AN EVALUATION OF PLAYFULNESS AMONG CHILDREN
WITH PHYSICAL DISABILITY
(A CASE STUDY OF INSTITUTIONAL BASED AND
COMMUNITY BASED
REHABILITATION CENTERS IN BENIN CITY)
BY
AMADI
PROMISE
OT/13/1462
A RESEARCH SUBMITTED TO THE SCHOOL OF
OCCUPATIONAL THERAPY, INSTITUTE OF HEALTH
TECHNOLOGY, UNIVERSITY OF BENIN TEACHING
HOSPITAL BENIN CITY EDO STATE NIGERIA.
JULY, 2016
CERTIFICATION
This is to certify that this essay was written by Amadi promise (Miss) and submitted to the
department of occupational therapy, institute of health technology Benin city in partial
fulfillment of the requirement for the award of diploma in occupational therapy .
………………………………………………
MR TAYO .S. ELEYINDE
………………………………
DATE
(HOD)
……………………………………………
MR TAYO S. ELEYINDE
…………………………
DATE
(PROJECT SUPERVISOR)
……………………………………………
AMADI PROMISE
…………………………
DATE
( RESEARCHER )
DEDICATION
This work is dedicated to God almighty who never sleeps nor slumber, and who through all this
years has lead me all the way, and has thought me lessons of trust, patience and hardwork, I also
dedicate this work to my mum who went through all to see me through this phase of my life, and
to my siblings for their moral and financial support.
ACKNOWLEDGEMENT
Thank you first and foremost to God from whom all things are possible. It is no doubt that His
strength allowed me to preserve and persist, despite any obstacle in my path during this journey,
It has been his grace all the way. This process never would have been possible without the love
and support of my lovely mum. I am so thankful that she pushes me to be a better person every
day. Thank you for believing in me and encouraging me to fulfill my goals. Much love goes to
my wonderful brothers (Sunny, Iyke, Ugo, and Obinna) and my sister (mrs Otalor) who through
all these years stood as role models and source of encouragement.
I wish to acknowledge the wisdom, guidance and patience of my supervisor Therapist and HOD
occupational therapy department Eleyinde .S. Tayo throughout the project journey and through
my journey here as a student in school of occupational therapy. Your encouragement,
understanding and time inspired me to carry on .
I would like to sincerely acknowledge and appreciate my cousin brother Solomon (T Solo) for
your immerse support and technical assistance.
To my Therapist, friend, and adviser Miss Lashman D. I wish to say big thank you for playing
the role of a sister throughout this journey, you are very much loved.
To Mr Emore, I wish to say a very big thank you for your brotherly advices and encouragement,
your words of wisdom and smiles revives even the hopeless hearts. Thank you for been a big
brother throughout this journey.
Appreciation goes to my wonderful friend Dr Seun, for your kind support and brilliance, you
made this journey easy.
To my editor in chief Mr Gabriel Kona your contribution made much meaning.
And to my wonderful friend and senior in the profession Therapist Kehinde, your contributions
and suggestions were highly appreciated.
I wish to acknowledge the staffs and student of occupational therapy who through this years
were my family, in particular Sandra and courage.
I am particularly in debt to the wonderful children and their parents who allowed me to enter part
of their world to gain an understanding of play.
ABSTRACT
It is undisputed that play is the primary occupation of children and that playfulness is an
essential element of play. If more were understood about the circumstances allowing for
playfulness, it would be possible for therapists to create optimal conditions to promote it.
Therefore, occupational therapists value play as a significant occupation in a child’s life and thus
continuous research on play cannot be over emphasized in the profession.
This project explores the nature of play in children with physical disabilities, seeking to
determine whether they engage in play or if their disabilities restrict them from playing, and to
also look at the factors that possibly inhibit their play performance.
This study investigated differences in play behavior in 20 children (8 boys and 12 girls)
diagnosed with cerebral palsy, paraplegia, etc from the ages of 6 months to 17 years. Qualitative
play behavior was assessed using Test of Playfulness (ToP) (Bundy 2008). Pediatric functional
independence measure (WeeFIM) was used to assess the severity of impairment in these
individuals and their movement abilities.
using the statistical package for social sciences (SPSS) the study found out that 45% of the
children were playful while 55% were non playful, and that severity of impairment, movement
ability are some of the factors that restrict the play behavior of the children rather than their
diagnosis.
