The Role of Play in
Pediatric Occupational
Therapy
Kari J. Couch, Jean C. Deitz, Elizabeth M.
Kanny
Key Words: play and playthings (therapeutic)
• professional practice
Objective. This study examined the roLes that pLay occupies within current occupationaL therapy practice with
preschooLers.
Method. Two hundred twenty-four pediatric occupationaL therapists compLeted maiL questionnaires designed to
ascertain how they use pLay in their practice, their knowLedge and use ofpLay assessments, andpotentiaL constraints
on their use ofpLay.
Results. ALthough respondents indicated that play was
important in motivating children andftequentLy used
pLayas a treatment modaLity or reinforcer, they Less ftequentLy assessedpLay behaviors or wrote treatment goals
and objectives reLated to pLay. Differences were found
between schooL-based and non-schooL-based respondents
regarding the discipLine or modeL that addresses play in the
work setting, the use ofpLay assessments, and constraints
that Limit the use ofpLay in the work setting.
Conclusion. The resuLts suggest a needfor increasing
the emphasis on pLay in entry-Level curricuLa and continuing education, improving clinician access to vaLid and
reliable play assessments, and completing studies designed
to examine the use and efficacy ofplay in occupational
therapy intervention.
P
Kari J. Couch, MS, OTRfL, is Doeroral Srudem, Universiry of
Washington, Seattle, Washington, and Occupational Therapist, Valley Medical Center Children's Therapy, 400 South
43rd Street, Renton, Washington 98055.
Jean C. Deitz, PhD, OTRfL, FAOTA, is Associate Professor and
Graduate Program Coordinator, Depanment of Rehabilitation
Medicine, Universiry of Washington, Seattle, Washington.
Elizabeth M. Kanny, PhD, OTRfL, FAOTA, is Assistant Professor
and Head, Division of Occupational Therapy, Depanment of
Rehabilitation Medicine, Universiry of Washington, Seattle,
Washington.
This articLe was acceptedfor pubLication January 20, 1997.
lay is one of three primary occupational roles addressed in the theoretical foundation of occupational therapy. Therapists use play in practice for
both assessment and intervention (Knox, 1993; Rast,
1984, 1986; Reilly, 1974), but specific uses of play in
pediatric occupational therapy vary. Bundy (1991) and
Florey (1981) cited concerns that occupational therapists
were not addressing the role of play relative to occupation
(e.g., player) and expressed the need for occupational
therapy, as a profession, to embrace playas a legitimate
area of practice and to validate its importance through
research. Despite this identified need, little research exists
that delineates how occupational therapists are incorporating play into practice. In addition, several testimonial
articles suggest constraints that may be contributing to a
lack of emphasis on play skills by pediatric occupational
therapists (Anderson, Hinojosa, & Strauch, 1987; Bundy,
1992, in press; Robinson, 1977; Vergara, 1993). These
constraints include negative attitudes toward play, greater
emphasis on nonplay skill development (i.e., motor
skills), failure ro assess play, role delineations that are setting specific, and reimbursement.
The need for knowledge of current practice patterns
related to occupational therapy has prompted some
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111
research efforrs related ro pediatrics. Surveys of therapists
have provided some information on the scope of pediatric practice, with implications for education of personnel as well as future directions for research (Chandler,
1994; Crowe, 1989; Lawlor & Henderson, 1989). Other
research endeavors have focused on differences in play
behaviors across populations (Bundy, 1989; Harrison &
Kielhofner, 1986; Howard, 1986; Restall & MagillEvans, 1994) or on the use of playas a treatment modality (Daub, 1988; Pratt, 1989; Rast, 1984, 1986). Most of
these studies have involved preschoolers. Despite these
efforts, information on current practice patterns related
to the use of play in pediatric occupational therapy with
preschoolers is limited. Such information assists therapists in understanding current practice, in developing
programs for personnel preparation, and in identifying
directions for research.
