways to express them, requiring
direct application in everyday life contexts. Role-playing then seems a more appropriate
tool for matching learnt social interactions to real life (Baghdadli & Brisot-Dubois, 2011).
Another way to intervene is illustrated with a study of 60 children with ASD in
school integration situations, which compared interventions focussed on children
with ASD versus their classmates (Kasari et al., 2012). When the intervention targeted
the group of classmates, children with ASD were more often considered as members
of the social network of the class than when the intervention was centred only on
them. They became playing partners and were less frequently isolated during class
breaks. Moreover, not only were changes observed in the attitudes of peers, but the
social skills of the children with ASD also improved.
140   Play in Children with Autism Spectrum and Other Neurodevelopmental Disorders

10.2 Types and Form(s) of Play Favoured by Children with ASD

According to Doody and Merz (2013), research examining the types of play favoured
by children with ASD is limited. The understanding of the play preferences of children
with developmental disabilities might be very challenging, particularly when they
do not use the language consistently or do not have the cognitive ability for self-
awareness.
Nevertheless, different features emerge when describing play among children with
ASD: they often play with objects in a repetitive, restrictive, rigid, and non-symbolic
manner, centred on sensorial particularities and/or on physical understanding.
These features can be seen as a ‘serious game’ and a form of intentional play, as these
children have such a thirst for knowledge. So, if we change our view on their activities,
their play is rather a difference than a disability. For many children with ASD, ‘banging
a doll’ or ‘pouring sand in different containers’ are activities that require directed and
skilled actions and could be considered a form of play, as well as an occupation for
its own sake (Spitzer, 2003). With these examples, the distinction between repetitive
and not-directed behaviour is very thin. Moreover, when sensorial stimuli, which are
not spontaneously part of play, are added to support the children’s motivation and
attention in play (e.g., multiple sound effects during the activity, lighting effects,
sensory materials), this may increase the repetitiveness of their behaviours to the
point of sensorial fascination and self-stimulation actions. This form of automatic
behaviour may not meet the criteria for play as an intentional occupation and may
lead to isolation. However, for ASD children with restricted play interests, play might
be the opportunity to experience a lot of fun, to play with peers, or to join a group of
children with the same concerns, for example, ‘manga’ or ‘trains’.
Children with ASD encounter difficulties in occupying their leisure time. For
them, ‘free’ time is often a period of stress, as they do not know what to do in such
a non-structured time. A new trend of research and intervention focussing on ‘how
to occupy myself’ in leisure is developing to improve their occupation during leisure
time (Chan et  al., 2014; Seward et  al., 2014). In fact, the primary skills needed to
occupy leisure time can be impaired in children with ASD. Children must be able to
make choices between different kinds of play and to initiate behaviours with selected
objects. It is, therefore, important to offer them real tools to help them deal with
leisure time. As spare time is not much fun for them, it is also necessary to offer them
activities they like, such as the sensory play they spontaneously choose.
We can also note that other types of play are very successful in leisure time,
for instance, those related to new technologies. One of their advantages is their
attractiveness (Wainer & Ingersoll, 2011; Shane & Albert, 2008). In fact, touch screens
or playful interfaces are all assets that stimulate children’s motivation. Moreover, the
programmed, predictable, and emotionally neutral environments of new technologies
are particularly appreciated by children with ASD (Shane & Albert, 2008; Ramdoss
et al., 2012). “Computer-proposed tasks are clearly defined and promote the focus of
 Play Environment and Participation of Children with ASD   141

attention by reducing the distractions caused by irrelevant sensory stimuli” (Murray,

1999, in Grossard & Grynszpan, 2015:67). With such devices, children can play during
their free time and also learn in a fun way, but with the risk that excessive use can lead
to confinement and social isolation (Durkin, 2010; Ramdoss et al., 2012).
Robot-assisted therapy (RAT) (Diehl et al, 2012) is a large growing research area
about using technology in diagnostic, play, and learning of children with ASD (Robins
et al, 2012). Several types of robots have been researched. Vehicle-like robot ‘Labo-1’
supporting children play and using robots as social mediators in order to interact
with other people (Werry et  al., 2001). Humanoid-shaped robots showed the most
promising results (Wainer et al., 2014). Snowman-shaped robot ‘Keepon’ encourages
joint attention (Kozima et al., 2007). Robot ‘Bandit’ elicits positive social responses
like speech, interactions with robot (Feil-Seifer & Matarić, 2006). Robot doll ‘Robota’
engages children in imitative interaction play (Robins et al., 2006). Humanoid robot
KASPAR “encourages interaction between the children and copresent adults as a
salient mediating object and help children to learn about tactile social behaviour”
(Wainer et al., 2014).
In conclusion, the play of children with ASD is especially different from that of
typical children; however, “careful observations have often come to the conclusion
that many kinds of play are less affected in autistic children than was expected”
(Trevarthen et al., 1998:109).

10.3 Play Environment and Participation of Children with ASD

The socio-cultural context is known to have a fundamental role in a person’s ability to

participate in an activity such as play (Pierce, 2001). Children with ASD may engage
in play that is personally meaningful, but not socially conform and well-accepted,
and most of the research on play amongst children with developmental disorders
describes “deficient normative activities” or “failure to engage in expected activities”
(Spitzer, 2003:72). They behave remarkably differently when part of a peer group.
The participation in play amongst children with ASD reflects the core features of the
condition. It is complicated by persistent socio-communication deficits in attention,
imitation, and social responsiveness (Sigman & Ruskin, 1999). They inconsistently
respond to peers when the latter initiate play with them (Attwood et al., 1988). They
also have limited use of joint attention and other nonverbal skills, as well as marked
spoken difficulties to ask for objects, request information, and share emotions, which
make them unsustainable in social play (Schuler, 2003). Even when they show active
interest in playing, they seem strange to typically developing children because they
behave and talk in an idiosyncratic way (Boucher & Wolfberg, 2003; Jordan, 2003; Wing
& Attwood, 1987; Wolfberg, 2009). This kind of social interaction is often considered
undesirable, and response from peers is a negative reinforcement. In circumstances
of mutual avoidance, children with ASD are at high risk of being excluded by peers or
142   Play in Children with Autism Spectrum and Other Neurodevelopmental Disorders

often exclude themselves from peer interactions. Thus, the aloofness associated with
children with ASD results largely from peer group responses to them (Wolfberg et al.,
2012).
Indoor and outdoor free-time activities with peers, which allow children to
experience enjoyment, are known to offer the best opportunities for all children
to engage with their environment and have the best chance of ensuring their
participation (Heah et  al., 2006). Playing is essential for friendship (Theodorou
& Nind, 2012). However, children with a disorder, such as ASD, spend more time
in controlled and learnt activities with adults rather than with peers, which raises
important psychosocial barriers, such as making friends with whom to play (Miller
et al., 2010). Children with high-functioning autism experience friendship differently
than typically developing children or people with another disorder. They have fewer
friends, and the friends they do play with are usually peers also with a disorder. They
report a lower quality of friendship with less intimacy and closeness than their typical
peers (Petrina et al., 2014). Finally, research on the inner experience of participation
in play for children with ASD is emerging and needs further investigation.

10.4 Conclusion

Children with ASD present sensorimotor, cognitive, and socio-emotional skills

impairments that can hinder play, particularly social play. An examination of
their play preferences and interventions centred on their play competence are still
rare (Wolfberg et  al., 2012). When professionals have to deal with the challenging
behaviours and the lack of language of children with ASD, “play is more likely to
be viewed as a luxury only to be targeted when more basic deficiencies have been
remedied” (Wolfberg et  al., 2012:59). However, play in early intervention solicits
positive emotions in children and develops their interest in social interaction.
Introducing play and designing appropriate play opportunities for children with ASD
need to be the primary concerns for educators, clinicians, and parents.

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Francesca Caprino and Vittoria Stucci
11 Play in Children with Multiple Disabilities

11.1 Introduction

Play, a universal behaviour, documented in every culture, may have atypical

characteristics in the child with multiple disabilities. The lack of access to sensorial
inputs and the additional motor, cognitive, and communicative impairments
observable in these children can cause a delay in all areas of development and may
also lead to play behaviours that are not as rich as those of their peers.
Children with multiple impairments have enormous problems not only in receiving
the multitude of stimulations coming from the environment, but also in properly
decoding them. As a result, they experience a kind of ‘chaotic misinformation’ that
may produce a sense of danger (Frohlich, 2007), and that massively interferes with
the development of play skills.
Yet, in these cases, play has an even more important role with respect to a
child with typical development (Brodin, 1999): through play, children can not only
demonstrate their skills, but also acquire new ones in many areas of development.
Of particular importance is the relationship between the development of play
skills and the development of communicative skills (Brodin, 1991; Pizzo & Bruce,
2010), an aspect that highlights the importance of play as a factor that gives the child
with multiple disabilities the opportunity of relating with his or her environment.
It is for this reason that caring for a child with multiple disabilities must include
activities that affect play; activities that aim not only at bringing out and strengthening
the child’s skills, but that are also capable of influencing the contexts in which the
child interacts.

11.2 Play and Multiple Disabilities: the Literature

Most of the research on play in children with multiple disabilities focuses on

the use of play as a tool for evaluating children’s skills and as a strategy suitable
for achieving educational or therapeutic objectives. For what concerns the use of
play for assessment and diagnostic purposes, the quality of play is reported by the
literature as a parameter capable of providing information about the degree of overall
development of the child with multiple disabilities (Finn et al., 1988; Mar, 1996) or
about specific aspects, such as the development of object permanence (Bruce, 2012)
and language (Pizzo & Bruce, 2010).
While no tools for evaluating the play skills of this population have been specially
validated or developed, some assessment tools designed for children with multiple
disabilities do have items that refer to ludic behaviours and are used to observe

© 2017 Francesca Caprino and Vittoria Stucci

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License.
148   Play in Children with Multiple Disabilities

the various components of the child’s development. This is the case involving the
Callier-Azusa scale (Stillman, 1978), a tool to evaluate the development of the deaf-
blind child and with multiple disabilities that includes, in the subscales that refer
to the degree of perceptive, motor and social development, numerous behavioural
items that describe play activities involving practice play (e.g., grabbing and shaking
objects, throwing, rolling, bouncing, and catching a ball), construction play (e.g.,
stacking blocks, handling Plasticine, cutting, colouring), symbolic play (e.g.,
presence of pretend play), and play with rules. The INSITE developmental checklist
for multihandicapped sensory-impaired infants and young children (Morgan et al.,
1999), used with children up to six years of age, includes numerous items that refer to
observation of play activities.
The literature relative to the use of play as a tool for achieving educational or
rehabilitative objectives, in particular in early interventions aimed at infants and
young children, refers to the research in which the ludic activity is utilised to improve
perception skills and to increase residual sensorial functions, movement (Lieberman
& Tolla, 2000), communication (Michael, 1990), socialisation with peers (Hanline &
Correa-Torres, 2012), and cognitive development (Fleer, 2014).
A major line of research investigates the role of play in rehabilitative–behavioural
activities aimed at reducing maladaptive behaviours (self-injury, aggressiveness, self-
stimulation). According to the so-called communication paradigm, these behaviours
are nonverbal forms of communication aimed at obtaining gratifying environmental
responses (Emerson, 2001) and can be replaced with more appropriate and
functionally equivalent conduct, such as simple activities involving manipulation of
objects or toys (Lancioni & O’ Reilly, 2010). As a result, this allows the child to reach
the same objectives sought with inappropriate behaviour while expanding his or her
behavioural repertoire at the same time.
In recent years, above all, in the occupational therapy environments (Pharam &
Fazio, 2008) and also thanks to the research and intervention initiatives developed
by specialised centres for children with multiple disabilities and their families,
approaches that encourage the development of the ludic factor, considered as
an objective in itself and capable of positively affecting all aspects of the child’s
development and quality of life, have been rather successful.

11.3 Impairments in Functions Linked with Play and Ludic

Activities

Children with multiple disabilities have congenital or acquired impairments in

one or both sensorial channels, that can be associated to a severe development
and intellectual delay, motor deficits, severe behavioural disturbances, and other
dysfunctions linked to additional organic pathologies that are neurological or of
other origins.
 The Role of the Environment for Participating in Play Activities   149

Deaf-blindness,1 meaning the combination, with different degrees, of sight

and hearing impairments not associated with other disabilities, can be considered
a condition in and of itself. In these cases, generalised problems arise due to
sensorial distortions that make interaction with the environment more difficult. Such
difficulties, however, are not as severe compared with those encountered by children
who have additional motor or cognitive impairments. In the presence of multiple
disabilities, it always becomes necessary to develop educational and rehabilitative
interventions that are specific from a methodological and instrument perspective.
In some cases, some developmental milestones considered essential for the general
development and for the emergence of play abilities were not achieved: these may
include joint attention (Nunez, 2014), turn taking, or understanding of cause–effect
relationships (Finn et al., 1988).
Children with multiple disabilities may exhibit unusual responses when
presented with objects or activities, take a lot of time to process stimuli, or on the
contrary, exhibit excessive, intense, and at times, even violent activities with forms of
self- or other-directed aggressiveness.
Spontaneous ludic behaviours often involve maladaptive responses: these
children have very low motor responsiveness levels in the presence of gratifying
stimuli, stereotypical behaviours apparently independent from adaptive purposes,
and the tendency to use the object for self-stimulation (Coppa et  al. 2005; Nisi &
Ceccarani, 1993).
Social skills may be severely compromised and require specific action that
guides the child to overcome his or her isolation. In more serious cases, it becomes
necessary to start from the development of awareness of the presence of others to
arrive gradually, in situations with a high level of structuring, at establishing positive
interactions.
In general, for cases involving multiple disabilities, there are not only low levels of
initiative and exploration, but also less involvement in symbolic and cooperative play.

11.4 The Role of the Environment for Participating in Play Activities

Due to the previously described factors, participation by children with multiple

disabilities in play activities typical for their age may be very limited. This reduced
degree of participation is not attributable, however, only to personal impairments,

1 According to the Declaration of the European Parliament on the Rights of Deaf-Blind People (2004),
“deaf-blindness is a distinct disability that is a combination of both sight and hearing impairments,
which results in difficulties having access to information, communication and mobility”. http://www.
europarl.europa.eu/sides/getDoc.do?pubRef=-//EP//TEXT+TA+P5-TA-2004-0277+0+DOC+XML+V0//
EN&language=SL
150   Play in Children with Multiple Disabilities

but also to the characteristics of the living environments. Parents of children with
multiple disabilities often feel they are incapable of playing with their children
(Brodin, 1999). Early interactions in the mother-child dyads are particularly critical.
In their research from 2007, Coppa and Orena observed that the mothers of children
with multiple disabilities tend to fill all the empty spaces of the ludic interaction with
hyper-stimulatory behaviours. The same authors also point out how the exchanges are
characterised by communicative expressions of the mother, especially verbal ones. In
addition, the mothers find it difficult to get in synch with their children and tend not
to leave space to process the stimulus, demonstrating a tendency to normalise the
interaction.
The characteristics of the play spaces may also represent a barrier. Factors such
as lack of access to play areas and playgrounds and the presence of potentially
disturbing factors (such as noise, insufficient lighting) can also make a difference
in terms of opportunities to participate in play activities. Additional participation
problems may be due to the unavailability of play materials that are suitable, adapted,
or specifically designed for play and leisure time of infants and young children with
multiple disabilities.
Play participation opportunities are also strictly correlated to the degree of
inclusion of the child with multiple disabilities in school and in his or her community,
to the possibility of playing with peers with or without disabilities, and to the
presence of support from services that utilise professionals with specific training for
this complex type of disability. It is these services that play a critical role in providing
information and advice to parents and in guiding them, through a working alliance,
to get in synch with their children in various pleasurable play activities.