This work therefore is an eye opener that therapist should engage children with physical
disability in play as this will enhance their optimal integration into the community and their
overall development.
TABLE OF CONTENTS
Abstract ……………………………………………………………………………….
Contents ………………………………………………………………………………
List of Tables …………………………………………………………………………..
List of Figures …………………………………………………………………………
List of Appendices ……………………………………………………………………..
CHAPTER ONE : ………………………………………………………………………
1.1 Introduction …………………………………………………………………………….
1.2 Statement of problem …………………………………………………………………..
1.3 Research questions …………………………………………………………………….
1.4 Objective of the study ………………………………………………………………..
1.5 Relevance of the study …………………………………………………………….
1.6 Delimitation …………………………………………………………………………
1.7 Definition of variables ………………………………………………………………..
CHAPTER TWO : selected review of literature ………………………………………..
2.1 Introduction ……………………………………………………………………………..
2.2 Physical disability and selected condition ………………………………………………
2.3 Play and play theories ………………………………………………………………….
2.4 Types of play ……………………………………………………………………………….
2.5 Specific patterns of play ……………………………………………………………………..
2.7 Play and development ……………………………………………………………………
2.8 Theories of child development …………………………………………………………….
2.9 Importance of play assessment ……………………………………………………………
2.10 Tools for researching play …………………………………………………………………
2.11 Playfulness in children with disability ………………………………………………………
2.12 Factors affecting play participation …………………………………………………………
CHAPTER THREE : METHODOLOGY …………………………………………….
3.1 Research design and methodology …………………………………………………….
3.2 Research design ………………………………………………………………………
3.3 Study population ……………………………………………………………………………
3.4 sampling technique ………………………………………………………………………..
3.5 Procedures ……………………………………………………………………………………
3.6 Inclusion criteria …………………………………………………………………………….
3.7 Exclusion criteria ……………………………………………………………………………..
3.8 Instruments and measure ………………………………………………………………………
3.9 Description of Data analysis …………………………………………………………………
CHAPTER FOUR: RESULTS ………………………………………………………
4.1 Data analysis result ………………………………………………………………….
4.2 Findings …………………………………………………………………………….
4.3 Summary of results …………………………………………………………………..
CHAPTER FIVE : DISCUSSION ………………………………………………………
5.1 Interpretation of results ………………………………………………………………..
5.2 Limitation ………………………………………………………………………………
5.3 Summary and Conclusion ……………………………………………………………..
5.4 Recommendations …………………………………………………………………..
References ……………………………………………………………………………
Appendix ……………………………………………………………………………..
LIST OF TABLES
Table no
content
1. Demographics of study participants
2. Age grouping
3. WeeFIM scale of severity of impairment distribution
4. Dependence distribution
5. Distribution of ToP scores
6. ToP frequency distribution
page no
LIST OF FIGURES
Figure no
1. Movement ability
2. Number of children
3. Diagnosis
4. ToP keyform measure score
content
page no
LIST OF APPENDICES
Appendix A: informed consent forms
Appendix B: ToP definitions
Appendix C: ToP protocol sheet
Appendix D: ToP keyform
Appendix E: WeeFIM instrument
CHAPTER ONE
Introduction
Play has been identified as one of the primary occupations in which people engage,
according to the America Occupational Therapy Association (AOTA) practice framework as
defined by Parham and Fazio, play is "any spontaneous or organized activity that provides
enjoyment, entertainment, amusement or diversion " and is " an attitude or mode of experience
that involves intrinsic motivation, emphasis on process rather than product and internal rather
external control, "as - if" or pretend element; takes place in a safe unthreatening environment
with social sanctions.
Playfulness on the other hand is an important aspect of play specific to the individual.
The approach that a child takes to the activity of play can be described as playfulness (Bundy
1997). Playfulness is defined as consisting of four elements: intrinsic motivation, internal
control, freedom to suspend reality, and framing (Skard and Bundy 2008). Hence play is an
essential component of an individual’s development.