This study was designed to examine the roles of play
within current occupational therapy practice with preschoolers 3 to 5 years of age. On the basis of the literature
review, the following research questions were addressed:
1. How do occupational therapists working with
preschool-age children incorporate play into their
practices?
2. Do occupational therapists working with preschool-age children assess play behaviors, and, if
so, what methods do they use?
3. Are there differences between school-based and
non-school-based settings that influence the roles
that play occupies within pediatric occupational
therapy?
Method
Sample
Systematic sampling procedures were used to select 251
registered occupational therapists who indicated on their
American Occupational Therapy Association (AOTA)
membership applications that they work with children 3
to 5 years of age. All were members of the Sensory Integration, Developmental Disability, or School System
Special Interest Sections.
Instrument
A mail questionnaire was used for data collection because
of the nature of the research questions and the potential
ability to reach a large, representative sample of pediatric
occupational therapists from diverse geographical locales.
A questionnaire booklet was developed specifically for
this study (Dillman, 1978). The questionnaire items were
developed on the foundation of an extensive literature
review and recommendations from pediatric clinicians
and researchers. There were 17 questions in Likert or
multiple choice format and 1 optional open-ended question. The questionnaire contained four sections: demographics, general use of play in occupational therapy practice, use of play assessments with preschoolers, and facrors
that influence the use of play in pediatric occupational
therapy.
To establish content and face validity, the questionnaire's content, completeness, and presentation were critiqued by a panel of seven occupational therapists, including five practicing in pediatrics and two nationally
recognized play experrs. It was then pretested with a convenience sample of six occupational therapists who were
considered representative of the study sample. On the
basis of their verbal and written feedback, the questionnaire was modified to improve question clarity.
Data Collection
Questionnaires were sent ro the sample, with follow-up
mailings at 3 and 7 weeks after the initial mailing to facilitate a high response rate (Dillman, 1978). Confidentiality
was ensured by using numerical coding.
Results
Of the 251 surveys sent, 10 were unusable because the
therapists had not worked with preschoolers within the
past 2 years. Therefore, 241 potential respondents comprised the final sample from which 224 questionnaires
were returned. Not all respondents answered each query,
despite requests to do so. Thus, the value of n for individual questions varied slightly. The response rate was 93%
(total questionnaires mailed and usable divided by rotal
number mailed minus unusable). Of the 222 respondents
to the demographic section, 140 (63%) had bachelor's
degrees in occupational therapy, 24 (11 %) had entry-level
master's degrees in occupational therapy, 25 (II %) had
advanced postprofessional master's degrees in occupational therapy, 31 (14%) had advanced master's degrees in
another field, and 2 (1 %) had docroral degrees.
Respondents' first year of occupational therapy registration ranged from 1957 to 1994. Most respondents
worked more than 10 years with preschoolers, and the
least amount of experience reported was 1 ro 2 years. One
hundred fifty-three (68%) worked primarily in schoolbased settings, and 71 (32%) worked primarily in nonschool-based settings (e.g., hospital, private practice, neuromuscular center, private birth-ro-three program).
Use ofPlay in Practice With Preschoolers
Of the 222 respondents who completed
regarding the perceived importance of play
for motivating a child to participate in
(91 %) stated that play was very important,
the question
opportunities
therapy, 202
17 (8%) stat-
112
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ed that it was important, and 3 (1 %) stated that it was
somewhat important. No respondents marked that it was
not important.
Of the 222 respondents who completed the question
about the predominant use of play within their current
practice with preschoolers, 205 (92%) answered that they
used playas a modality to elicit motor, sensory, or psychosocial outcomes in their clients. Four (2%) cited the
use of play predominantly as a "free-choice" activity or as
a reward during, or at the end of, an intervention session;
9 (4%) stated that they used play equally as both a modality and a reward; and only 4 (2%) stated that their predominant use of play was as an outcome by itself
Table 1 shows the percentages of caseloads with
which play was used for varied purposes by school-based
and non-school-based respondents. Twenty wrote in the
"other" response to this question that they used play to
build rapport, to distract, or to evaluate skills not otherwise related to play.
clientele. The write-in responses indicated that 27 (25%)
respondents assessed play through other means, such as
parent report or site-specific play checklists.