11.5 Facilitating Play in Children with Multiple Disabilities

Children with multiple disabilities, under proper conditions, can utilise the richness of
the ludic experience, and with it, reach significant development objectives, provided
that there are facilitating contexts: the most important factors are the relationship with
the adult and the type of toys and structure of the overall physical context (Brodin,
1991). Another crucial factor is selecting the play materials (Brodin, 1999). Indeed,
such a selection must be based on specific observations of the child and correspond
to his or her specific perceptive, cognitive, motor, and communicative characteristics,
as well as his or her preferences. There are numerous types of materials starting with
simple tactile exploration games (such as containers filled with different materials:
water, sand, balls, etc.). The child, using enjoyable and comfortable procedures,
must be able to safely perceive, understand, and manipulate the materials and with
minimal help (Canalini et al., 2005). If necessary, specific assistive technologies can
also be used, such as switches that allow children with motor or sensory impairments
to activate a toy through alternative methods.
 Facilitating Play in Children with Multiple Disabilities   151

In selecting toys and playware, it is important to consider the degree of

accessibility and the presence of enhanced sensory characteristics, such as acoustic,
visual, tactile, or gustatory feedback (food can also be an excellent play material); it
is also important to encourage the child to choose and explore the proposed material
(Coppa et al., 2005).
With children who exhibit behavioural stereotypes or who use specific objects
for which there would seem to be a strong stereotyped attraction, it could be useful
to propose similar materials within the context of activities that may develop into
functional learning. If, for example, the child spends a lot of time on self-stimulating
activities, that is, passing the hands in front of the eyes, play activities should contain
strong visual elements, such as lights that turn on and off, software with cause–effect
activities with dazzling visual feedback, and so on.
Observation, a key element of the intervention involving play skills, must be
carried out possibly within the daily living contexts and with the help of professionals
who can correctly interpret the child’s responses when presented with the proposed
materials. In particular, satisfaction with the proposed play activities can be evaluated
through systematic measurement of positive reactions, that is, of ‘happiness indices’
(Dillon & Carr, 2007).
The ‘indices of happiness’ are used to evaluate the level of pleasure and wellness
in persons without language skills by measuring easy-to-observe behaviours (e.g.,
laughing, smiling, clapping hands) correlated with inner emotional states. Some
research has shown how these manifestations can be actively increased by modifying
the environment and that their frequency increases, in particular during play
activities. It is important to consider, when observing such indicators, that each child
can express his or her wellness in a subjective manner and that the responses may
occur much later than those exhibited by children with typical development.
The physical and perceptive characteristics of spaces and their organisation also
play an important role: in addition to being accessible, spaces must also be capable
of stimulating the child and providing a suitable range of possible activities (Brodin
& Lindstrand, 2006).
To increase the child’s independent exploration, play environments should
be designed and organised so that their function is immediately recognisable: it
is possible, for example, to create paths and dividing lines of the play areas using
materials with contrasting colours and different types of roughness, or by using
elements with olfactory clues, selecting and arranging the furniture to reduce sensory
and cognitive obstacles to a minimum (Canalini et al., 2005).
For infants, small ludic environments (a play corner) can be created in which
materials provide auditory, visual, tactile, and olfactory stimuli and where the child,
according to a non-directive approach, can move freely and enjoy the proposed
experience.
When setting up the activities in the play corner, it is important to carefully select
the stimuli (chosen based on the observation of the child’s preferences) and to create a
152   Play in Children with Multiple Disabilities

rigorous path for learning the prerequisites necessary for interacting with the various
elements that ‘enrich’ the environment.
Constant monitoring, always based on observation, will make it possible to
measure the attention and pleasure maintenance level of the play corner stimuli.
Because adults play a fundamental role, they can motivate, provide models, as
well as help and support ludic activities.
Of particular importance, especially in younger children, is the physical vicinity of
the mother (Brodin, 1991), a figure that can promote early experiences of fundamental
importance for the development of play skills. The first thing that the child plays with
is his or her body, but to do this, it is necessary to be familiar with it and to be capable
of locating each part.
The child with multiple disabilities does not easily become aware of what is
around him or her therefore, a guide, even physical, is needed to encourage him or
her to explore and experiment. The caregiver can facilitate the child to experience his
or her body, helping him or her to touch own parts, stimulating and proposing play
actions (ball pit play, rocking games) or relaxing activities (e.g., playing in water).
Finally, to overcome the problems that many parents have when playing with their
children, it is important to provide support that facilitates their ability to observe and
to enter in contact with their children, helping them to propose stimulating activities
and to interact in the most appropriate manner, without replacing them.
When developing the rehabilitation project, the various professionals must
maintain a constant channel of communication with the child’s reference figures.
Caring for the child with multiple disabilities must include care for the entire family
and the use of an ‘ecological’ approach that will affect all contexts of the child’s
everyday life.

11.6 Conclusion

Even children with multiple disabilities can play, making independent choices,
enjoying what they do and not expecting any reward, except the pleasure of playing
itself. However, in many cases, free and self-determined play must be considered not
as a starting point, but as an objective to achieve, creating even highly structured
activities that accompany the child as he or she learns increasingly complex play
skills, and adopting measures that will have a positive effect on the characteristics of
the environment.
Given the heterogeneity of the motor, linguistic, intellectual, and sensorial
characteristics of children with multiple disabilities, the intervention must be highly
individualised and be based on specific observations of individual behaviour in
family contexts and at different times (Gleason, 2008). Similarly, environmental
changes must be personalised while also taking into account a child’s progress and
development.
References   153

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Sylvie Ray-Kaeser and Helen Lynch
12 Occupational Therapy Perspective on Play for the
Sake of Play
Despite play being identified as being a core aspect of occupational therapy (OT) from
as early as 1922, the focus on play receded and did not come to the fore again until
research and writings from therapists, such as Mary Reilly (1974), and further work
that came from the emergence of the new science of occupation in the 1980s and
1990s (Hocking, 2009). The resurgence of occupation coupled with global influences,
such as the evolving ICF (WHO, 2001) and ICF-CY (WHO, 2007), has resulted in a shift
away from the traditional biomedical model to an occupational model; practice is
orienting more towards participation than body function and structure (Figure 12.1).
Participation in play is related to an interaction between the children’s motivation
and abilities, the characteristics of the environment, and available activities matching
their preferences (Figure 12.1).

Figure 12.1. Focus on participation in play

An OT perspective on play is closely intertwined to the study of play from an

occupational science perspective. Hence, this overview of the contribution of OT to
play includes the study of play as an occupation (occupational science) as well as the
translation of this knowledge into practice (OT). In occupational science and OT, play
is named as a core element in the classification systems of occupations across the
lifespan. It is viewed as the most common occupation of children, and playing one of
the many daily routines, such as dressing, eating, and showering. Being a player is the
primary occupational role of a child. Play is any fun activity that produces a sense of
joy in the participant; it is viewed as a way of being, a state of mind, called playfulness
(Lane & Bundy, 2012). Play is significant because it gives children a sense of mastery
(Reilly, 1974), it transcends life’s’ distresses (Sutton-Smith, 2008), and it is central to
how children learn, especially in the early years (Bateson, 2011).

© 2017 Sylvie Ray-Kaeser and Helen Lynch

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License.
156   Occupational Therapy Perspective on Play for the Sake of Play

Multiple disciplinary perspectives provide a strong basis for the theory of play as an
occupation (Parham 2008). These include cognitive, psychodynamic, anthropological,
motor, psychological, social, and competence fields of study. Researchers have built on
these disciplinary perspectives to form an occupational therapy perspective specifically
that reflects a biopsychosocial view of play. Research on play in the occupational science
literature includes considering play in terms of occupational behaviour (Reilly, 1974) and
play as occupational development (Humphry, 2002; Wiseman et al., 2005), integrating
research on different play types and purposes, along with the influences of the physical
and social environment on play (Knox, 1996; Pierce et al., 2009; Schneider, 2009).
From a body function and structure perspective, play is regarded as an important
aspect of child development, consisting a variety of movements and manipulation
of the environment: through play, the child develops sensory integration, physical,
cognitive, and language skills (Tanta & Knox, 2015).
In relation to activity and participation, play includes a sociocultural perspective,
where it is acknowledged that play is viewed and valued differently according to cultural
values, customs, and norms (Bazyk et al., 2003; Parham, 2008). Studies of children with
disabilities have found that these children experience social exclusion in play activities
due to difficulties in joining similar physical play activities as their peers (Law et al.,
2013; Poulsen et al., 2007).
Regarding the environment, the physical environment is known to have a significant
influence on the occupational development of the child (Lynch, 2012; Pierce, 1996).
Researchers have found that the physical environment shapes play (Lynch, 2009;
Prellwitz & Skar, 2007) and that playfulness is influenced by the environment (Rigby
& Huggins, 1997). Concerning systems and policy contexts, play is considered as an
occupational justice issue and a fundamental occupational right (Wilcock & Townsend,
2000). Conditions such as play deprivation, inability to engage in play, exclusion from
play activities, and inaccessibility to playgrounds or other play spaces can be alleviated
through social or political actions (Moore & Lynch, 2015).
Overall, play is a quality of life issue, improving the health and wellbeing of
communities, groups, and individuals (Parham, 1996). Play as healing exercises
“cognitive and affective flexibility to aid resilience”, which is “central to human
adaptability” (Dell Clark, 2015:375). Play serves adaptation and has an adaptive
function. It is believed to facilitate inclusion, social participation, and flexibility in
thinking, learning, and problem-solving (Stagnitti & Unsworth, 2000).
While occupational science research values the extrinsic functional contribution of
play to child development, it also values the intrinsic contribution for the child: “play
is a vehicle for meaning” (Parham, 1996:78). Through interviews or observation with
children and their families, the subjective meaning of play occupation has been studied
(Prellwitz, 2007; Spitzer, 2003a; Tamm & Skar, 2000). While the subjective meaning
for the child may not always be apparent, using an occupational science approach to
understand play helps us to see that it is the individual’s experience of the activity that
determines whether it is enjoyable (Pierce, 2001; Spitzer, 2003b).
 Definition of Play from the Discipline of OT   157

To summarise, an occupational perspective of play is that it “only occurs when

there is a ‘just right’ fit between the child and the environment” (Cooper, 2009:33),
that it can be both productive as well as pleasurable and that it can be embedded in
obligatory tasks and requires effort (Humphry, 2002). While play may be defined as
pleasurable, it can still be productive, and therefore, there is no dilemma in arguing
that play is also “serious business” (Bruner, 1976:20).

12.1 Definition of Play from the Discipline of OT

Play is defined in OT as any spontaneous or organised child-directed activity that is

an interaction between the child and the environment, which “provides enjoyment,
entertainment, amusement or diversion” (Parham & Fazio, 2008:448). It is characterised
by core elements: intrinsic motivation, where the child is free to engage; controlled by
the player; freedom from external rules or direction; with attention on the play process
rather than on the product of play (Rigby & Rodger, 2006; Skard & Bundy, 2008).
Although it is viewed as providing amusement and diversion, it should not be confused
with being frivolous; it is the means through which the child learns and develops, the
source of wellbeing, and is consequently an aspect of childhood that requires serious
consideration. The American Association of OT (AOTA) acknowledges the importance
of play in its “Societal Position on Play (Primeau, 2008:707):

OT practitioners support, enhance, and defend children’s right to play as individuals and as
members of their families, peer groups, and communities by promoting recognition of play’s crucial
role in children’s development, health, and wellbeing; establishing and restoring children’s skills
needed to engage in play; adapting play materials, objects, and environments to facilitate optimal
play experiences; and advocating for safe, inclusive play environments that are accessible to all.

12.2 Play in OT (how OT Contributes to the Topic)

Play has a central place in OT as primary means and goals for intervention with
children (Parham & Fazio, 2008). This means that play in OT may not be play at all: it
is often addressing functional skills for play or utilising a playful approach to target
other skills (play as a means to an end). OT is also concerned with making sure that
the child’s basic needs are met, so that they are able to play (e.g., environmental
adaptations). Consequently, Bundy (2011) considers that there are five facets of play
that have particular relevance to OT practice with children and families:
1. Skills for play
2. Approach to play (play attitude)
3. Play activities
4. Environmental supportiveness for play
5. Source of motivation for play
158   Occupational Therapy Perspective on Play for the Sake of Play

The occupational therapists (OTs) base their intervention on their knowledge of

these five facets, with specific attention to play activities and characteristics (form,
function, meaning, and context), of the art of play and science of human occupation
(Hinojosa & Segal, 2012). They closely analyse how intra-individual characteristics
and environments support or interfere with play to generate multiple therapeutic
strategies at three levels of service.
1. Universal
–– Assisting in the promotion of play for all children through the development of
policies.
–– Educating the community on the importance of play.
–– Advocating a universal design for the public play areas and equipment.
2. Targeted
–– Providing play environments usable for children at risk of developing health
challenges.
–– Assessing, selecting, and adapting play materials, equipment, toys, and games.
–– Providing assistive technology for play for the ‘at risk’ group of children.
3. Intensive
–– Encouraging child-parent playful interactions and educating families to balance
their time with playful activities.
–– Enabling engagement in play and play inclusion of a child with disability.
–– Expending a child’s cognitive, physical, social, emotional, and play skills through
individualised intervention.

The OTs provide assessment of a child’s play and playfulness, although play
assessments have a limited role to date in OT practice (Miller Kuhaneck et al., 2013).
As play typically occurs in the child’s environment, play assessment requires tools
that facilitate an accurate and authentic assessment in context; therefore, observation
of unstructured play in context is most common (Bundy, 2011) with observational
tools such as the Test of Playfulness (ToP) (Skard & Bundy, 2008) as well as the
environmental supportiveness of the player’s motivation for play (TOES) (Bronson &
Bundy, 2001). Other forms of assessment include parent interviews about the play
experiences of their child (Play History, Takata, 1974; Initial interview with parents,
EIP, Ferland, 2003) or interview with the child (Pediatric Interest Profiles, PIP, Henry,
2000; Pediatric Activity Card Sort, PACS, Mandich et al., 2004). They also assess the
play behaviour of a child (Revised Knox Preschool Play scale, RKPPS, Knox, 2008;
Child Initiated Pretend Play, CHIPPA, Stagnitti, 2007; Evaluation of ludic behaviour in
children, ECL, Ferland, 2003). To date, no assessment has been developed in OT for
assessing motivation for play, and this has been noted as being an aspect requiring
further research (Bundy, 2011).
OT intervention for play can be in the form of play as means versus ends
(McLaughlin Gray, 1998) and play as both means and ends. In each case, where OT is
working directly with the child, the therapist can utilise varied approaches that can
 Play in OT (how OT Contributes to the Topic)   159

be considered as a continuum from a teaching approach (non-play), to directed play,

to guided play, and then free play (Table 12.1).