Meanwhile physical disability refers to the disability (limitations) caused by
developmental delay, disease of central and peripheral neurological system, traumas or other
congenital disease of the musculoskeletal system. Physical disabilities include conditions such as
cerebral palsy, muscular dystrophy, spinal bifida, rheumatoid arthritis, skeletal deformities,
amputations etc. And all these conditions impart great on one’s ability to engage in play.
It is widely accepted that any form of disability poses significant limitation to play
behavior, and that disabled children do not have some play skills as their typically developing
peers. Missiuna and Parlock suggest that disabled children may experience so many barriers to
play, that play deprivation can become a secondary disability.
Barriers may be either within the child or imposed by caregivers, society or the physical
environment. Playfulness as a quality that has been associated with adaptability may be crucial
aspect of play assessment and intervention for children with disability, Hence an extensive study
in this area vis-a-vis the institutional based and community based rehabilitation centers in Benin
city will be necessary to further understand the pattern of playfulness for the children living with
physical disabilities.
Statement of Problem
Researches have shown that children with physical disability appear to have decreased
play and playfulness when compared to typically developing peers. Children with physical
disabilities may have physical, social, environmental and personal barriers to play (Missiuna and
Parlock 1991).Hence there is a need to evaluate the playfulness of children with physical
disability with special focus on the environmental and physical factors influencing playfulness.
Research Question
This research study will investigate the following research questions
1. Do children with physical disability engage in play at all?
2. What is the quality of play of children with physical disability?
3. Do differences occur with respect to play between male and female children with
disability in institutional based and community based rehabilitation centres?
Objective of the Study
1. The purpose of this study is to evaluate the playfulness of children with physical
disability using the test of playfulness (TOP).
2. To determine the factors responsible for restricting the playfulness of children with
physical disability
3. To appraise the suitability of the rehabilitation centres in enhancing play in children with
physical disability.
Relevance of Study
At the end of the study, it is believed that the study will help:
1. Identify environmental and physical barriers limiting the playfulness of the children and
making appropriate recommendations to overcome them
2. To educate parents and guardians on ways to enhance the playfulness of their children
with physical disability
3. In making recommendations on the different strategies and assistive devices that can
enhance playfulness in children with physical disability.
4. The study is also expected to serve as basis for further studies in the same area for a
larger population
Delimitation
This study will be carried out among 20 children with physical disability in institutional
based and community based rehabilitation centers in Benin metropolis, which includes Project
Charlilove and pediatric occupational therapy out-patient clinic university of Benin teaching
hospital.
Definition of Terms
1. Play: Any spontaneous or organized activity that provides enjoyment, amusement,
entertainment, or diversity and an attitude/mode of experience that involves intrinsic
motivation, emphasis on process rather than product and internal rather than external
control, and “as if” pretend element takes place in safe non-threatening environment with
social sactions.
2. Pattern: The regular and repeated way in which something happens or is done.
3. Playfulness: The quality of being fun and lively.
4. Child/Children: A young human being or group of young human beings below the age
of puberty (10-16 years) or below the legal age of majority (18years).
5. Physical Disability: A physical disability is a limitation on a person’s physical
functioning, mobility, dexterity or stamina.
6. Rehabilitation: To bring (someone or something) back to a normal, healthy condition
after an illness, injury, drug problem etc
CHAPTER TWO
LITERATURE REVIEW
There is a large literature exploring play and abundant research on the impact of play on all
areas of development. However, limited research exists on the playfulness among children with
physical disability. Hence this chapter presents a review of existing literatures on the research
topic.
Physical Disability and Selected Conditions
A physical disability is a limitation on a person’s physical functioning, mobility,
dexterity or stamina. Many causes and conditions can impair mobility and movement. The
inability to use legs, arms or body trunk effectively because of paralysis, stiffness, pain or other
impairments is common. It may be the result of birth defects, disease, age or accidents. These
disabilities may change from day to day. They may also contribute to other disabilities such as
impaired speech, memory loss, short stature and hearing loss.