Next, respondents were asked to indicate from a list
of 12 assessments those that they used in their practices.
The list was a combination of assessment tools found
within the occupational therapy and early childhood
education literature that address some facet of play
behavior and included organized checklists, criterion-referenced tests, and norm-referenced tests. Some of the
tools were developed solely for use as play assessments,
whereas others either use playas a modality for assessing
other skills or include play within or as one of many
domains (see Table 3). Thirty-nine (29%) of 133 respondents indicated that they used more than one of the
choices listed. Assessments reported in the "other" category included the Hawaii Early Learning Profile (Furuno, O'ReilJy, Hosaka, Inatsuka, & Zeisloft-Falbey, 1994),
the MilJer Assessment of Preschoolers (Miller, 1982), and
the Coping Inventory (Zeitlin, 1985).
Eighty-one (63%) of 129 respondents indicated t\vo
or more ways of learning how to assess play or to use specific play assessments (see Table 4). Parenting and journal
reading were among the write-in responses of the 24
(19%) responding to the "other" option.
When asked to provide narrative feedback about the
changes they would like to make in the use of play in the
occupational therapy intervention process, 30 respondents indicated that they would like to use formal play
assessments. Additional comments related to this included requests for continuing education and publications on
the topic of play.
Assessing Play Behaviors
Of 222 respondents, 138 (62%) stated that they assess
play behaviors, and 84 (38%) stated that they did nor.
Seventy-nine percent of the non-school-based respondents assessed play behaviors compared with 54% of the
school-based respondents who did. The respondents who
answered yes to the inquiry were requested to complete
three additional questions targeted at gaining more specific knowledge regarding their use of play assessments
(see Table 2). The majority reported that they predominantly assessed play through clinical observations. Few
stated that they used norm-referenced or criterion-referenced assessments with more than 80% of their caseloads. Furthermore, 62% of 109 respondents reported
that they used norm-referenced assessments, whereas
59% of 107 respondents reported that they used criterion-referenced assessments, with some percentage of their
Use ofPlay in Various Practice Settings
Respondents identified personal frame of reference and
role of occupational therapy as the two most important
factors relative to the development of therapy goals that
Table 1
Percentage of Respondents Who Use Play in Pediatric Occupational Therapy
Percentage of Caseload
Play Is Used as a._Oo'_ _
Therapeutic modality
School-based (n = 144)
Non-schaal-based (12 = 68)
Total (12= 212)
Reinforcer during intervention
School-based (12 = 141)
Non-school-based (12 = 62)
Tota! (11 = 203)
Way ro develop role behaviors
School-based (12 = 129)
Non-school-based (rt = 6 I)
Total (11= 190)
81-100%
----
51-80%
21-50%
1-20%
0%
63
77
67
27
19
25
7
4
6
4
0
2
0
0
0
20
29
23
17
18
17
25
16
22
37
36
37
12
20
16
15
15
IS
24
25
24
37
33
36
----
----
I
2
II
8
10
Note. Percentages may nor equal J00 due to rounding error. The vaJue of n varied according to~he number of respondents for each p;rr of each question.
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113
Table 2
Percentage of Respondents Who Used Play Assessments Within the
Past 12 Months With Identified Portions of Their Caseloads
Play Is Assessed
Through rhe Use of...