Table 12.1. Continuum from therapist initiated to child-initiated play (adapted from Henrick, 2015 and
Wood, 2007)

Relationships OT- Therapist- Therapist- Child-initiated or Child-initiated,

child in play initiated and initiated or child- therapist- child-led, and
directed responsive scaffolded and child-directed
guided

Kind of activity Activities are Activities are Activities are Activities are
taught and playful or play- playful, play- intrinsically
practised based based, self- motivated, self-
chosen, and chosen, voluntary
voluntary
Kind of play Work or non-play Directed play Guided play, i.e., Free play
i.e., playful work work-like play
← ← ← ←……moving from extrinsic motivation to intrinsic motivation………. → → →

Play as means to an end. The OTs use spontaneous and/or organised play as an
attractive tool or medium to act upon the primary consequences of the disability and/
or prevent psychosocial difficulties. They use playful activities to improve specific
skills, which are expected to develop abilities in a range of daily activities. In this
form of intervention, the child is directed to using play objects and play activities, in
order to enable the development of specific motor, sensory, cognitive, emotional, and
social skills. The child may not have a choice in the activity and may have less control
in the play than if it was freely chosen and self-directed. Hence, the play form in this
mode of intervention is more typically oriented towards directed, adult-led activity, to
support learning. Play is primarily used in this instance as a motivator for engaging
the child in therapy (Bundy, 2011; Miller Kuhaneck et al., 2013). Play as a means to an
end refers, therefore, to playful activities rather than play.
It is known that interventions using playful activities yield better results than
repeated exercises, for example, to increase the range of movement of children with
burn injuries (Melchert-McKearnan et al., 2000). There is evidence that playful motor
intervention with children at risk of developmental delay provides positive outcomes
(Fromberg & Bergen, 2015). The OTs use objects’ and toys’ motivational properties
to increase the appeal of therapeutic activities, address common performance skills,
and support engagement in occupation. They create therapeutic situations in which
children can experiment new skills with fewer risks and use play to encourage
children’s participation.
Play as a therapeutic medium is also used outside clinical contexts, working, for
example, in the family home in response to traumatic events or child’s inner conflicts
(Johnson et  al., 2015). More recently, play interventions have been developed to
160   Occupational Therapy Perspective on Play for the Sake of Play

address obesity and increasing physical activity in childhood through playground

design (Bundy et al., 2008; Bundy et al., 2011; Engelen et al., 2013).
Play as ends/goal. When the OTs use play as the goal, this takes on many forms:
the OT may consider addressing play skills of the child or addressing social and
physical environmental enablers for play.
One OT intervention where activities, such as play, can be the goal is the Cognitive
Orientation to Daily Occupational Performance (CO-OP) programme (Polatajko &
Mandich, 2004). In this cognitive intervention, the therapist supports the child to
identify and explore new strategies for learning a desired skill, such as riding a bike
through problem-solving and practising in weekly therapy sessions. When play is the
goal, the intervention uses playful activities rather than self-directed play; the child
does not engage in a form of play that is flexible, where he or she can move from one
activity to another at will. Instead, the child focuses on the chosen play activity and
through directed engagement and guided discovery (i.e., guided by the OT), practises
new strategies for successful achievement of the activity. An example of specific OT
intervention where play is the goal is the Learn to Play programme from Australia,
where the therapist begins by using a directed play approach until the child becomes
more competent in play skills and moves to guided play (Stagnitti, 2004). The focus
of this programme is to enable adults to direct the child in pretend play, beginning
with the child’s developmental level and modelling the play activity. The child is
encouraged to develop six core skills: sequence of play actions, object substitution,
play scripts, doll/teddy play, social interaction, and role play (Stagnitti, 2009). In a
more recent work, further developments in play-based approaches have expanded to
include interventions for children with ADHD, in home contexts and incorporating
parents and friends in the therapy process (Wilkes-Gillan et al., 2014). Each example
of intervention approaches demonstrates the current move towards contextual,
participatory methods in provision of play-based OT, with a strong focus on changing
the environment as a way to enable play.
The OTs include goals related to environmental supportiveness for play and
skills for play aimed at improving play participation of children with special needs,
enhancing parent-child interactions and play access. They can help families that
struggle to manage their complex daily occupations with a child with disabilities.
They identify the strategies the parents use at home to manage their child and support
them to find and use the most appropriate ones for integrating play into the life of the
whole family. They use their knowledge to adapt play and play materials. In such a
family-centred approach, intervention is not always specifically aimed at reaching
specific goals for the child only, but also for the parents and child to play without
assistance from the therapist (Lane & Bundy, 2012).
The OTs also enable all children to play and promote playfulness and spontaneous,
active community play experiences for children for the value of free play for its own
sake (Lane & Bundy, 2012). This is in adherence with the overarching outcome of
OT to promote engagement in occupation to support participation. They use their
Conclusion   161

knowledge to notice play inequities. They address the children’s engagement in

play within the context of their lives, the home, school, and community (Parham &
Fazio, 2008). They support the parents to engage fully with their children through
play and avoid play deprivation knowing that the actual hurried lifetime, the changes
in family structures, and increased attention to organised extra-scholar activities
reduce the time for free play in families (Singer et al., 2009). They support teachers
and educators to create play opportunities in the school and day-care environment,
in school playgrounds, as many schools restrict the play by removing play equipment
and break time (Bundy et al., 2008; Ramstetter et al., 2010).
Combining play as means and play as ends. In other OT interventions, play is utilised
as both a means to an end and also as the goal. One example of this is an OT intervention
called Ayres Sensory Integrative approach (ASI), which provides opportunities for children
with sensory-processing disorders to engage in active, child-led, and child-driven playful
and fun activities with achievable challenges in a secure (safe) environment (Schaaf &
Miller, 2005). This is an example where intervention is required to be play-based and the
child is facilitated to engage in physical activity play primarily, through child-initiated,
therapist-responsive activities. In this form of intervention, the child is not fully engaging
in free play, but is more accurately taking part in guided play, where the therapist sets
up the environment, so that the child will choose certain play activities (Weisberg et al.,
2013). It is a form of guided play that meets their developmental needs and is based on the
intrinsic motivation of the child (Table 12.2).

12.3 Conclusion

OTs are in a unique position to promote play for children in general and for children
with disabilities, creating opportunities for an inclusive environment of play and
providing education on the need for play to promote a healthy and playful life. To date,
few studies have examined the effectiveness of using different approaches to play in
intervention: to compare the effect of directed-play versus guided play versus free-
play in enabling play occupation. Yet, in educational studies, play-based learning has
been shown to be more effective than direct instruction, especially for pre-schoolers
(Hirsh-Pasek et al., 2009). More research is needed to explore the different forms of
play-based intervention, and specifically, the place of guided play or free-play as
an effective means of enabling participation in play occupations for children with
disabilities. If free play is the serious work of the child, then we must ensure that play
occupation is more central in our work, as part of our role in enabling play as ends,
and not just considering play as a means to an end.
162   Occupational Therapy Perspective on Play for the Sake of Play

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Michele Mainardi
13 Contribution of Special Education to the
Promotion of Play for the Sake of Play

13.1 Introduction

Thanks to play, a child, for what concerns his or her personality as well as learning
and self-assertion tools, can develop his or her identity and discover and exert his
or her own power of free and intentional action on the environment and on persons,
on relationships between subjects who play and on things. Play situations are
certainly one of the opportunities where the chid enjoys the pleasure of competence.
Discovery, emergence, and differentiation of interests and abilities are some of the
basic factors in the play activity and of its intrinsic underlying motivation (Santer
et  al., 2007). Success and pleasure provide incentives for and orient motivation.
Conversely, ‘resistance to assimilation’, ‘difficult access’, and failure can be first
factors of exclusion and dependence, and then, of anger, frustration or resignation,
and renouncement (learned helplessness).

13.2 Development of the Child, Developmental Disability,

Special Education

Every child has innate and early skills that allow him or her to have certain forms
of interaction with the surrounding physical and social world (Vygotskij, 1978).
The ‘state of development’ of a person depends on countless factors. It is the end
result of his or her behaviours, internal events (such as beliefs, expectations, self-
perception, goals, intentions, physical structures, sensory and neural systems), and
the effect of external factors, including social influences, roles in society, and the
physical environment (Bandura, 1992).
The results and manifestations of development are the product of an indefinable
quantity of processes. All individuals develop continually in their own way and
at their own pace (Shaffer et  al., 2002); consequently, “everyone has a unique
developmental trajectory and outcome” (Skelton & Rosenbaum, 2010: 1).
This concept of development, and of the numerous factors influencing such
growth, has led special education to focus increasingly on how and under what
conditions an ability can be developed, and on how a disability can be managed in the
interest of a person’s global development, acting independently on the facilitators,
and obstacles to development and to the opportunity of doing something, so that
each person can develop and act to the best of his or her abilities, regardless of his
or her distance from or reference to standards (World Health Organisation, 2002).

© 2017 Michele Mainardi

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License.
 Development and Play in Special Education   167

Special education operates where the concepts of development disability and

child development intersect, but there are still many unanswered questions about
such an intersection (Rosenbaum, 2008; Rosenbaum, 2009; Skelton & Rosenbaum,
2010).

13.3 Development and Play in Special Education

Play must be considered a process that embraces a wide range of abilities, motivations,
behaviours, social situations, environments, contexts, and opportunities (Moyles,
2005).
A child who plays draws great benefit from this activity (Caffari-Viallon, 1988;
Hewes, 2006; Selleck, 2001; Sheridan, 1977); however, not all have the same play
opportunities at either a quantitative or qualitative level. This depends on the
various obstacles or facilitators encountered in the context where the person
develops. These obstacles and facilitators, interacting with a person’s abilities
and developmental disabilities, can disturb or favour the play activities just like
they disturb or favour his or her daily habits, placing the child in a situation
offering complete opportunity or, on the contrary, a handicap (Fougeyrollas, 1995;
Rosenbaum, 2008).
In special education, more than anywhere else, play is often subordinated to
other education or developmental priorities, or proposed according to forms and
modalities that with regard to the ludic activity traditionally recognise strengths
that can be used to enhance the attractiveness and effectiveness of rehabilitative or
compensatory learning activities (Saracho & Spodek, 1998, 2003).
Less frequently than others, a child with disabilities finds himself or herself
in situations that put him or her in the condition to play spontaneously, with
pleasure and in complete freedom (with regard to time and method). Rubin et al.
(1983) summarise the distinctive criteria of the play activity as follows. Play is: (1)
intrinsically motivated (not governed by appetitive drives, compliance with social
demands, or by inducements external to the behaviour itself); (2) controlled by
the players (spontaneous, free from external sanctions, its goals are self-imposed);
(3) concerned with a process rather than product (play asks “What can I do with
this object or person?”, and this question differentiates play from exploration that
asks, “What is this object/person and what I do with it/him/her?”); (4) non-literal
(play activities can be labelled as pretence); (5) free of externally imposed rules
(this distinguishes play from games with rules); and (6) characterised by active
engagement of the players (this distinguishes play from daydreaming, lounging, and
aimless loafing). Therefore, it is not enough that an activity has the characteristic
features of play to be considered as ludic.
What makes play unique and richer is the simultaneous presence of each of
the factors indicated in this definition; their impact on the development of a
168   Contribution of Special Education to the Promotion of Play for the Sake of Play

child with a development disability, on his or her experience in taking action in

different situations, and on the freedom to undertake such action; the emergence of
subjectivity and differentiation of the intrinsic motivation in taking action; testing
the possibility of playing. In education, attention aimed at the uniqueness of the
child with some impairments in his or her relationships with the world and with
learning qualifies special education. The attention focused on the characteristics
of the child with disabilities, on the educational environment, and on the play
opportunities (adequacy and accessibility) by special education qualify the
consideration that the latter has for play by children with disabilities.

13.4 Spontaneous Play in Special Education

An absolute priority in special education is to concentrate on free and spontaneous

play as a learning and development factor and on accessibility of experience
opportunities as a condition of the experience (Aufauvre, 1980; Loos & Hoinkis,
2001; Mainardi, 2010; Santer et al., 2007). Play is important for all children. Special
education must ensure that children with disabilities have the same opportunities to
play as everyone else: “Self-determination is an educational outcome” (Wehmeyer,
1996). The studies that focus on this issue (Nankervis & Stancliffe, 2006; Wehmeyer
& Garner, 2003; Wehmeyer et  al., 2003) show that self-determination is directly
correlated to the opportunities to make choices supported by the environment.
Educational contexts within which children with special education needs
develop must take into account that “Self-initiated free play experiences are vital
for the normal growth and development of all children” (Missiuna & Pollock, 1991:
882). The adequacy of the environment, the accessibility of the situations and of
the play opportunities, and the frequency of the experience affect the possibility of
experiencing play and oneself in play.
The specific educational context with special consideration for (1) the
individual child, (2) accessibility of the living and development environment, and
(3) the predisposition of opportunities for choice and free action determine the play
opportunities and must be the focus of attention of education professionals and
education consultants of families of children with disabilities. The child who due to
endogenous, educational, or environmental reasons cannot carry out active roles in
play situations, involving responsibility of choice and management of activities, is
a child with a disadvantage (Bronfenbrenner & Ceci, 1994).
According to Bronfenbrenner (1992), personal attributes have the power to
influence psychological and social development (“developmentally instigative
personal characteristics”) just like the “hierarchical environmental system of
influence” in which the person is inserted, as well as time.
Sontag (1996), based on the considerations by Shonkoff et al. (1992), states that
the influence on the development by exogenous factors at the base of a disability
 Spontaneous Play in Special Education   169