Some of such Physical disabilities include conditions such as cerebral palsy, muscular
dystrophy, spinal bifida, juvenile rheumatoid arthritis, skeletal deformities, and amputations.
Even chronic health conditions that tend to restrict physical activity, such as heart disease,
leukamia, and cystic fibrosis, can also be considered physically disabling.
Cerebral palsy
CP is a non progressive disorder that is caused by a lesion in the brain, prior to 2years of
age. The disorder causes impairments of postural and voluntary movements, and may also
involve speech, vision, hearing, and perceptual impairments. Although the damage to the brain
does not worsen over time, motor impairments become more apparent and have a greater impact
on functioning as a child ages (Glanzman, 2009). Comorbidities may be present including
autism, epilepsy, intellectual disability, visual, and hearing deficits, hydrocephalus,
microcephaly, scoliosis, and hip dislocation (Glanzman, 2009; Kirby et al., 2011). CP may
impact client factors such as muscle and movement functions, which can impact performance
skills. Some skills that may be impaired include posture, mobility, coordination, strength, effort,
and energy (Bowyer & Cahill, 2009). CP can be categorized by body parts affected, the quality
of motor movement related to muscle tone, and the level of functional skills present. CP can be
classified as diplegia, hemiplegia, or quadriplegia. Diplegia includes involvement of the lower
extremities, whereas hemiplegia includes involvement of one upper extremity and one lower
extremity on the same side. Quadriplegia includes involvement of both upper and lower
extremities, and can also include the trunk (Bowyer & Cahill, 2009). CP can further be
categorized by the type of muscle tone reflecting the quality of movements. The muscle tone
categories are spastic, athetoid, ataxic, hypotonic, and mixed. Tight, rigid muscles are said to be
spastic or high tone. Muscle tone that varies and includes writhing movements is athetoid.
Intentional movements that appear uncoordinated are ataxic. Loose muscles are classified as
hypotonic or low tone. Finally, mixed includes characteristics of two or more of the other muscle
tone categories (Bowyer & Cahill, 2009)
Muscular Dystrophy
Duchenne muscular dystrophy (DMD) is an X-linked recessive genetic disorder
in which skeletal and cardiac muscle are dysfunctional (Smith & Swaiman, 1999). This
progressive disease of the muscle is characterized by progressive dystrophic necrosis of the
muscle cells (Menkes, 1995). DMD is caused by an absence of dystrophin, an
intracellular protein that composes .002% of total muscle protein (Hoffman et al., 1987;
Knudson et al., 1988). This absence corresponds with a genetic mutation that disrupts
normal dystrophin translation (Smith & Swaiman, 1999). The gene for DMD is located
on the Xp21 band of the X chromosome (Boyd & Buckle, 1986; Francke et al., 1985;
Ray et al., 1985) and is expressed primarily in males since this genetic defect is a
recessive trait (Smith & Swaiman, 1999). The incidence of DMD is approximately 1 in 3,300
males (Emery, 1977; Moser, 1984; Scheuerbrandt et al., 1986; van Essen et al., 1992). The
disease is most often recognized by 3-4 years of age. Children with DMD may begin to walk
later than normal children, experience more falling than expected, and progressive gait failure
eventually becomes apparent. DMD can also often be characterized by neck flexor weakness
with poor head control and a typical waddling gait (Menkes, 1995; Smith & Swaiman, 1999).
The course of this disease is gradual, with most individuals losing ambulation near the end of the
first decade (Smith & Swaiman, 1999). Throughout adolescence, weakness increases and
manifests throughout the muscles, including arms, hands, face, and neck muscles. Pulmonary
and cardiac function may be compromised and must be monitored.
Spina bifida
Spina bifida is the term most commonly used to describe a congenital defect of the
vertebral arches and spinal column. This condition occurs in the fourth week of prenatal
development and can be identified by amniocentesis (Krosschell, K. L., & Pesavento, M. J,
2007). This defect may be mild, with the laminae of only one or two vertebrae affected (spina
bifida occulta) and no malfunction of the spinal cord, or it may involve an extensive spinal
opening with an exposed pouch made up of cerebrospinal fluid (CSF) and the meninges
(meningocele) or CSF, meninges, and nerve roots (myelomeningocele).