Clinical observa[ions (n = 132)
Norm-referenced assessmenrs (n = 109)
Crirerion-referenced assessmenrs (11 = 107)
Percentage of Caseload
81-100%
51-80%
21-50%
1-20%
0%
63
19
12
14
12
16
15
6
26
24
0
38
41
9
6
Note. Respondenrs who answered mis quesrion were among rhe 138 who indicared rhar rhey assessed play behaviors. Percentages may nor equal 100 due ro
rounding error. The value of 11 varies according ro rhe number of respondenrs for each parr of rhe quesrion.
focus on playas a childhood role in the work setting. The
complete results for the six factors listed on the survey are
displayed in Table 5. They cited developmental and sensory integration frames of reference, followed by the
"other" response, as those used most frequently (see Table
4). The 23 write-in responses reflected an approach that
used a combination of frames of reference. The frames of
reference were listed in the questionnaire without definitions. Twenty-nine percent of 20 non-school-based therapists indicated using the developmental frame of reference
most frequently. By contrast, 50% of 75 school-based
therapists indicated using this frame of reference most frequently. Sensory integration was cited by 44% of the
non-school-based respondents and 33% of the schoolbased respondents.
Ninety-two (42%) respondents indicated a collaborative team approach as the discipline or model used to
address the role behaviors of play within the work setting. Education and occupational therapy were listed as
the most frequently used discipline or model. Responses
in the "other" category included social work and child
life (see Table 6).
Discussion
This study yields a timely view of current practice patterns as they pertain to the use of play in pediatric occupational therapy with preschoolers. The high response
rate (93%) seems to reflect therapist interest to contributing to the body of knowledge in this area. The results of
this study suggest that although occupational therapists
who work with preschoolers use play in a variety of ways,
the use of playas a treatment modality is most prevalent.
Despite the theoretical foundation that play holds for the
profession, the majority of respondents reported using
playas a means of developing role behaviors related to
play with 50% or less of their caseloads. Ten percent
reported never using play for that purpose.
Use ofPLay in Practice With PreschooLers
Therapists reported using play considerably more often as
a modality or reinforcer than as a means of developing
role behaviors. This finding appears to be congruent with
responses that sensory integration and developmental
114
frames of reference were used most frequently in both
school-based and non-school-based practice. Play is used
as a modality in both approaches. In sensory integration,
play is used as a treatment medium and motivator to promote organization of sensory information (Bundy, 1991).
In the developmental approach, play activities are used as
treatment mediums to assist in a child's progression from
one stage to another (Llorens, 1974). Few respondents
indicated that they used frames of reference that have
their base in occupation, despite the theoretical importance that occupation holds within the profession (AOTA,
1995). This last finding warrants exploration regarding
therapists' perceptions of playas occupation and the relevance of frames of reference such as the Model of Human
Occupation (Kielhofner, 1995) to pediatric practice.
Non-school-based respondents used child-directed
play and a sensory integration treatment approach more
often than did the school-based respondents. The relationship between child-directed play and sensory integration therapy would be expected because sensory integration therapy is characterized by a large component of
child-directed play (Bundy, 1991). In addition, the
prominent use of the developmental approach appeared
to be related to the high frequency of team approaches to
play in the respondents' work settings.
Table 3
Assessment Tools Used by Respondents
for Evaluation of Play Behaviors
Assessmenr Tool
Percenrage of Respondents
Guide ro Srarus of Imirarion (deRenne-Srephan. 1980)
Parren Scale (Parren, 1932)
Speciflcarion for a Play Milieu (Takara. 1971)
WeeFIM® (Guide fir the Functional Independence
1
1
3
4
Mea.ltlrefir Children. 1993)
Guide ro Play Observarion (Florey. 1971)
T ransdisciplinary Play-Based Assessmenr (Linder, 1993)
Play Hisrory Inrerview (Takara, 1%9)
Preschool Play Scale (Knox, 1993)
Orher
Barelle Developmenral Invenrory (Newborg. Srock,
Wrek, Guidubaldi, & Wvinicke. 1984)
Vineland Adaprive Behavior Scales (Sparrow, Balla, &
Ciccheni, 1984)
N~
5
11
11
13
20
20
22
~
= 133. WeeFIM® = Funcrional Independence Measure for Children.
The percenrages do nor equal 100 because mulriple responses by one responNote.