(organic causes of genetic or environmental origin) is important, but it has been

proven that the environmental characteristics contribute significantly to a child’s
skills. The psychomotor competences of the child significantly affect the behavioural
manifestations, and in particular, spontaneous play, adaptive behaviours, and
mother-child interactions.
The type and degree of disabilities, as such, are not predictive indicators of
instigator characteristics of a person’s specific development. The characteristics of
a child generally associated with development include health problems (heart and
neurological disorders), personality traits, and their behavioural manifestations;
the convictions of family members as far as how and what influences the enrichment
of a child’s development; instead, neither gender nor general family characteristics
(family structure, economic situation, profession, health, ethnic group, etc.) would
seem to have an influence as specific instigator factors.
Other studies (Zetlin et al., 1987) report how some adults (parents or education
professional) exert too much control on the child (hyperprotection, priority on
interventions based on education, and development purposes aimed at acquiring
specific instrumental skills), while others assume different attitudes, more open to
the independent and self-initiated experience. Other research studies confirm the
reduction in expectations towards independent activity of the child with disabilities
by the adult in relation with the decreased initiative and reaction times (Eheart,
1982; Gunn et al., 1982; Jones, 1977; Serpa & Meneres, 2003).
Physical, social, personal, and environmental barriers that limit the play
experiences of children with disabilities must be delineated and considered in a
facilitatory approach to the promotion of free play at home and at school (Missiuna
& Pollock, 1991). Children with disabilities may find themselves in a situation with
an accumulation of difficulties due to (1) greater dependence on their caregivers
compared to other children; (2) spending more time than their peers at home; (3)
passive involvement in activities made necessary by possible requests to provide the
person with assistance. In addition, parents who are called on to act as a therapist
with the child have less time and are less inclined to prepare and accompany free
play situations, especially if they are not considered as particularly significant
activities within the PEP (Personalised Education Plan).
Special education must consider that children with developmental disabilities
may have a disadvantage in the exploration, interaction, and use of experience and
play opportunities. There may be an impairment in the activity that allows the child
to discriminate play, and therefore, take full advantage of the experiences through
the senses and movement (Goldschmied & Jackson, 1994; Hutt et al., 1989; Karrer
et al., 1979; Mainardi 1988; Ryan & Jones, 1975).
With respect to spontaneous and free play opportunities, special education
must prevent the additional accumulation of difficulties (secondary impairments)
in children with disabilities (Mainardi, 2013). To do this, special education must
170   Contribution of Special Education to the Promotion of Play for the Sake of Play

consider the ‘handicap’,1 that the child must or can cope with (Mainardi, 2010).
Attention with regard to the accessibility of opportunities and the adequacy of
toys, situations, and play materials must be focused on the child’s deficits and
subsequent functional limitations. The presence of disabilities has a more or less
direct effect on the quality and quantity of play opportunities and on their possible
impact on a child’s development.
The objective difficulties that the child encounters in the development process
represent the source, that is, the initial stimulus of the manifestation of compensatory
processes (Barisnikov & Petitpierre, 1994), but at the same time, the objective
disabilities of the child motivate the compensatory activities also with his or her
entourage.
The presence of disabilities in a child must not, in any case whatsoever, lower the
level of expectations with respect to the importance of play, the inherent pleasure of
play, and the opportunities of playing. The caregivers (from parents to professionals)
must force themselves to allow the child to play and must intervene with caution in
moments perceived as impasses in the play activity not to compensate, but to respect
and promote the child’s intentionality and action.
It is of little importance if a child has a disability or not, the child must play. To
do this, it is important that the child has time, that there are playmates, and that he
or she is given space and accessibility to the environment; that the surrounding social
entourage enjoys playing, watching someone play, teaching to play, and considers the
importance of play for the development of the person who is playing.

13.5 “Let me (them) Really Play”: a Priority in Special Education

The risk that play is suffocated by other concerns or by ‘compensatory’ activities

that, with regard to play are merely instigative without having other important and
specific characteristics, exists to the extent in which the educational professional,
the family, and peers act as if it were enough to let children play. A child’s play must
be motivated, safeguarded, and developed in all cases, but even more so, for the case
involving children with a handicap.
It is of vital importance that whoever is close to the child should not only focus on
compensating for a deficiency or a disability (Harrist & Bradley, 2003). It is crucial to
think of the child. The impairment must be bypassed, so that the child can take full
advantage of his or her condition, just like any other child:

1 In special education, the purpose behind the notion of handicap is to be able to distinguish, in
operative terms, the influencing factors that make it possible to provide specific references to the
mediation and support activity to facilitate accessibility of experience opportunities, from the general
condition of the person with a disability (Mainardi, 2010).
References   171

1. Free and spontaneous play is the right of every child, as is the possibility of being
able to fully exploit adequate and accessible play opportunities (at a physical,
cognitive, affective, and social level).
2. The child with some type of impairment must be able to have the chance to
play with satisfaction and success: he or she must be able to distinguish the
opportunities and the specific characteristics of the free play situations and to
experience and to exercise his or her abilities to intervene on the development
and management phases of the play sequence as a fact and event in his or her life.
3. Play situations must be adaptated and made accessible (Mainardi, 2010) and
must allow the child with some type of impairment to be included within his or
her natural social context and his or her group of peers.

Special education must have the following educational priority: “Of prime importance
for play, however, are the relationships that the adult develops, which give children
the confidence to act autonomously, make choices, follow their interests and interact
with peers. In other words, creating a context in which children feel psychologically
safe and socially included” (Santer et al., 2007:59).

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Vaska Stancheva-Popkostadinova and Tatjana Zorcec
14 Play in Early Intervention for Children
with Disabilities

14.1 Introduction

Early intervention is described as a system designed to support family patterns of

interaction that best promote child development (Guralnick, 2001), consisting in
multidisciplinary services provided to children from birth to five years of age (Shonkoff
& Meisels, 2000).
Blackman sustains that “the goal of early [childhood] intervention is to prevent
or minimise the physical, cognitive, emotional, and resource limitations of young
children with biological or environmental risk factors” (2003:2).
Numerous studies emphasise the benefits of early intervention in the process of
achieving developmental targets and goals for children with disabilities. Play has a
central role in early intervention for children with disabilities, and it is used both
for assessment and intervention. Some researchers regard play as a developmental
domain, some as a medium for the development of specific skills (Bergen, 1987), while
the others consider play as a domain for assessment, intervention, and curriculum
activities (Lifter et  al., 2011) in the process of delivering intervention procedures
aimed at improving the a child’s developmental and learning abilities (Casby, 2003;
Lifter, 2008; Linder, 1993; Nwokah et al., 2013; Pierce, 1997).
Adults often use playtime to help children learn and often demand that play
is functional to scopes other than fun. Obviously, learning is really important, but
adults must not forget that when children play, ‘function’ is not what they are looking
for. Children are simply playing and having fun. We know that play is intrinsically
motivated and children are strongly determined to do this activity. When adults
attempt to structure and direct the children’s play, sometimes their intervention can
be stressful and children can respond rebelliously (Sutton-Smith, 1987). Needless to
say, adults must support play, facilitate and promote positive play. This support is
especially beneficial for children with developmental delays.

14.2 Play in Early Intervention

One of the first extended overviews concerning the use of play in early intervention
was proposed by Doris Bergen, who made an interesting review of the existing
literature on the “suggested uses of play for assessment, prevention, and intervention
with special needs children” (Bergen, 1991:1). The vision and proposals she stressed
are still actual: play-based model of assessment conducted by a trans-disciplinary

© 2017 Vaska Stancheva-Popkostadinova and Tatjana Zorcec

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License.
 Play in Early Intervention   175

team; advantages and recommendations for overcoming the disadvantages of uses of

play in early intervention for children with disabilities.
The use of play as a context for assessment and intervention and as a vehicle
for successful inclusion in early care and educational settings intensified in the
1990s (Buchanan & Johnson, 2009). In their analysis of the use of play in early
intervention, Lifter et al. (2011) delineated two important benefits of play for children
with disabilities: facilitation of the development of more advanced play skills and the
provision of a natural playful context to make it easier important clinical activities,
such as the assessment and the implementation of educational and rehabilitation
activities with a wide variety of goals in different developmental areas.
Early intervention programmes for children with disabilities are generally based
on three different approaches: behavioural, developmental, and a combination of
both. While the first approach is mainly addressed to implement new abilities in the
child through specific ‘ad hoc’ plans of intervention, the last two are more related to
the use of play and will briefly discussed in what follows.
The developmental approach is generally play-based and carried out in the child’s
natural environment. While adults play an integral part when applying the methodologies
related to this approach, they do not actively structure or lead the learning opportunity.
Play-based approaches to learning support the concept of natural environments presented
in the early intervention literature (Dunst, 2007; Dunst & Bruder, 2002; Hanft & Pilkington,
2000). Play activities are used to implement goals in a variety of developmental domains
(Sandall et al., 2005) for child-focussed interventions (Wolery, 2005).
Several studies have provided evidence of systematic relationships between
developments in play and developments in other domains (Lifter et  al., 2011). The
integration of activities addressed to teach new skills into the play routines can be
effective in improving both play and other developmental domains (Dunst, 1981).
Combined programmes have been developed using principles from both the
behavioural and developmental approaches. In what follows, some example are
shortly presented.
The Early Start Denver model promotes learning through play in natural routines,
in combination with structured teaching techniques associated with behavioural
therapies; it aims at developing play skills and language abilities (Rogers & Dawson,
2010). TEACCH (Treatment and Education of Autistic and related Communication
handicapped CHildren) is an intensive intervention programme to promote learning
and development, in particular, in the areas of communication and social skills,
independence, coping skills, and skills for daily life. Children are supported by
creating a very structured learning environment (Peeremboom, 2003). JASPER
(Joint Attention Symbolic Play Engagement Regulation) targets the foundations of
social communication (joint attention, imitation, play), uses naturalistic strategies
to increase the rate and complexity of social communication, and includes parents
and teachers as implementers of the intervention to promote generalisation across
settings and activities and to ensure maintenance over time (Kasari et al., 2012).
176   Play in Early Intervention for Children with Disabilities

14.3 Play-based Assessment

Assessment of development of sensorimotor and social play, as well as the onset,

quantity, and quality of symbolic play in children can give indications about the
possible delays in other developmental domains, and may support and validate other
assessment measures that denote developmental problems (Bergen, 1991).
Play-based assessment occurs either in a special setting that has been designed to
elicit a wide variety of behaviours (Linder, in 1990, gave a detailed description of this
approach) or by observing play at the child’s own home or within the setting where
the existing early intervention programme is carried out.
Fewell et al. (1997) delineate the following advantages of play environment as a
setting for the assessment: fewer demands on the child; more choices for the child to
demonstrate his or her competencies; more active role of the child in the assessment;
play allows the examiner to measure the child’s skills across several play tasks and
in several domains.
The existing empirical literature indicates that there are numerous benefits to
using play assessment and intervention with young children: in fact, the assessment
is conducted in the natural environment of play, emphasises learning in the context
of daily routine, including child-preferred activities (Buchanan & Johnson, 2009);
furthermore, play is motivating and elicits the highest level of a child’s functioning
(Kelly-Vance, 2008). In comparison to other types of assessment, play-based
assessment was found to take less time and resulted in more favourable parent and
staff perceptions (Myers et al., 1996); it removes many of the limitations associated
with traditional assessment, and in case of children with disabilities, it offers also a
number of opportunities to adapt the context to their needs (Fewell et al., 1997).
The trans-disciplinary play-based assessment is a method, developed by Linder,
that brings together parents and professionals and gives the latter the opportunity
to evaluate young children in a natural environment. Trans-disciplinary play-based
assessment is a criterion-referenced developmental assessment approach designed
to assist the planning of interventions for children with disabilities. During the
assessment, the child and his or her parents play with developmentally appropriate
toys, while the team members, through observation, assess the child’s strengths
and weaknesses across all developmental areas. The team members also make
observations about the parent–child interaction (King et  al., 2009). No specialised
test materials are required and the assessment is not standardised: this allows for
cross-cultural use. Assessment is unstructured, and a child’s developmental status
is examined through the informal context of play. The information obtained during
the assessment is used to formulate the main goal and objectives of the further
individualised intervention.
This type of assessment is less stressful for children and less burdened to the
family. Linder (1993) indicates that the advantages of the adoption of such a method
include: the use of the natural environment, a better rapport with examiners,
 Challenges in Using Play in Early Intervention   177

parent involvement, major flexibility in testing domains, the assumption of an

integrated, holistic perspective on child development, and more useful information
for planning intervention. The application of the transdisciplinary play-based
assessments needs less time to complete than multidisciplinary standardised
assessments (Myers et al., 1996), and it is a cost- and time-effective method (Bergen,
1991).
Bergen (1991) also stresses that developmental levels and delays may be effectively
assessed by a team of specialists observing children in a play environment, and that,
if the team maintains sensitivity to the elements that should be present for play to
occur, the method can be successful without distorting the meaning of play.

14.4 Challenges in Using Play in Early Intervention

The scientific literature sustains the benefits of the play as an integral part in early
intervention programmes; nevertheless, there are some challenges and limitations
related to the context, parents, and practitioners.
Some early intervention researchers (Bray & Cooper, 2007; Dunst, 2000; Moore,
2008; Rix et al., 2008) report that children with a disability or developmental delay
are not always supported to be included in play experiences, and that, play contexts
may be overlooked as to their qualities of excellent sites for learning in both centre- or
home-based interventions.
In order to achieve the goals of interventions, self-confidence and skills of parents
in their abilities to nurture and teach their children must be enhanced (Nwokah
et al., 2013). Some studies report parental dissatisfaction with the pressure to carry
out activities as part of a programme as well as insufficient support to encourage
their child to play (Rix et al., 2008). Matthews and Rix (2013) pointed out as a key
challenge for parents involved in early intervention programmes to encourage their
child to play and learn through enjoyable, daily childhood experiences. There are
specialists complaining that parents do not seem to appreciate the role of play in child
development, nor did they prove to be able to play with their children, especially
when it comes to shared-object play and pretend play (Cumming & Wong, 2012;
Nwokah et al., 2013).
On the other side, some authors (Bray & Cooper, 2007; Moore, 2008; Muir et al.,
2008) found that many early childhood practitioners feel unprepared for and lack
the knowledge and skills to implement appropriate interventions within their regular
play-based programmes and routines. This may create some tensions and may impact
the effectiveness of the interventions.
Both specialists and parents of children with disabilities need to be aware of the
elements that must be maintained as play activities, as well as about the characteristics
that play must assume to be truly playful, to the purpose of maintaining those
elements whenever they use play in early intervention (Bergen, 1991).
178   Play in Early Intervention for Children with Disabilities

14.5 Conclusion

Play is a normal activity in the childhood and is widely used in early intervention
for children with disabilities. Nevertheless, the overemphasis on using play in early
intervention as a means of instruction can be a serious barrier for the development of
spontaneous and voluntary play by the child; in addition, in the early intervention,
practice play is far from being the only determinant of any learning that takes place
(Smith & Gossom, 2010).
Play can contribute significantly in helping children to feel in control with
their lives, in using their preferred modes of interaction, and it is also crucial to the
development of their self-worth and their competence (Bergen, 1991). The experience
of using play in early intervention can contribute for achievement of ‘play for the sake
of play’ for children with disabilities, but to reach this goal, future studies are still
needed.