Juvenile Rheumatoid Arthritis (JRA)
JRA is a major cause of physical disability in children younger than 16years of age. It has
an overall prevalence of 10 to 20 per 100,000 children (Miller & Cassidy 2007). JRA usually
begins between 2 and 4 years of age and is more common in girls. It is the most common form of
arthritis in children (Rogers in Case-Smith & O’brien 2010). Arthritis is best described by
certain major changes that may occur in the joint. These are Joint inflammation; Joint contracture
(stiff, bent joint); Joint damage; And/or alteration or change in growth. Other symptoms include
joint stiffness after rest or decreased activity (also referred to as morning stiffness or gelling).
Curvature of the spine
Lordosis, kyphosis, and scoliosis are the three major deformities of the spine. These
conditions may occur functionally, posturally, and structurally. They may occur secondary to
muscle imbalance, bony deformities, or other pathologic conditions such as Cerebral Palsy, or
they may occur ideopathically. They may be congenital or acquired. Lordosis is an
anteroposterior curvature in which the concavity is directed posteriorly, also called hollow back.
This condition often occur secondary to other spinal deformities or to an anterior pelvic tilt.
Kyphosis is the posterior curvature of the spine also called round back Scoliosis is the most
common and serious of the spinal curvature disorders, usually involving lateral curvature, spinal
rotation and thoracic hypokyphosis. Lateral curvature can be caused by poor posture, leg length
discrepancy, poor posture tone, hip contracture or pain. From the clinical features of children
with this conditions it is obvious that their performance component will be affected, which
includes
1. Sensorimotor components:
 Sensory : tactile, visual etc
 Neuromusculoskeletal : reflex, ROM, muscle tone, strength, endurance, postural
control, etc
 Motor : gross coordination, bilateral integration, fine coordination and dexterity,
praxis.
2. Cognitive integration and cognitive components: level of arousal, recognition,
orientation, memory, generalization.
All these selected conditions can affect how a child plays, the kinds of play the child
engages in and the child’s ability to use play as an avenue to learning and generalizing new skills
or concepts. Although experiential background, personality, environment and gender also affect
how play skills develop, how children approach play and the learning that the child takes from
the play activity. Children with disability will have distinct difference in their play. They may
even need to be taught specific play skills before they can begin to learn through play or engage
in play activities (Mary, 1998). However, to what extent and specific play pattern that may be
required to be taught will certainly vary from one environment to the other, hence the
appropriateness of this study.
Play Theory
Play is an important component in a child’s life. It’s a crucial part of life that has been
commonly associated with freedom, pleasure and enjoyment (Bundy 1993; Huizinga, 1955 &
Sulton Smith 2001). Contemporary literature in this field states that play and leisure are
resources for transcending negative life experiences and contributing to the capacity to cope with
stress, increase self concept and self esteem, and enhance social competence (Banche 2008).
Play has been described as a complex construct by scholars, who have tried to define it, but a
complete consensus as to its definition has not been reached (Ferland, 2005; Parham, 2008).
Contemporary play theories emerged around the twentieth century and can be classified into
biological, psychodynamic, cognitive or socio-cultural theories (Parham 2008).
Researchers have explained children’s development through play in terms of discovery,
learning, mastery, self-esteem, self-concept, adaptation, creativity, self-expression and social
skills. (Blanche, 2008; Ferland, 2005). Child’s development through play occurs in a natural way
and it is not necessary to stimulate typically developing children to play. Play is an ideal way to
discover the world through practice with different objects and experiences. (Ferland, 2005).
Through play children can explore the relationship between their body and the environment
using sensory information, gain information about the properties of objects and develop rules
about their own temporal and spatial location (Reilly, 1974).
Self expression and creativity are also promoted by play, play is the pure expression of who a
person is because it is free (Bundy, 1993); thus, play is a wonderful setting for children to
develop and show their personalities. Creativity is related to the freedom to suspend reality
element of play. In play children decide what is real and what can transform according to their
desires. The kind of imagination present in pretend play (e.g inanimate objects treated as
animate), is related to the development of creativity, humor and originality in problem solving
(Ferland, 2005). A sequential development of play has been described in different developmental
dimensions such as cognitive (Piaget,1951; Mecune-Nicolich, 1981), social participation (Brain
& Mukherji,2005) and occupational performance (Knox, 2008).