11
denr were allowed. The respondents who answered mis quesrion were among
rhe 139 who indicared mar rhey assessed play behaviors.
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Specification for a Play Milieu [Takata, 1971]) were developed for research purposes or are not commercially
available and may be difficult for clinicians to locate and
use in their work settings. Furthermore, the tOols that are
commercially available (e.g., Transdisciplinary Play-Based
Assessment [Linder, 1993], WeeFIM® [Guide for the
FunctionaL Independence Measure for Children, 1993]) are
limited with regard to the scope of play behaviors and
the role behaviors related to play that they address. In
addition, they may lack reliability and validity Studies.
The findings that on-the-job training and continuing education were rated as the most frequent sources for
gaining knowledge about play assessment and that two
thirds of respondents indicated that entry-level occupational therapy course work and praeticums had not provided such training might suggest to educators that their
curricula are not adequately addressing the three central
roles of occupational therapy: self-care, work, and play
(Knox, 1993). This education must address role behaviors of play and the theoretical base of occupation as it is
related to play. In addition, occupational therapists who
work with children need more continuing education
workshops addressing role behaviors of play and publications regarding play in order to continue to address the
occupational role of play.
Table 4
Type of Training Through Which Respondents
Acquired Knowledge of Play Assessments and
Frames of Reference Used by Respondents
T raining and Frame of Reference
Percentage of Respondents
Play assessment training (n = 129)a
Graduate scudies
Other
Emry-Ievel course work
Cominuing education
On-the-job training
Frame of refetence (n = 219)b
Rehabilitative
Model of Human Occupation
Neurodevelopmemal
Other
Sensory imegration
Developmemal
15
19
36
50
81
0
2
8
II
37
43
a Percemages do not equal 100 because multiple responses by one respondent
were allowed. bTotaJ percemage equals 101 due to rounding error.
The percentage of respondent's caseloads with which
they used playas a way to develop role behaviors closely
matched the percen tage of documented goals that included a play component. This suggests that when therapists address this issue during intervention, they formally
document it.
Assessing PLay Behaviors
Respondents indicated a desire to use formal play assessments, yet such assessments may not be easily accessible
for pediatric occupational therapists. Many of the play
asseSSments cited by respondents (e.g., Preschool Play Scale
[Knox, 1993], Play History Interview [Takata, 1%9],
Use ofPLay in Various Practice Settings
This study uncovered several key differences with regard
to occupational therapists' use of play with preschoolers in
Table 5
The Importance of Specific Factors in Developing Therapy Goals Focusing on Playas a Childhood Role
Ratj~gs (%)
----
---
Not
Important
Importam
Factor
2
3
4
44
57
49
31
28
30
16
10
14
4
4
4
5
0
3
2
I
2
44
42
43
27
28
28
18
18
18
6
6
6
5
6
5
2
2
2
1
8
3
2
9
4
9
25
14
24
18
22
65
40
57
5
4
5
2
17
7
4
15
8
7
23
12
16
21
18
70
23
55
5
3
5
9
5
8
14
15
14
30
27
29
18
18
18
30
36
32
3
4
3
16
12
14
24
18
22
24
33
27
17
15
16
19
21
20
3
3
3
---
Personal frame of reference
School-based (n = 144)
Non-school-based (n = 68)
TotaJ (n = 212)
Role of occupational therapy in work serting
School-based (n = 143)
Non-school-based (n = 67)
Total (n=210)
Physician prescription
School-based (n = 141)
Non-school-based (n = 67)
Total (n = 208)
Reimbursemen[ issues
School-based (n = 140)
Non-school-based (11 = 65)
TotaJ (n = 205)
Availabiliry of play assessmems
School-based (11 = 142)
Non-school-based (n = 67)
Total (n = 209)
Practice setting philosophy
School-based (n = 1.35)
Non-school-based (n = 66)
Total (n = 201)
Note. n = 224. Percentages ;;:;ay not equal 100 due
to rounding
Median
----
error~The value of n varies according to the number of respond~ms for each question.