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Odile Perino and Serenella Besio
15 Mainstream Toys for Play

15.1 Introduction

When considering the topic of devices to support the play of children with
disabilities, it is important to notice that the contributions may come from two fields:
care (rehabilitation, education) and the play itself. Within this second field, play
is considered as an activity for pleasure. Its goals and results are not linked with a
specific capacity, but concern the child’s whole developmental areas: personality,
motor, social, cognitive, emotional. Its primary objective—and maybe the only one—
is ‘to play’.
Pleasure of play, according to Huizinga’s definition (1938), comes from free
activity; this is the reason for children’s autonomy is valued, even if very little, so that
they can take charge of their own play and deeply feel themselves, making experience
of their own sensitive and emotional being. If it is difficult to share a definition of
play, however it is possible to describe playfulness, which is the capacity of any
child to fully and freely engage in play, according to Winnicott (1971). Playfulness is
represented by four domains: active engagement, internal control, social connection,
and joyfulness (Cornelli & Sanderson, 2010).
Toys and games, which belong to the concrete reality around children, are the
essential mediators between a child and him or her/self, a child and the others,
children, or adults. When used in good conditions, they allow children who
have impairments to find playfulness in its four dimensions, in relation to their
developmental level.
For this reason, the features of toys and games should be analysed as precisely as
possible to find out their specific ‘ludic springs’ which are suitable for children with
disabilities. Moreover, the conditions of access to play materials inside the play areas
and the toys’ arrangement should also be taken into account, as well as the roles
concretely played by adults when supporting children with disabilities as they use
toys and games.
The following three milestones belong to the concept of ‘play framework’ (Perino,
2006), which is a way to think about devices for play in their entirety.
First, concrete objects of play, which are appropriate to the player’s abilities
and interests, are to be chosen, including all types of games and toys, from rattles to
videogames.
Second, the adults’ role, parent or professional is to be considered as a major
element around the children playing with toys to support free play and feelings
of safety and capability. The interpersonal distance between adults and children
is modulated according to the physical and psychological needs of the player and
the appropriate toys to give playfulness and “the capacity to be alone” (Winnicott,

© 2017 Odile Perino and Serenella Besio

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License.
182   Mainstream Toys for Play

1958) the opportunity to raise. The adoption of the cited play framework allows
adults to adequately separate playtime and play spaces from the other activities,
to support children in understanding what are the aims of such moments and why
the adults’ behaviours change in this specific area and time of life. Adults should
always be supportive towards children, encouraging them by positive feedback and
congratulating for their achievements.
Third, the physical arrangement of toys and games within play areas is to be
minded and verified to the purpose of adjusting it to the players’ possibilities. Toys
and games can be presented inside thematic areas as isolated or unorganised.
Usually, they are shown and kept well in view, except in specific cases. Furthermore,
it is important that toys are organised according to their specific possible way of use,
to support the child’s capacities of classification, seriation, and categorisation, which
are at the basis of creating one’s own wellbeing (Rosenfeld, 1992).
The theoretical method of choosing toys or games is based on the level of
competence required in using them (Garon, 1981; Piaget, 1945). It encompasses the
following three steps:
1. To analyse a toy or a game to determine the type of play it subtends or implies,
the ‘category’ it belongs, which depend on its functionalities, without taking
too much into account the manufacturer’s declared goals. The latter could bring
useless elements, for marketing reasons.
2. To detect the physical features of objects, which make them easily usable within
their own category: are they big enough, easy to grasp, well-coloured, do they
have sounds or not?
3. To verify whether some elements of the objects can make “ludic springs” more
attractive than other ones within the same category.

When analysing toys and games, first of all, it is essential to be aware of the toy safety
issue (European Parliament and Council, 2009). In many countries, in order to be
commercialised, toys must pass safety tests, which mainly concerns the aspects related
to their mechanical and physical properties—such as flammability, migration of certain
elements (i.e., chemical products), electric systems. Furthermore, age determination is
required, when parts of toys are not suitable for children under three years.
If the observance of these standards helps to ensure an overall safety, they do not
always guarantee the best security of players:
–– Sometimes, children use toys in a way that is not consistent with their intended
purposes or proposed age.
–– Old or used toys can lose their original qualities to the point that they do not meet
anymore the defined safety standard
–– Homemade or artisanal toys may not be in line with the safety standards
–– Last but not least, in the case of children with disabilities, an increased vigilance
is needed because in some cases—due, for example, to sensorial impairments—
the use of toys can lead to risky situations
 Devices for the Play of Children with Intellectual Disabilities   183

15.2 Devices for the Play of Children with Intellectual Disabilities

Any category of toys can encompass supports of play, depending on the players’
interests and levels. The first step to choose appropriate toys is to bear in mind the
degree of the players’ intellectual impairment and the types of play they would be
able to be involved on, consequently choosing toys for practice symbolic, constructive
play, or for rules-based games.
Then, within a specific category, the choice depends on the player’s interests and
tastes for some aesthetic aspects (colours, dimensions, etc.), sensorial effects (texture,
smell, etc.), and also for the type of use (action to be made, manipulation, etc.).
Therefore, the choice also depends on the toy’s power to facilitate the play activity
and to make it particularly attractive to the child.

15.2.1 Toys or Games Features

Practice play. Toys for this type of play provide strong stimuli and require non-
complex or few successive actions by the child; each sequence of play is short
enough to allow children to keep enjoying play, without losing their interest (which
is frequent in young children and in children with intellectual impairment); toys that
propose unpredictable effects or with non-visible mechanisms of activation are not
useful because they do not give children the opportunity to connect their action with
its results, thus maintaining children in a kind of ‘magical thinking’. In addition, in
order to avoid stereotyped sequences of play and to help the child evolve and adopt
new different kinds of gestures and more complex movements, it is useful to provide
different objects to make the same ludic activity, for example, pop-up toys that are
operated in different ways.
Symbolic play. For a player interested in symbolic play, the shape and size of the
toys must be as realistic as possible; moreover, they must represent aspects of the real
and daily life environment.
Make-believe play can be difficult for children with intellectual impairments who
find it hard to understand that one object can be used as it was another one or that a
person can play a different role from his or her own usual one. For many children with
intellectual impairments, realistic objects within a thematic area are easier to use for
reciprocal exchanges and role recognition, whereas costumes need the support of a
reflective metacognitive thought and may be frightening to some of them.
Constructive play. With assembling toys, it is important to pay attention to
the duration of play sequences, to avoid lack of interest and maintain the effect of
surprise and willingness to continue. When toys are made of parts to be assembled, it
is also important to pay attention to the complexity of the connection between them,
because in most cases, these children can show difficulties in psychomotor abilities.
184   Mainstream Toys for Play

Furthermore, it could be hard for them to mentally represent the final result, and
consequently, to maintain the attention until it is achieved.
Rule-based play and games. In this case, games must be relevant to the cognitive
capacity of the player, particularly regarding reasoning, making hypotheses,
deduction, and time of concentration required.

15.2.2 Roles of the Adults

The adults’ role is a very important issue to support children with intellectual
impairment with finding a form of autonomy in an emotionally secure environment.
Adults help children to feel joyfulness in play whilst providing support as patient,
enthusiastic partners, and very often, as models during role-play sequences with
toys. They can also physically guide the children showing them concretely how to
do things, how to use objects. Repetition in learning these practical aspects of play
can be useful. Albeit the adults’ presence aims to support the child’s autonomy, it has
been shown that play unfolds on a lower level, without an adult.
Adults should use a gentle, but determined attitude in playing with children, to
support them in maintaining their attention, entering a ludic sequence, respect and
share the roles and the rules, accept the influence of chance.

15.2.3 Physical Contexts for Play

For children with intellectual impairments, toys for practice play should be as most
realistic as possible and should not be displayed as part of a group of toys rather in
an isolated way, and shown one after the other, first, to turn on the child’s interest
and second, to activate exploratory behaviours (Bozena, 2007) and the pleasure of
deep understanding. In the case of symbolic play, toys should be proposed inside a
consistent play area with complementary objects (for example, a doll and a cradle to
play ‘mummy’, or fruits, dishes and pots to play ‘cooking’).

15.3 Devices for the Play of Children with Hearing Impairments

When considering free play for children with hearing impairments, the question is:
where does joyfulness of play, within the different play categories, come from?
The adults’ choice of devices for play depends on the player’s interests and tastes
concerning a specific type of play activity, a kind of sensorial effect, or the pleasure for
a specific kind of manipulations. Therefore, the choice also depends on the physical
features of the toys to facilitate the child’s play or make it particularly attractive for
players with hearing impairments.
 Devices for the Play of Children with Hearing Impairments   185

Play sequences are less frequent between children and adults when a hearing
impairment impedes or makes it difficult to communicate. It is important to
encourage play with suitable toys, consistent play areas, and well-informed adults
and partners.

15.3.1 Toys or Games Features

Practice play. For all children, the interest towards toys for practice play comes from
perceiving the effects of their actions: exploring, understanding cause-and-effect,
discovering surprising effects, and enjoying a sense of mastery. At the same time,
pleasure of internal control and social connection is there.
In the case of children with hearing impairment, the need to recur to alternative
sensorial channels gives importance to toys with visual or tactile stimuli. Visual and
tactile effects are especially attractive if they have an immediate significance and if
they establish a direct relationship between a cause and an effect.
Symbolic play. As for any child, pleasure of symbolic play is to use things in
unusual ways, to be another, express oneself and one’s feelings, understand the
social environment.
Different toys relative to various topics are required to put various and different
roles in place. Realistic toys, in shapes and sizes, are proposed inside thematic areas
to suggest complementary roles and support gestural communication. Toys are
proposed within consistent ensembles to allow children to go forward in a scenario,
for example, a doll and a cradle.
Symbolic play is very important in the case of children with hearing impairment,
for it gives them the possibility to explore and use different modes of communication,
to act different roles, thus taking the other’s point of view and adopting various styles
of interaction. The use of verbal language and/or the sign language can introduce
interesting variables mainly in this type of play, primarily in the case of social play
with peers.
Constructive play. No particular shrewdness is needed for supporting constructive
play of children with hearing impairment. Nevertheless, this type of play requires a
certain level of concentration on an activity over time, while these children usually
do not like to stand and prefer to move around, sometimes without a real scope. This
is one of the reasons to choose attractive toys for these children and support them to
become concentrated and committed.
Rule-based play and games. The choice is made according to the children’s
cognitive abilities, and also to the communication abilities needed. The knowledge of
the sign language also by the part of the other play companions can be useful in some
cases, otherwise solutions should be found to favour communication exchanges,
which are adequate to the play rules, so that possible difficulties in reasoning can be
overcome too.
186   Mainstream Toys for Play

15.3.2 Roles of the Adults

As these children might not able to communicate verbally their needs and desires or
find it difficult to understand parental and societal rules, they can incur behavioural
difficulties. Moreover, hearing parents of deaf children tend to be more directive and
controlling in their interactions with their children (Vaccari & Marschark, 1997).
For all these reasons and to facilitate the players’ autonomy, the roles of adults,
their place, and the distance from children should be very carefully considered.
For example, to sit face-to-face is required to show toys, invite to play as suitable
partners, and promote visual or physical interactions. Above all, within a group
of children, adults must not forget to ascertain that all the verbal messages are
understood by children with hearing impairments. However, when a play sequence
between children is starting, adults should not interfere, leaving that communication
between them develop as it is possible—through gestures, signs, or verbal cues—so
that they can play freely.

15.3.3 Physical Contexts for Play

Toys are always in view, each one is placed inside a specific area according to the type
of play they are able to favour.
Symbolic play areas must be organised in a logical and consistent manner for the
following reasons:
–– To facilitate imitation between children and between children and adults.
–– To facilitate adults handing toys, children, as well as gestural and verbal
communication.
–– To allow children with hearing impairments to observe the other players, to
encourage social interactions and joyfulness.
–– To allow sharing of complementary roles within the same scenario and the
development of that scenario; for example, by installing furniture, so that
children play face-to-face instead than side-by-side (Thériault & Doyon, 1987).

15.4 Devices for the Play of Children with Visual Impairments

Where does joyfulness of play, within the different play categories, come from, in
the case of children with visual impairments? Of course, also in this case, the choice
of devices for play will depend on the player’s interests and tastes, but also on the
physical features of the toys that will be used.
Furthermore, these devices cannot be considered without regarding consistent
play areas and well-informed adults.
 Devices for the Play of Children with Visual Impairments   187

15.4.1 Toys or Games Features

Practice play. Pleasure of the first play activities comes from sensorial effects,
intellectual motivation in understanding the toys’ functions, sense of mastery, and
sharing communication about play sequences.
For children with visual impairment, toys must be steady, easy to manipulate
with an overall shape, easily understandable by touch. Toys must be made in such
a material that can be put inside the mouth for discovering dimensions, shape, and
sensorial features. They should also be safe to make it possible an exploration without
the eye’s control.
Toys for children with visual impairment should give importance to sensorial
stimuli other than visual: tactile, hearing, olfactory, kinaesthetic; in the case of
sensorimotor play, they must offer diversity, and from time-to-time, unusual sensorial
effects (vibration, magnetic effects) so as to arouse curiosity and surprise. They should
be activated through precise gestures and offer precise feedback: this will implement
children’s pleasure and give them eagerness to succeed. Musical toys are particularly
attractive when they give immediate and direct feedback to their activation.
Symbolic play. For children play roles as actors, toys must have realistic shapes
and must be easy to understand by touch, to facilitate message transmission through
objects. Thus, they cannot be too big for the children’s hands. When using action
figures, for example animals, they must be as realistic as possible to be picked out
among others. Anyway, symbolic play should always be introduced by an adult who
describes the main theme of play (for example, kitchen, seller, jungle animals, garage)
to facilitate entering in a play.
Usually, pretend play is delayed in children with visual impairment with respect
to typically developing ones (Lerner et  al., 2015); only when they are around 6-9
years old, they will be able to attribute concrete objects a function different from the
expected and normal one.
Constructive play. It is useful to propose toys whose elements or parts are not
too light in term of weight, to reinforce the sensations of touch and to make the final
constructions stand up and in a steady way. Links between these elements should be
easy to make, for example, through magnetic or Velcro systems; auditory feedback
when elements are correctly connected could be useful.
The pieces of puzzles should be well-designed and easily recognisable—better
if they are in relief—so that children are willing to complete it; puzzles that are
included within borders are preferable as children can better orient their actions and
understand by themselves if they have terminated.
Rule-based play and games. Children with visual impairments, as all the other
children, usually like to play many games with rules. Of course, in order to find great
pleasure in playing and possibly winning boards, pawns and others pieces of the
game should be explored by touch, or adapted to this purpose.
188   Mainstream Toys for Play

The case of colour-blind children should be carefully considered when planning

a game with coloured material: some colours are confusing and can make the games
hard to play, if not impossible; it is important to be careful with non-differentiated
colours and to change them where possible.
What is of utmost importance, nevertheless, is that these children understand
well the rules of the game, and above all, that they can ‘experience the rule’, which
organises the players’ group around itself. Children with visual impairments can, in
this way, experience the value of turn-taking, of decentralising their thoughts from
themselves only, by sharing and subjecting to an indisputable rule and also to the
chance. In this sense, if the cognitive challenge of the game is lower than expected is
not a problem, because the pleasure of practicing the power of the rule is important
in itself (Duflos, 1997).

15.4.2 Roles of the Adults

With any category of toys and games, adults help children find their autonomy, even
if it has been demonstrated that without adults’ assistance, play unfolds at inferior
levels. Adults can effectively also act as mediators between children with visual
impairments and their companions, so that play can be facilitated, go on, and become
joyful and exciting.
For example, in the case of constructive play, frequent feedback on how the
construction is going on can be useful because these children find it hard to mentally
represent a three-dimensional object to be built as well as the consequent steps to
be done for finalising their project. To help children with visual impairments to
understand the issues of three-dimensionality and of complex constructions, the best
way is to invert the usual phases of constructive play, which are usually made of a
building phase and a deconstruction phase (the relative importance of these phases
varies depending on the competence and the age of the players). With children with
visual impairments, the issue of the third dimension is more difficult, and it must
be tested by starting with the second phase. By touching, in fact, the children can
realise the size and the volume of the construction already finished. Then, by tearing
it down, they come to understand the transition from the complex construction to
the simple pieces that compose it. When they truly understand this, they can start to
build by adopting a three-dimensional perspective.