The biological perspective to play is generally related to the theories of optimal arousal, meaning
play is considered as one of the ways through which the brains of many species are enhanced and
enriched by the playful exploration of the environment (Burghardt, 2005).
The psychodynamic theory of play was constructed principally by Freud who was
interested in play as a means through which children project their unconscious desires and
conflicts. The psychodynamic theory explains play as a way for the child to connect their internal
(conflicts, desires), and external (reality) worlds. (Reilly, 1974).
Regarding cognitive developmental theories, Piaget did not develop a play specific
theory, but his theory of cognitive development significantly influenced our understanding of
play. He is one of the most cited authors in the field of children’s play and his most important
contribution was to state that play is one of the means by which children develop symbols
(Piaget, 1951).
Socio-cultural theory states that play is crucial for social life and culture. Some theories
in this category state that play is influenced by culture with play behaviors of human beings built
on culture. (Fleer, 2010; Huizinga,1955).
Types of play
Self and object play: many types of play emerge as a child develops .each type of play is
important in building skills for successful play participation. Often, types of play that are
described in the literature coincide with play theory. Two types of play are associated with
movement and exploration.
Active play refers to motor control and movement in space through overcoming
obstacles. Exploratory or sensorimotor play involves children’s ability to explore themselves
and the objects around them using their sensory system: sight, sound, touch, smell and taste
(Hughes, 2010).
As children become able to explore their environment and develop their
sensory and motor abilities their play with objects becomes more complex (Hughes, 2010).
Repetitive motions and banging are replaced with more refined attempts to interact with objects
in varied ways. Manipulation and constructive play require a child to combine previously
developed skills of imitation and purposeful anticipation. When children near their second year,
they attempt to integrate all the information that they have observed and copied. Play is seen as
children use objects to represent other things in symbolic play and create increasingly complex
make-believe situations for themselves.
Social play : social play is a crucial part of child’s ability to participate in play, social
play involves interaction with at least one other individual and consists of three phases:
Orientation - which involves awareness of the child and other children, the play materials, or
active choice not to enter play; Parallel or proximity play – which is playing independently
beside or near another child, using the same space or materials, or engaging in similar activities;
and Common focus, including taking turns, sharing, giving, and requesting, showing something,
and making requests to play. (Bass & Mulick, 2007; Power, 2000; Yang, Wolfberg, Wu & Hou,
2003). In social play, children learn to interact through imitation and modeling, which develops
essential interactive behaviors (Aeri & Verma, 2004; Bandura, 1989 & Power, 2000). Social play
is foundational for building skills in the early years of child’s life, and deficits in this area tend to
become more pronounced later without successful intervention. (Strain,1981& Strain & Danko,
1995).
Specific Patterns of Play
The California based national institute for play (2014) described seven play patterns
which includes: Attunement play; Body play and movement; Object play; Social play;
Imaginative or pretend play; Story telling – narrative play; and Creative play
Attunement play: This type of play occurs when a connection is established between
people through interacting with each other. This is a natural type of play that occurs from
early in child’s development. Examples include when a baby and mother make eye
contact and exchange smiles.
Body play and movement: Any play that helps your child develop their understanding
of how their body works falls within this category, running, jumping, skipping, dancing,
and singing are joyful activities that can stimulate coordination but also help drive
learning. This play is so important in that it promotes muscle coordination and also helps
children learn about their natural environment, for example, jumping improves your
child’s coordination and teaches your child something about gravity. Singing songs
develops your child’s vocal chords but also teaches your child about music. This pattern
of play is significantly defective in the children with physical disability.
Object Play: When children use physical object in their play they are conducting object
play. Whether the child is playing with toys, banging pots and pans or kicking a ball, they
are developing their curiosity through object play. This pattern of play is also
significantly defective in the children with physical disability.
Social Play: This involves play between people . This type of play covers a range of
activities with your child such as play between children and includes rough and tumble,
making faces, and building connections with others.