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115
school-based versus non-school-based settings. The difference that 79% of non-school-based respondents versus
54% of school-based respondents assess play may be
related to the fact that the roles of the occupational therapist may differ in these settings. This difference, in turn,
could affect therapists' use of play in such settings. As
school-based settings focus on the educational relevance
of intervention, other team members may not value play
as an important focus of intervention for occupational
therapists, but it may be addressed by other educational
team members. In contrast, if all team members believe
that role behaviors of play are important, they may assume
that other team members 8fe addressing such issues. In
such a case, especially if there is a lack of communication
between team members, there is the possibility of play getting lost altogether, being addressed by no one.
Documents that delineate the role of the occupational therapist in public schools cite playas an occupational
therapy intervention area (Stephens, 1989; Washington
Occupational Therapy Association, 1988). However, the
results of this study suggest that occupational therapists
may relinquish play to other team members and instead
focus their intervention efforts on other performance
areas, such as gross and fine motor skills.
Reimbursement issues and physician prescriptions
may be more often viewed by therapists in non-schoolbased settings than school-based settings as factors influencing the development of therapy goals related to play.
In practice environments that rely on third-party reimbursement, intervention may be limited to specific interventions outlined in insurance contracts, and service
must be provided on specific physician prescription. Such
interventions are often specified to be "medically necessary," and the wording of goals and objectives must
match reimbursement requirements. Such limitations
may hinder therapists' ability to address playas an occupational role.
Limitations
The sample population was restricted to AOTA members. It is unknown whether use of a sample of both
AOTA members and nonmembers would have resulted
in slightly different findings. A second limitation, inherent to survey research, is the reliance on self-report.
Directions fir Future Research
Though play is valued by occupational therapists who
work with preschoolers, constraints such as practice setting philosophy and educational opportunities may impede the scope of its use in practice. More studies are
needed to provide additional knowledge and validation of
the role behaviors of play to overcome such constraints
116
Table 6
Discipline or Model That Addresses
the Role Behaviors of Play
Discipline or Model
Percenrage of Respondents
Team approach
Educacjon
42
24
Occupational therapy
20
None
Speech
Other
~syc~~ogy
6
3
3
2
Note. n = 2]7.
and to support the value of using play within occupational therapy practice.
Additionally, it would be important to ascertain what
professional colleagues in various work settings perceive as
the most important intervention services that occupational therapy provides. It also would be meaningful to compare the value that parents, teachers, and occupational
therapists place on play skills and role behaviors. Finally,
studies are needed that demonstrate how to best use play
and examine the effects of play interventions within
occupational therapy practice.
Conclusion
The results of this study provide information on the current use of play within pediatric occupational therapy and
some important considerations regarding educational
opportunities, assessment tool development, and research.
If occupational therapy is to continue to address the roles
of self-care, work. and play, we need to find ways to more
effectively address the role behaviors of play within our
practice and to communicate the importance of playas a
role behavior to our colleagues, our consumers, and the
public. J;,.
Acknowledgments
We rhank Ilene Schwanz, PbD, for assiscance wich chis scudy; Anita
Bundy, SeD. OTRlL, FAOTA, and Susan Knox, PbD. OTR. FAOTA, for
assiscance wirh rhe developmem of the quesrionnaire; Denis Anson,
MS. OTR, for assisrance with scacisrica1 analysis; numerous coJleagues
for assistance wirh rhe pretesring of the quesrionnaire; and all the
therapists who responded to the survey.
This research was panially funded by gtants from the Paula M.
Carmen Memorial Scholarship Fund (Gram No. 63-6265) and the
Departmem of Special Education and Rehabilitation Services (Gtam
Tide, "Preparation of Related Service Personnel: Preservice Training
of Occupational Therapists to Provide Services to Children with
Emotional and Behavioral Disorders," No. 84.029F).
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