15.4.3 Physical Contexts for Play

As children with visual impairments cannot mentally represent the space around
them beyond their own body, toys and elements of games must be proposed inside
well-demarcated areas to be easy to catch, find, take up again after having been
 Devices for the Play of Children with Communication Disorders   189

thrown or located in a specific position, and so on. The toys must not ‘disappear’
far from the players, irrespective to the type of play they belong or to the child’s age;
auditory feedbacks whenever possible should be used and added.
For pretending play and role-play, toys must be arranged inside thematic areas
and consistent ensembles. It is very useful to propose complementary objects on the
same theme to support exchange between partners, go forward in the theme, and
explore several roles, expressions, and behaviours.

15.5 Devices for the Play of Children with Communication

Disorders

When a child has communication disorders, all the types of play can be involved and
deprived if not properly and specially prepared and supported. Play is, in fact, made
of communication and is communication in itself. Where does joyfulness come from
in these cases? Once again, preferences and tastes of the child should be studied, as
well as the toys’ features and the play context organisation.

15.5.1 Toys or Games Features

Practice play. Usually, children with communication disorders like very much to enjoy
body movement play and are interested in toys that facilitate and intensify these kinds
of play. Consequently, they would like toys that support gross motor skills, like balls,
slides, and all the devices that can be found at the playground. According to Fontaine
(2005), communication between children is intense and implemented during play on
structures for gross motors skills than with small toys.
Symbolic play. Children with communications disorders do not like at all to
experience situations in which their difficulties can be reveiled to their playmates,
and consequently, highlighted. Thus, during role-playing, they do not act as
protagonists, but prefer to be ‘followers’. On the other hand, they need to express
their emotions and find the right words or modes to tell the world how they feel.
While pretending play can give them the possibility to enlarge and sustain their
knowledge of the semantic field of words, including its metaphorical aspects,
playing roles can be interesting for letting them to imagine themselves in situations
and roles different from the usual ones, thus understanding and using new words,
new concepts, new ways of communicating: this is the case of acting in roles and
also useful for them; puppets, puppetry, disguises, figures, toys based on cartoons,
play dough, etc.
When these children use systems of Alternative Augmentative Communication
(AAC), adaptations should be made to toys and play contexts to give them the
possibility to take part actively to the play situation.
190   Mainstream Toys for Play

Constructive play. Usually, there is no specific attention to adopt to constructive

play in the case of children with communication disorders.
Rule-based play and games. This type of play should usually be easy to play,
depending on the intellectual level of the players. The main goal is to support children
to have the possibility to win this type of games, as they are often losers with them;
thus, the role of chance should be taken into consideration, and whenever possible,
controlled. Obviously, to support play for the sake of play, the games must not be
directly addressed to the precise children’s deficit.
It is important also to have some parts of the board games translated into written
words or into symbols if the child uses AAC codes.

15.5.2 Roles of the Adults

The main role of adults, when they act as playmates of children with communication
disorders, is to add language to all the play sequences, to let them better understand
the play rules, to support them in expressing their feelings and ideas, as well as to
facilitate the play relationships, by decoding their peers’ proposals and also by letting
peers understanding their modalities of communication. Depending on the type of
impairment, verbal language can be accompanied by gestures, or written words or
symbols.

15.5.3 Physical Contexts for Play

Toys are installed inside specific areas of the environment where play activities will
take place. A role-play area is installed to enable children to play face-to-face, to
support communication, and to facilitate complementary roles. Many devices and
materials are prepared and made available as a support for AAC users; they can
be created on the basis of the play activity or of a player’s specific communication
needs, or made available as general-purpose support tools. In some cases, typical
functioning children should be introduced to the knowledge and use of these
particular communication modes.

15.6 Devices for the Play of Children with Physical Impairments

As for any other child, also for children with physical impairments joyfulness of play
comes from the satisfaction of the player’s interest and tastes. Therefore, the choice
of toys depends on their physical features, and the identification of the play activity
is related to the specific preferences of the child as well as on his or her abilities
and competences. Due to their difficulties in movement, which often show up as
 Devices for the Play of Children with Physical Impairments   191

slowness, fatigue, and inaccuracy, time of play activities and sequences is one of the
most important issues to be addressed.
It should not been forgotten that physical impairments are often associated
with other kinds of impairments, such as language and communication disorders,
intellectual and/or sensorial impairments. In these cases, the access to play activities
becomes even more difficult and complex.

15.6.1 Toys or Games Features

All the toys’ categories can be proposed to children with physical impairments, but it
is essential to take into account first the movements that are necessary to use the toys;
it should be considered; in particular:
a. how the toy can be used: with which parts of the body, if it is possible to use it by
means of other parts of the body;
b. which kinds of action are needed (grasping, pulling, pushing, inserting, plugging,
sliding, picking up, combining, and so on);
c. which precision and coordination of movements are required and also to what
extent strength should be adopted.

Modification to traditional and mainstream toys should be considered by substituting

the activation systems, introducing handles, buttons, grasping solutions, and other
possible devices, so that the toy can be easier used by the child; these modifications
are, of course, different from child to child, because they are created or adopted on his
or her own movement abilities. More complex modifications—due in more complex
movement impairments—very often include the use of a personal computer as a mean
to control concrete objects on the environment.
Second, often children with physical impairments have less perseverance in play
situation as well as in other daily activities due to the difficulties they meet and the
time they require to complete a task: for this reason, short play sessions are preferable,
so that they can maintain their interest and commitment.
Third, it is not infrequent that these children are sitting in wheelchairs or use
other supports, and this fact should be taken into account also to choose toys and
play activities: a wheelchair imposes some distance from the floor, for example, or
requires a suitable height of tables or other work surfaces, so that they can have a
complete visual control on the toy or game and can easily reach and use them as they
want.
Practice play. Toys for this type of play are solid, easy to hold and to be used, steady
for sensorimotor and gross motor skills play. They are of good quality for lighting,
musical, tactile, and other effects. The ludic springs are well-defined and easy-to-
produce even if physical possibilities are reduced in terms of strength and gestural
192   Mainstream Toys for Play

precision. The use of these toys should also be carefully considered in relation to the
children’s motor devices to facilitate play and make it as safe as possible.
Outdoors play activities should also be included, because kinaesthetic discovering
is important to create awareness of one’s own body as a whole.
Symbolic play. Toys are realistic and easy to use; they allow children to take on
roles and enter situations to experiment in play what they cannot do and live in their
real life. Symbolic play is the way for children with physical impairments to express
their emotional life, fears, dreams, and satisfactions. Dolls and other traditional
toys for symbolic play (puppets, theatre characters, miniature objects, etc.) can be
chosen or modified for being easy to use. Costumes and disguises should also include
wheelchairs and other movement supports to give these children the possibility to
fully take part in play sessions together with their peers.
Constructive play. To allow these children to play with construction toys, it is
essential to choose them according to the size of pieces and their weight, nor too
small nor too heavy. The most important is to consider carefully the mechanism to
assemble the elements; magnetic or Velcro links are preferable, so that construction
play becomes possible even in case of imprecise gestures or jerky movements. In some
cases, mainstream toys can be modified, so that they can be manipulated and used:
handles and various kinds of systems to take the pieces and assemble or disassemble
them can be adopted.
Rule-based play and games. When rule-based play is based on movement, only
seldom it is proposed to these children, due to their physical impairment, even if
they can take place in the game by playing different roles within the game; some
specific types of games have been invented—the most famous one is ‘baskin’—and
are currently being disseminated. Board games can be difficult to play due to their
form and dimension, but also in this case, some changes can be undertaken to
enlarge the accessibility of the material. Pawns are easy to grasp with sometimes
magnetic bases, while bigger dice are easy to throw and control or can be replaced
with other devices.
Play time is shortened when possible, mainly for decreasing the fatigue due to a
prolonged motor engagement; in fact, tiredness related to difficulties in controlling
movements may adversely affect the motivation and the quality of the involvement
in the game.

15.6.2 Roles of the Adults

Children with physical impairments are more dependent on the others’ supports in
their life, and this is what happens also in playing. As play companions, adults should
let them take their time, without taking their place; they should wait for children
to play and have the opportunity to give their autonomous suggestions to go on in
playing, for example, by transforming toy functions or game rules.
 Devices for the Play of Children with Autism Spectrum Disorders   193

The adults’ role is also to become an effective play mediator, so that these children’s
peers can be supported in creating fruitful and joyful interactions; sometimes, only
some tricks are needed to let play activities start and go on in a satisfactory way. When
other kinds of impairments are associated to the physical one, the role of the adults
can be even more relevant, as they have to help peers in interpreting, communicating,
acting as facilitators or scaffolders in the best way.

15.6.3 Physical Contexts of Playing

Toys and games are carefully selected, according to an analysis of their components;
toys in many cases should be modified and made accessible.
Space is one of the most important aspects of the play context in this case: play
environments should be large enough to facilitate children’s movement, to let them
move autonomously; their use of motor devices should be carefully considered, both
as to space dimensions and as to the height and accessibility of work surfaces.
Furthermore, appropriate and comfortable play situations should be prepared,
as a child sitting in a wheelchair can be in a higher or lower position with respect to
his or her peers, and, according to the type of play, this may require the adoption of
certain logistic measures, so that gazes can be exchanged, the materials for playing
can be available, and so on.

15.7 Devices for the Play of Children with Autism Spectrum

Disorders

Any category of play can encompass supports of play, depending on the players’
interests and developmental levels. For children with ASD, the type and degree of
impairment—which explicitly matter human relationships, symbolic functions,
and play development—can vary widely. Furthermore, intellectual disability can
be associated to other impairments, as well as specific extraordinary abilities—the
so-called ‘islets of abilities’ or ‘splinter skills’.
All these aspects should be considered before proposing toys or games to these
children, who in some cases, actually do not seem to enjoy play or wish to be involved
in.

15.7.1 Toys or Games Features

Within all toys’ or games’ categories, objects may not be replaced every day. For the
players’ emotional wellbeing, a balance has to be found between well-known toys and
games, and new ones. In order to get a kind of continuity and logical evolution within
194   Mainstream Toys for Play

the play activities, choice of toys and games varies from already known functionalities
to different ones: this is to make sure that games have common traits with functions
that evolve from one to the other.
Practice play. In most cases, play with objects consists of two steps: the first
consists of an exploration of the overall shape of objects without paying attention
to their use, while only later an understanding of the functionalities of these objects
takes place.
Children with ASD are not attracted by the overall shape of the objects, as they
are more interested by some specific aspects, or small details. When proposing toys
to attract their attention, weight is an interesting element due to proprioceptive
sensations and the body consciousness; texture of the object is also important, as well
as sensorial feedback it can produce (visual—mainly light—auditory). Sometimes,
this feedback is only provoked by the particular way adopted by the child in using the
toy. The cause-and-effect relationship is also a positive element of toys for children
with ASD, if it is easy to perceive and understand.
Some toys for practice play are particularly interesting as they can initiate social
connection, for example, by throwing, catching, giving, and giving back.
Symbolic play. Role-playing is particularly tricky for these children who often feel
challenged by representing and changing roles, adopting the point of view of other
persons, acting as if they were other persons.
This play activity is then initiated by adults who help in simplifying roles and
activities and break it down into subsequent steps, each of them corresponding to
one specific isolated action with objects (for example, interpreting ‘being a musician’
only by playing drums).
For symbolic play with figurines and miniatures, isolated toys are more
appropriate than ensembles to support a precise play activity: for example, playing
with a car and moving it forward instead of managing a whole garage. Once effective
play sessions with one object are obtained, it becomes possible to use toys that can be
related to the same topic to expand the children’s play.
Constructive play. For children with ASD, adults propose games that have a clear
goal and end; they encourage players by showing them what it is possible to do with
this type of toys, and how. They choose the toys that can be used for a short play time,
so that children finish the activity quickly and feel successful.
Assembling games are changed from time to time to make play evolve according
to the different types of connections between the elements. In some cases, children
with ASD can become and reveal experts in those types of toys and spend a lot of
time in assembling small elements not always according to a clear and recognisable
project of construction. Putting together pieces, completing a puzzle as quickly as
possible, repeating for the sake of repetition may seem, in these cases, the only scope
of their play. More complex toys in these cases can be proposed to interrupt the sterile
repetition of gestures and activities, if this reiteration is perceived as devoid of joy.
 Devices for the Play of Children with Autism Spectrum Disorders   195

Rule-based play and games. Very often, rules are simplified and games shortened
for these children, while instructions are made as clear as possible. Games that are
more appreciated by children with ASD are association games where the ludic spring
is given by activities of comparison and differentiation.
Children with ASD need simple rules because the social situation is so challenging
for them that it is essential that rules are very easy to understand for playing with
joyfulness. Rules can be contemporarily a problem and an advantage for children
with ASD: in fact, they facilitate understanding of the play activity, because they put
clear limits to control the situation; on the other hand, they highlight the tendency
of these children to act in a well-regulated and repetitive manner and they prevent
them from the adoption of flexible shortcuts during the activity. Then, there is the
possibility that they appreciate this type of toys and games; this could be a way, for
them, to face human relationships.

15.7.2 Roles of the Adults

Adults whom the children know well are essential, so that they are not frightened by
the social context. Adults should act as play partners or models, and usually, they
propose the play sequences.
They can initiate role-playing and encourage it by reminding the children
stories and tales they already know and proposing to interpret them. In the case of
construction play, the adults show examples of how to continue the construction and
avoid the children with ASD to repeat always the same sequence—for example, asking
them to do something new, or to do it in a different way—or propose the children to
explain which is their project.
In rule-based games, one of the roles of adults is to simplify the play situation
to avoid or minimise frustrations; for example, within games such as snakes and
ladders, by taking the dice off so that each player’s turn is respected (Hogan, 1997).

15.7.3 Physical Contexts for Play

For emotional comfort and wellbeing, the number of toys presented at the same time
is reduced to two or three, and the overall environment is quiet, without sudden noise
or changes in lighting. As social relations with non-familiar people are not easy for
these children, adults promote parallel play between players by putting in place more
thematic play areas and supporting children with ASD, so that they can imitate and
play on their own, but alongside other children.
196   Mainstream Toys for Play

15.8 Devices for the Play of Children with Multiple Disabilities

To support children with multiple disabilities in play, adults use to present toys or
mainstream objects as supports of play, depending on the players’ levels, interests,
and tastes. Play is an activity that involves the child’s whole personality: emotional,
intellectual, social, physical. The free play and the autonomy of the player remain
concepts that keep their meaning irrespective to the importance of disability. It is the
reason why play is so important for children with multiple disabilities.
As multiple disabilities always concern sensorial impairment, often the focus of
the play activity is on sensorimotor toys to support the sensorial and kinaesthetic
experiences; it is anyway possible to propose also toys related to other types of play,
mainly with the support of an adult.
With respect to the type of impairments these children have, possible additional
supports can be considered: for example, the need to adopt codes of AAC, to recur to
specialised materials and toys or to on-purpose modification of mainstream toys, to
choose toys that can offer precise sensorial stimuli, and so on.