Imaginative or pretend play: Whenever a child invents stories from their imagination
and acts within that story, they are engaging in a unique form of play. Examples include
playing prince/princess, acting as a shop keeper and playing doctor.
Story telling- narrative play: Whenever you or your child read aloud or tell a story you
engage in story telling play.
Creative play: This play occurs when people use imagination to create new ways or
ideas about doing things for example, a person might experiment to find a new way to
use musical instrument.
Play and Development
According to Academic Research paper writing 2015, Every child needs play as
this greatly contributes to their physical, social, and emotional well-being. There are
different reasons why people play and these include excitement, and pleasure. By
playing, children get a chance to not only express themselves but also spend time with
their parents. In addition, through playing, children can learn how to cope with their own
feelings especially when they feign feelings such as anger, sadness, and worry. This
makes them gain positive emotions and can thus significantly contribute to a good selfsentiment and good health. Furthermore, it also fosters relationships and enables children
feel relaxed and have fun.
Play is an activity that is chosen freely and is motivated and directed from within.
Adequate space for play and a wide variety of play materials can be crucial in the
development of children (Goldstein, 2012). In early childhood education, play is
particularly valued and embedded in the curriculum. It makes towards the cognitive,
physical, social and emotional well-being of children and youth (Ginsburg, 2005).
Children undergo many developmental changes from the moment of their birth until
they reach five years of age. These first years are very important in children’s growth especially
because they determine the personality of the children. Some of the milestones experienced in
terms of children’s development include physical, social, cognitive, and linguistic growth
because children develop their body parts, the strength, and ability to move, cry, and talk.
Additionally there are also physical milestones such as rolling, sitting, crawling, standing
without support, walking, and running that children experience. Emotional milestones include
smiling at people, laughing and responding to diverse situations in different ways. Children also
develop cognitive milestones such as exploration of new objects such toys, picking up things and
disarranging them, making inquires like why some things are the way they are. Linguistic
milestones that are experienced include babbling, imitating speech sounds, talking and singing or
mimicking some rhymes. As each child grow, the developmental milestones evolve but the
growth takes place at different paces for different children.(Academic Research paper writing
2015).
Theories of child development
Piagets theory of cognitive development
B.J Wadsworth, 1996`
Eriksons stages of psychosocial development
Stage
Basic
Important events
Outcome
Feeding
Children develop a sense of trust when
caregivers provide reliability, care and
affection. A lack of this will lead to mistrust
Children need to develop a sense of personal
control over physical skills and a sense of
independence. Success leads to feelings of
autonomy, failure results in feelings of shame
and doubt.
Children need to begin asserting control and
power over the environment. Success in this
stage leads to a sense of purpose. Children who
try to exert too much power experience
disapproval ,resulting in a sense of guilt
Children need to cope with new social and
academic demands. Success leads to a sense of
competence, while failure results in feelings of
inferiority
Teens need to develop a sense of self and
personal identity. Success leads to an ability to
stay true to yourself, while failure leads to role
confusion and a weak sense of self
Young adults need to form intimate, loving
relationships with other people. Success leads
to strong relationships, while failure results in
loneliness and isolation.
Adults need to create or nurture things that will
outlast them, often by having children or
creating a positive change that benefits other
people, success leads to feelings of usefulness
and accomplishment, while failure results in
shallow involvement in the world.
Older adults need to look back on life and feel
a sense of fulfilment. Success at this stage
leads to feelings of wisdom, while failure
results in regret, bitterness and despair
conflict
Infancy
(birth to 18
months)
Trust vs.
Early
Autonomy
childhood(2
vs. Shame
to 3 years)
and doubt
Preschool (3
to 5 years
Initiative vs. Exploration
School Age
Industry vs. School
(6 to11
Inferiority
Mistrust
Toilet training
Guilt
years)
Adolescence Identity vs.
(12 to 18
Role
years
confusion
Social relationship
Young adult
(19 to 40
years)
Intimacy vs.
isolation
Relationships
Middle
adulthood
(40 to 65)
Generativity
vs.