15.8.1 Toys or Games Features

Practice play. Toys for play are chosen on the basis of the child’s possibilities to
explore them; objects that can offer multisensorial and rich proprioceptive experience
should be preferred. Smaller toys are proposed where sensorial stimuli they offer are
identifiable and rely on proprioceptive sensorial abilities, such as vibration.
Symbolic play. Depending on the players’ capabilities, role-play sequences can be
developed, mainly with realistic toys or miniature, as they help to play precise roles
and to represent specific real situations.
Constructive play. The presence of a possible visual impairment introduces
many limits and constraints to the type of toys that can be used for constructive play;
furthermore, the possibility to develop a project and to mentally represent the final
result of a construction can be reduced, mainly due to multiple sensorial impairments.
Thus, careful attention should be dedicated during the selection phase, as to the
tactile and auditory aspects of the toys. Sizeable toys with assembling systems must
be easy to use without requiring strength.
Rule-based play and games. They should be consistent with the players’
competences, their ability to concentrate, and their interests. With respect to the
different types of sensorial impairments that are involved in the multiple disability,
adapted or alternative board games can be used, which recur to special communication
systems or to specific devices.
Conclusion   197

15.8.2 Roles of the Adults

Adults must be convinced that play is essential for children with multiple disabilities
too. A kind of empathy is necessary, with verbalisation of what is going to happen,
using physical contacts, for example. Explaining, giving meaning, encouraging,
congratulating, and being a patient and delighted partner are the main roles of adults
in play with children with multiple disabilities. They also should pay attention to give
children enough time to play.

15.8.3 Physical Contexts of Play

The physical context in these cases should be particularly studied and arranged to
avoid any risk of injury, and at the same time, to motivate children with multiple
disabilities to engage in play activities even if they can at first appear noisy, disturbing,
and challenging.
According to the different types of sensorial impairments that are present, the
context should be well-defined, protected, sometimes with clear and identifiable
boundaries. In some cases, the room itself becomes a play occasion or object, as
sensorial stimuli can be offered by the floor, or the ceiling. To maintain interest in
play, it is essential to regularly change toys and games while maintaining the same or
nearly the same ludic springs.
In a socially inclusive context, within a free play sequence, it is possible to make
children with multiple disabilities meet typically developing peers, on a condition
that play areas are organised with a sensorial quiet atmosphere for what concerns
‘sensorial proximity’, sensorial contacts, and ludic relationships (Hulsegge & Verheul,
1989).

15.9 Conclusion

The action of playing can be defined as a subtle alchemy brought about by the
coming together of a subject, an object, circumstances, and others subjects. The
relationship between a human being and his or her environment is always or most
always organised around a material element, a sensorial and cognitive artefact that
leads to make activities. Paradoxically, this relationship is at the core of what makes a
human’s thinking independent from our abilities, competences, or age.
Every human action is guided by the interaction with a physical element; playing,
which in essence is an activity, needs a mediating object to allow the child to express
himself or herself.
While playing, the inclusion of children with disabilities is achieved by providing
them with mainstream toys selected according to their capacities: first, to play with
198   Mainstream Toys for Play

others and second, to help parents to give the childhood more importance than to the
disability.
Unfortunately, the complexity of toys, depending on their cultural and market
aspects, and on what they represent from one generation to the next leads adults
to consider them as inadequate for the capacities of children with disabilities. It is,
hence, essential to provide mainstream adequate toys accompanied by empathic
helpers who are able to facilitate the utmost important interactions between the
player and a toy, so that the player’s interest can be triggered.
Toys are the first thing adults have in mind when they think to give a child a very
appreciated present, or simply a tool to play. But, toys are never neutral, and there is
not a toy that suits everyone; differences related to the chronological age, to personal
attitudes, to gender, to familiar and cultural traditions, to various ways of life should
be considered when choosing a toy. There are toys for indoor and for outdoor spaces,
for playing alone or with the peers or even with the adults, for playing together or
for winning over the others, and there are toys that favour different types of play,
as this chapter has tried to demonstrate. Furthermore, the world around the child is
full of objects that can become toys, depending on the curiosity, the imagination, the
situation, the play companions.
Nevertheless, there are some other characteristics that should be taken into
serious consideration, especially when the child who receives or is offered the toy
has some kind of impairment: its usability and accessibility. Does it meet the child’s
possibilities to interact with it, to enjoy it? Does it respond to the child’s preferences
and abilities? Does it help the child to overcome his or her difficulties or limitations,
or on the contrary does it pose additional limitations? Does it create discouragement
because it is difficult or impossible to be used by the child or because it is too simple
in comparison with the child’s possibilities and expectations? Is it attractive enough
to potentially augment the opportunity to play with friends? Is it challenging enough
to give the child the opportunity to explore new, more complex types of play?
Adults—parents, teachers, professionals—might need advice when choosing the
right toy for these children; they should be accompanied to merge in the most fruitful
way the child’s and the toy’s characteristics in the perspective of creating the best
opportunity to have fun and to fully enjoy play. They also would know more about
how to play with these children, how to support motivation and engagement even
when tiredness, fatigue, indifference, or frustration come forward, and also how to
create the more promising contexts for playing, especially inclusive ones.
The chapter has presented some hints on this topic, and should be considered,
in the authors’ intentions, as a path to make the first steps, to proceed then towards
more complex and exhaustive routes in the near future.
References   199

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Angharad Beckett, Carol Barron, Nan Cannon Jones, Marieke
Coussens, Annemie Desoete, Helen Lynch, Maria Prellwitz,
and Deborah Fenney Salkeld
16 Influence of Environmental Factors on Play
for Children with Disabilities – An Overview

16.1 Introduction

This chapter considers the impact of the environment on the play experience of
disabled children or children with disabilities. The International Classification of
Functioning (ICF) defines ‘environment’ as “social attitudes, architectural features,
legal and social structures, as well as climate, terrain and so forth” (WHO 2002:10).
Whilst this is a helpful opening definition of ‘environment’, for the purpose of this
chapter, we adopt the following elaboration of the concept of social environment,
which, we argue, is in keeping with the WHO’s definition:

“the immediate physical surroundings, social relationships, and cultural milieus within which
defined groups of people function and interact. Components (…) include built infrastructure;
(…) social and economic processes; wealth; social, human, and health services; power relations;
government; (…) social inequality; cultural practices; the arts; religious institutions and
practices; and beliefs about place and community. The social environment subsumes many
aspects of the physical environment, given that contemporary landscapes (…) and other natural
resources have been at least partially configured by human social processes” (Barnett & Casper,
2001:465).

As stated in the preamble to the United Nation Convention on the Rights of Persons
with Disabilities (UNCRPD, 2007, para. e), disability ‘results from the interaction
between persons with impairments and attitudinal and environmental barriers that
hinder their full and effective participation in society on an equal basis with others’.
Whilst the language of the UNCRPD may differ slightly from that of the ICF, the ICF
model shares this understanding of disability. Environmental factors are understood
to operate as barriers or facilitators of people with disabilities; to be enabling or
constraining.
In this chapter, we focus on the constraining—or disabling—aspects of the
environment on the play experiences and opportunities of children with disabilities.
This is not because we fail to recognise that there are examples of good practice ‘out
there’, where children with disabilities have been empowered in their play. Such
examples exist and are to be celebrated. They are, however, the exception rather than
the rule.
Taking the UK as an example, the findings of a recent UK Public Inquiry by
the Charity Sense, chaired by Lord Blunkett and Lesley Rogers, are revealing. The

© 2017 Angharad Beckett et al.

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License.
202   Influence of Environmental Factors on Play for Children with Disabilities

inquiry exposed many environmental factors acting as barriers to play for children
with multiple disabilities. The inquiry found that amongst parents of children with
disabilities interviewed, 81% reported difficulties in accessing the mainstream
play groups and local play opportunities for their child. Many said that they had
experienced negative attitudes towards their child, and that this was the most
significant barrier to accessing the mainstream play settings. Fifty-one percent of the
parents said their child had been intentionally excluded from play opportunities by
providers of play. Forty percent said that they faced additional financial costs when
seeking to access play opportunities. Many of the families consulted said there was
a lack of specialist support that could be accessed locally and were having to make
long journeys to access play settings. The inquiry also found that: many play settings
were not accessible to children with multiple needs; few settings had been designed
to welcome and support parents and non-disabled siblings, so that they could play
together with a child with disabilities; levels of awareness and relevant training in
medical conditions, communication methods, and multiple disabilities by play
professionals act as barriers to children accessing play provision; misguided notions
of ‘health and safety’ can result in children with disabilities, sometimes being denied
the right to play (Sense, 2016). Further, in June 2016, the advanced, unedited version
of the UNCRC Committee on the Rights of the Child’s ‘Concluding observations on
the fifth periodic report of the United Kingdom of Great Britain and Northern Ireland’
highlighted insufficient places and facilities for play and leisure for children in the UK,
in particular those accessible for children with disabilities (our emphasis). We suspect
that the situation in the UK would resonate with many countries across Europe and
beyond.
Our emphasis on barriers—disabling barriers—is a reflection of our adoption
within this chapter of perspectives from interdisciplinary Disability Studies. Disability
Studies have challenged the traditional approaches to childhood disability. In 1998,
a leading author in this field, Mark Priestley, proposed an agenda for research in this
area. Research at that time, he argued, had become “preoccupied with impairment,
vulnerability and service usage” and needed to recognise children with disabilities
as “social actors, negotiating complex identities within a disabling environment”
(Priestley, 1998:207, our emphasis). Research, he stated, needed to be informed by
new Disability Studies approaches to understanding disability. This new approach
represented a sustained critique of the ‘individual model’ of disability (Oliver, 1990)
and versions of this—that is, ‘medical’ and ‘personal tragedy’ models—which view
disability as a personal predicament. Whilst not denying the existence or impact of
impairments, this approach, which has come to characterise the approach taken by
many/most academics in Disability Studies, considers the ‘problem’ of disability to
reside within society, not within individual minds or bodies. From a Disability Studies
perspective, disability is a form of social oppression, not simply restricted activity
(however, caused) and results from actions on the part of the non-disabled majority.
These actions—through social structures, organisations, professional practice, and
 Barriers to Play for Children with Disabilities within Four Key Contexts   203

interpersonal interaction—impact negatively on the lives of people with disabilities.

Disability is a social relational category—an effect and quality of relationships of
power and exclusion between groups in our societies (Thomas, 2004). This approach,
thus, involved a paradigm shift. Disability became understood as a social rather than
an individual pathology (Goodley, 2014); a public issue, not simply a personal trouble
(Borsay, 1986).
Allied as it is to the disabled people’s movement and their politicisation of
‘disability’, Disability Studies have long worked to expose environmental factors
that act as barriers in the lives of people with disabilities, seeing this as the first step
towards challenging and dismantling these barriers. In this chapter, we take such
an approach. We identify a range of environmental barriers that ‘disable’ play for
children with disabilities, and by doing so, propose avenues for developing enabling
play environments for these children. Although in practice, many of these barriers are
inter-related, for the purposes of this chapter, we distinguish different broad barrier
types—physical, social, political, and cultural—occurring in a selection of social
situations or locations—built environment, educational settings, home, and natural
environments. These locations can also overlap (e.g., in the case of home schooling
or nature playgrounds in school settings). We distinguish them only to point to issues
that may be experienced differently in particular locations and to suggest specific
avenues for further research.

16.2 Barriers to Play for Children with Disabilities within Four Key
Contexts

General Comment 17 on the UNCRC stresses that children with disabilities encounter
‘multiple barriers’ in relation to the rights provided in Article 31, including
exclusion from social situations, where play takes place and friendships can be
formed, isolation, cultural attitudes, and stereotypes, physical inaccessibility,
and exclusionary or ineffective policies. Before considering some of these barriers
manifesting within our four key location types, we highlight the importance of
certain political and cultural barriers impacting across these locations. First,
political barriers: play for children with disabilities is not always given sufficient
attention by policy makers. At a global level, both the UNCRC (Article 31) and the
UNCRPD (Article 30) enshrine the right of children with disabilities to play and
leisure or recreation. Two General Comments on articles of the UNCRC, however,
have highlighted the key difficulties in protecting and upholding these rights.
In Europe, despite universal ratification of the UNCRC, different states have
progressed at different rates with regard to acknowledging and properly resourcing
play provision for children with disabilities (Barron et al., forthcoming). There is a
slippage between the ambitions set out within the international conventions and
their operation in relation to national legislation, policy, and practice. Further
204   Influence of Environmental Factors on Play for Children with Disabilities

research needs to establish how different states in Europe are developing policies
promoting inclusive play and monitoring their effectiveness.
In terms of cultural barriers, although studies indicate that children with
disabilities enjoy similar activities to their non-disabled peers (Engel-Yeger et  al.,
2009; Hilton et al., 2008; Imms et al., 2008), play is often positioned or understood
differently for them. Problematic discourses of play exist and have real effects (Joseph
& Roberts, 2007) in terms of the exclusion of children with disabilities. These children
are more likely to be considered ‘deficient’ in the abilities necessary for play, and
consequently, to be subject to greater adult intervention and surveillance in their play
activities, reducing their opportunities for free play (Goodley & Runswick-Cole, 2010).
Their play, as for many children, but perhaps more acutely in the case of children
with disabilities, is also more likely to be subject to the “play as progress” rhetoric,
which involves the “subordination of intrinsic play functions to other extrinsic
developmental functions” (Sutton-Smith, 1997: 18). This means that children with
disabilities risk missing out on experiencing play for its own sake and its associated
benefits.
We now turn to additional and specific barriers identified within our four
key locations. In what follows, we draw upon a narrative review of the existing
international research into barriers to play for children with disabilities undertaken
by the authors for the LUDI network and which is considered in depth within Barron
et al. (forthcoming).

16.2.1 Barriers in the Built Environment

A ‘built environment’ refers to the human-made space in which a human activity takes
place. For children playing, such spaces might include playgrounds, parks, and other
community play spaces. The outdoor public playground (Moore & Lynch, 2015; Webb,
2003) has been the main focus of research into play for children with disabilities
within built environments. Evidence suggests that these children encounter physical
barriers and are less playful where there is inadequate design—that is, when those
designing and providing play spaces have insufficient knowledge about disability
and universal design (Dunn & Moore, 2005; Prellwitz & Tamm, 1999; Rigby & Gaik,
2007; Woolley, 2013). Physical access to play spaces is an essential prerequisite to play
for children with disabilities.
The absence of or inaccessibility of play resources or materials is also important,
as are other issues that may create barriers within play spaces: noise, over-crowding,
temperature, unsuitable lighting, design, inaccessible surfaces, etc., depending
on the needs of individual children (Law et al., 1999; Rimmer et al., 2004). Finding
solutions to these barriers can be challenging, however, because ‘special’ accessible
features in playgrounds (as opposed to fully integrated accessibility) can also lead to
segregation (Dunn & Moore, 2005).
 Barriers to Play for Children with Disabilities within Four Key Contexts   205

Inaccessible built environments and the resulting lack of interaction between

children with and without disabilities can reinforce attitudinal barriers (Atmakur,
2013). Exclusion of children with disabilities by non-disabled peers within this type
of location (e.g., playgrounds) is as yet under-researched, but on the basis of existing
evidence about children’s experiences of play in a variety of contexts, this is likely to
be a significant problem. Children with disabilities have reported that they are not
asked to play by other children or that they have been told that they are not welcome
to join in games (Spencer-Cavaliere & Watkinson, 2010). Children with disabilities
may also self-exclude through fear of being seen to use play equipment in the ‘wrong
way’, and so, wait until playgrounds are empty before using it (Prellwitz & Skar,
2007). Alternatively, it may be necessary for parents to be present in play situations,
for example, to provide assistance to move around and use playground equipment
where the design of the playground does not support the child’s independent
mobility (Prellwitz & Skar, 2007). Children have indicated that they would prefer to
use playgrounds independently. Parental anxieties about stigma felt by their children
in such situations has led some families to avoid playgrounds (Prellwitz, 2007).

16.2.2 Barriers in Educational Settings

Educational settings may be formal (e.g., kindergarten, primary and secondary

school classrooms) or informal (e.g., school playgrounds and after-school clubs).
Such settings should provide a safe environment for children’s development, foster
active learning, and encourage positive peer relations (Moyles, 2013).
Evidence suggests that physical barriers exist within school buildings in some
countries (Santer et  al., 2007), reflecting the historic exclusion of children with
disabilities from education, or from ‘mainstream’ education. Accessibility for
these children within school playgrounds is not always considered (Rigby & Gaik,
2007), leading them to encounter similar difficulties to those in other outdoor play
settings (as aforementioned). Attitudinal barriers are also present within this type of
environment. Exclusion by peers has been reported by children with disabilities and
can occur during recess, for example (Spencer-Cavaliere & Watkinson, 2010; Taub &
Greer, 2000).
One way educational settings differ from wider built or natural environment
settings is that teachers and other education professionals are often present.
Evidence suggests that the attitude and behaviour of teachers can play a significant
role in relation to play for children with disabilities. Teachers initiate and facilitate
play between children with and without disabilities through modelling appropriate
behaviour and supervising play (Odom et al., 1993, 1996). Alternatively, however, they
sometimes create barriers by not supporting children with disabilities to engage in a
wide and varied range of play activities (Ozen et al., 2013) or by limiting opportunities
to make choices, take risks, embrace challenges, and make friends (Richardson 2002).
206   Influence of Environmental Factors on Play for Children with Disabilities

Educational professionals without appropriate levels of knowledge and sensitivity

may also deny the opportunity for play through the educational policy that they
deliver (Buchanon & Johnson, 2009; Richardson, 2002).

16.2.3 Barriers at Home

‘Home’ is a contested concept associated with a range of meanings and environments.

Most importantly, ‘home’ is what each individual understands it to be. For children
with disabilities, home may refer to the private family, but also to diverse care settings
(e.g., hospitals or orphanages). Home may be a space supporting playfulness, when
compared to other settings, particularly as the child ages (Law et al., 2007; Rigby &
Gaik, 2007). Nevertheless, evidence suggests that barriers exist here.
Evidence of physical barriers include children with disabilities requiring
assistance transferring between play spaces (e.g., up or down stairs), lack of space to
manoeuvre wheelchairs, or so much space being taken up by assistive technologies
and other equipment that accommodating visits from friends becomes difficult
(Brotherson et al., 2008; Connors & Stalker 2003; Geisthardt et al., 2002). Additionally,
attitudinal barriers manifest within home. Parents can be highly supportive of their
child’s play, but evidence suggests that some struggle to come to terms with their
child’s impairment and delay making physical adaptations to the home that would
remove physical barriers to play (Lewis, 1987). Peers’ attitudes may mean that
children with disabilities are not always invited to friends’ homes to play; equally,
they may not be encouraged or supported to invite friends to come to their homes to
play (Mundhenke et al., 2010; Sandberg et al., 2004). Parents’ perceptions of risk may
be important here: some parents have been found to restrict play in the home or not
allow friends to visit for play due to perceptions of ‘risk’ (Connors & Stalker, 2003).
Additionally, this may reflect concerns of parents regarding bullying and difficulties
that non-disabled children may have knowing how to play with their children (Oates
et al., 2011; Preece & Jordan, 2009). Barriers to play in the home may then reinforce
barriers in other settings: research has shown that children with ASD, who have fewer
playdates organised for them in the home, find engaging in play with peers in the
school playground more difficult (Frankel et al., 2011).

16.2.4 Barriers in the Natural Environment

Identifying entirely natural settings in our world is challenging. There are few
untouched wildernesses today (Cronon, 1996). Most natural environments that
children encounter will be to some extent managed or modified by humans (Lester
& Maudsley, 2007). Nevertheless, many authors agree that ‘natural’ spaces exhibit
fewer elements of human design than ‘built’ environments. The value of play in the
Discussion   207

natural environment has been given increasing attention recently. Concerns about a
‘couch potato’ generation of children glued to electronic media (Hancox, 2004) and a
‘bubble-wrap’ generation of children whose parents are too anxious to let them play
outside (Malone, 2007) are associated with increased valuing and promotion of play
in nature (Louv, 2005).
Several studies have emphasised the benefits of playing in and with nature for
children with and without disabilities (Blakesley et al., 2013; Pavey 2006; Kuo & Faber
Taylor, 2004). As noted earlier, however, the primary focus of studies considering
access to outdoor play for children with disabilities has been primarily on built
environments such as playgrounds (e.g., Moore & Lynch, 2015; Webb, 2003). The
right of access to nature for all children—a right referenced in the UNCRC—has often
been forgotten (Anderson-Brolin, 2002). Whilst various reports (for organisations
such as Play England and Barnados) highlight the importance of accessibility vis-
a-vis, natural environments for children with disabilities and cite examples of good
practice (Shackell et al., 2008; Lester & Maudsley, 2007), their overall message is that
accessibility and inclusion are currently the exception rather than the rule.
Little research has been undertaken that explores barriers to play within natural
environments for children with disabilities. Nevertheless, there is evidence of a range
of barriers faced by all people with disabilities when seeking to access the natural
environment, which would be worthy of further exploration vis-a-vis the experiences
of children with disabilities, in particular. Barriers include insufficient information
about physical accessibility, inadequate personal and private transport, inaccessible
facilities, and staff attitudes at sites (Burns et al., 2008; Countryside Agency, 2005;
Williams et al., 2004). Attitudes held by some professionals and parents can also be a
significant barrier to ‘nature play’ for children with disabilities. For example, staff at
outdoor recreation sites have been found to view outdoor, less-supervised activities
to be ‘too risky’ for children with disabilities (Gleave, 2010). Similarly, Ludvigsen
et al. (2005) found that some parents of children with disabilities, although initially
positive about the idea of adventure play, perceived play sites to be ‘unsafe’. Children
with disabilities have indicated that such ‘over-protection’ limits opportunities for
creativity, risk-taking, and physical challenge, all key factors in play (Andrews, 2012).

16.3 Discussion

This chapter considers the ways in which the social environment may limit the
opportunities for play for children with disabilities, but is not an exhaustive
consideration of this issue. We highlight, for example, the absence of consideration
within the current research of socio-economic factors that may impact on play for
children with disabilities. Economic barriers are likely to require further investigation,
alongside wider environmental factors that may indirectly or directly affect access to
play for these children—for example, the intersection of disability with other social
208   Influence of Environmental Factors on Play for Children with Disabilities

and cultural factors relating to gender or ethnicity. The interaction of diverse socio-
demographic characteristics deserves further attention.
Adults (teachers, parents, and other professionals) clearly have a key role in
relation to facilitating play for children with disabilities. The tensions noted in
educational settings and built environments between facilitating inclusion and
limiting self-determination, as well as the barriers that may be created by the disabling
attitudes of adults, require further research to identify strategies that can overcome
these attitudes and balance adult facilitation with child-directed play.
In relation to unequal play opportunities for children with disabilities, the barriers
created by impairments themselves must not be forgotten, but it is vitally important
to recognise that any intervention at the individual level needs to be considered in
relation to the environmental factors. Only by addressing disabling barriers external
to the minds and bodies of individual children can we address the disablism, which
disadvantages them, and remove obstacles to their right to play.
Finally, we suggest a framework for researching environmental barriers to play for
children with disabilities. It is important to view the social environment encountered
by children from the most immediate and personal through to the broadest social or
societal. Various dimensions of a child’s social environment might be examined, as
follows (adapted from Brown, 2001):
–– Accessibility: can children go where they would like to go? Are they fully included?
Can they do what they would like to do?
–– Resourcing: are their needs being met in ways that enable their play?
–– Social support or enablement: are they welcomed and supported by those around
them (peers and others)?
–– Equality: are they treated equally compared with other children? Are they
receiving equal opportunities for play?

The purpose of this list is not to rank different types of locations, but rather
to understand the different types of interaction that individuals have with the
environmental factors in given locations. It provides ideas about the types of
intervention that might ensure that environmental factors become facilitators, not
barriers to play for children with disabilities.

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Serenella Besio, Daniela Bulgarelli,
and Vaska Stancheva-Popkostadinova

Conclusion
This book is the first systematisation of the theme of play for children with disabilities,
within the specific frame of ‘play for the sake of play’.
It was meant to reflect the state of the art about play and children with disabilities
up to 2015, to become a useful tool for professionals and researchers in all the related
fields, and mainly to establish a point of reference for building up new knowledge
on this theme, trying to address the collective scientific discussion towards this new
framework.
The International Classification of Functioning, Disability and Health is
undoubtedly the most authoritative framing of impairment and disability, describing
the human functioning as a complex result of a system of interrelations between the
persons’ body, the environment in which they live, the personal determinants, and
the continuous necessary tension towards activity and participation.
This book wants to lay the groundwork for an overall exploration of the theme of
play for children with disabilities. After an overview of children’s play in the literature,
in search of firm and shared points of reference, it proposes—through comparison
with the existing proposals—its two main classifications, the first concerning the
types of play that occur along the child’s development (variously intertwined) and
the second relating to the types of disabilities that will be included in the study.
These introductory parts lead to discuss, in more depth, the characteristics that
play can assume for children with various types of impairments, according to the
studies published at the international level. Then, the text completes the background,
thanks to some final chapters that explore the contribution of some disciplines deeply
involved in the theme—occupational therapy, special education, early intervention—
propose a professional perspective on the assessment and choice of toys, and
finally, deal with the main environmental factors that can create barriers to the full
deployment of the child’s play.
The chapters’ authors—coming from various countries and different disciplines—
were then given a not easy task, mainly due to the fact that they have been requested
to treat the theme according to the particular constraints given by the described
framework.
The most important challenges they had to face were: a) the existing studies
usually treat the concept of play as a well-known and universal one, without adopting
a specific definition; b) in particular, the awareness about the difference between play
and play-like activities is not represented at all in the literature of play for children with
disabilities; and c) a variety of proliferating types of play are presented and explored,
but not rooted on precise descriptions, and this contributes to create misconceptions,
thus lowering the possibility to open plain debates at a scientific level, to compare the
214   Conclusion

results of different experimentations, to build new knowledge and new professional

practice on the possible new shared findings.
But the main novelty of this text is to stress the concept of ‘play for the sake of
play’ and to introduce a specific attention to this interpretation of play in the case of
children with disabilities.
In fact, misconceptions of play create some overlapping in the literature between
the two constructs of ‘play for the sake of play’ and ‘play-like activities’: and this is
even more true when it comes to the case of children with disabilities, where play is
almost uniquely considered as a technique to obtain educational improvements or as
a clinical evidence to assess the child’s development.
It is only the case to remind here that this creates, in turn, additional theoretical
problems, where it happens that ‘play for the sake of play’ starts to be described in
the literature as ‘free play’, thus loosing its specific and multifaceted characteristics
at an alarming extent, which cannot be confused in a sole shapeless pot. When play is
free—that means it is made only for the sake of itself—it might belong to very different
types and these ones should be very carefully explored.
Moreover, it is exactly play for the sake of play that is a right for all children and
should be claimed for, as testified by the most important international conventions,
and should be guaranteed to all children, including those who have some impairments:
play activities should be then accessible and inclusive with respect to contexts, tools
(toys, playgrounds, and other instruments), support methodologies (if they occur
within educational contexts), and relationships. And, this requires a radical change
in the societal attitudes and scientific approaches, a specific training for educational,
health, and social professionals, but also new directions in the overall policies,
including the investment of economic resources.
Play in children with disabilities is a new scientific topic and this book reflects
this novelty. It still suffers from some heterogeneity, because a comprehensive
theoretical framework is far to be reached in the general literature and it is the first
product of a brand-new scientific community, which is at the same time, international
and interdisciplinary, thus representing different experiences and cultural climates
as well as different scientific fields, which needs to find the most productive way to
encounter and create their own language and establish their fundamentals.
As editors of this publication and members of the network ‘LUDI—Play for
Children with Disabilities’, we consider this as a first step of the Action’s contribution
to the scientific community. Further products will come, developed by the other
Working Groups in which the Action is built upon, and the overall LUDI framework
will result, at the end, as a sort of construction made of Lego bricks that fit perfectly
one with the other to create the final perfect shape.
Many aspects should be further deepened, and we would like to remark here the
most important ones.
–– The voice of children with disabilities and of their parents should be carefully
collected and included, to the point of questioning the findings already reached.
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–– The role, the type, the characteristics of tools and of technologies should
be investigated with respect to the various types of play described, and this
will hopefully bring many important suggestions to the field of technology
development as well as to the professional practice.
–– The various possible roles that adults can assume within and in favour of the
children’s play activities will be more explored in the next studies: they can be as
competent play companions, can use suitable methods for assessment, and can
act as supporters of this new scientific topic.
–– The inclusive aspects of play should be deeply examined and treated as the only,
unavoidable, context to express play for the sake of play: this means to lead
the way towards big changes, in attitudes, procedures, and methodologies of
intervention; societies at large should become more accessible, more flexible,
more open to diversity.

Finally, a natural outcome of the LUDI’s work will be to clearly locate play as one of the
areas to establish and measure the Quality of Life (QoL) in children with disabilities.
QoL is related to the possibility of being autonomous and to the possibility of
inclusively taking part to everyday-life contexts. In children’s life, play is crucial
to actively experience autonomy and inclusiveness: during play, children can take
autonomous decisions and freely organise their activities, they can experience the
social dimension of life while interacting with other play companions, peers, or
adults.
But autonomy might be often reduced or even precluded to children with
disabilities: whenever their functional limitations face environmental factors, which
prevent them from making the right and effective experiences, they cannot access play
activities in a fruitful and proactive way. In terms of ICF, they can show a disability, due
to the physical impairments and/or to wrong, excluding, not usable or not accessible
environmental factors: the human field—methods, relationships, social attitudes,
and so on—and in the concrete world—objects, architecture, structures, and so on—
can, in fact, create barriers that prevent them from participation.
Building up research, knowledge, and societal attention around the topic of play
in children with disabilities is one of the fundamental steps towards the possibility to
support every child’s QoL.