Stagnation
Work and
parenthood
Maturity (65 Ego integrity
to death )
vs. Despair
Reflection on life
Importance of Play Assessment
Early childhood educators and clinicians know how important play is in children’s lives.
Play is not only an enjoyable and spontaneous activity of children but it also contributes
significantly to their psychological development. Stagnitti (2004) in his study concluded that
there is a need for a clinically sound play assessment in occupational therapy to encourage
occupational therapists to include play assessment in the assessment batteries, and incorporate
play as an important area of intervention. For children, play is essential and therefore a powerful
evaluation tool that provides a familiar and stress free arena in which the children can
demonstrate strengths and abilities. Play reveals children's physical, social, cognitive, and
emotional concerns and their ability to interact in social environments.
Tools for Researching Play and Playfulness
Valid and reliable measures of playfulness are difficult to find. There are two established
measures for playfulness: the Children’s Playfulness Scale and the ToP. Both of these
instruments have established psychometric properties, published results, and been used in
research. The Children’s Playfulness Scale has been revised and is valid for use by teachers in
preschool classrooms (Barnett, 1990). It is recommended that the person scoring the results be
familiar with the child, spending a minimum of 30 hours becoming familiar with the child’s
playful style (Muys, Rodger, & Bundy, 2006). It also should be noted that initial studies of the
Children’s Playfulness Scale were with typically developing children and did not determine the
assessment’s validity for children with disabilities.
The other measure of playfulness is the ToP (Skard & Bundy, 2008). Development of
the ToP by Bundy was influenced by the elements of play, cited in play literature. The ToP is an
observational assessment that attempts to objectively measure the four elements of playfulness:
intrinsic motivation, internal control, freedom to suspend reality, and framing. The following is
an expansion of these elements:
1. "Intrinsic motivation" refers to some (unnamed) aspect of the activity itself, rather than
an external reward that provides the impetus for the individual's involvement in the
activity.
2. "Internal control" suggests that the individual is largely "in charge" of his or her actions
and at least some aspects of the activity's outcome.
3. "Freedom to suspend reality" means that the individual chooses how close to objective
reality the transaction will be and, perhaps more importantly, is not bound by
unnecessary constraints of reality.
4. Framing refers to the ability of a player to give and read social cues about how to interact
with one another (Bundy, 1997, p. 3)
Children from ages 6 months to 18 years can be assessed using the ToP. The ToP has
been revised three times to reflect research on individual items, Rasch fit statistics, validity, and
user understanding (Muys et al., 2006). The ToP Version 4 was utilized for the study. The ToP
has been found to yield valid and reliable results in children who are typically developing
(Bundy, Nelson, Metzger, & Bingaman, 2001) and in children with special needs (Okimoto et
al., 2000; Reid, 2004). Several studies have investigated the use of the ToP with children with a
variety of diagnoses.
Researchers have used the ToP to determine the playfulness of children with autism,
attention-deficit hyperactivity disorder, cerebral palsy, spina bifida, and developmental delay
(Harkness & Bundy, 2001; Leipold & Bundy, 2000; Morrison, Bundy & Fisher, 1991; Okimoto
et al., 2000; Reed, Dunbar, & Bundy, 2000). The ToP has been identified as being most relevant
in a setting that supports free play in natural play settings.
The ToP was chosen for use in this study for a variety of reasons. First, the content of the
assessment was determined to be valid through a literature review, and a moderate correlation of
Version 3 was established with the Children’s Playfulness Scale (Barnett, 1990). Next, the ToP
is valid with both boys and girls (Tyler, 1996) and across different cultures (Porter & Bundy,
2000). Finally, inter-rater reliability has been reported at 95% (N = 300) with goodness of fit to
the Rasch model, and the test–retest is reliable. It should be noted that the most reliable scores
were determined with 15 minutes of observation and when children were tested twice, alone and
with a playmate (Skard &Bundy, 2008). The ToP is a valid and reliable assessment used in
occupational therapy to measure the playfulness of children in free play. Administration of the
ToP involves four major steps. The first step is identification of the player. In the playgroup
study, the players were the 20 children chosen for this study. The second step is selection of the
play environment. For assessment of playfulness in the playgroup study, each child would play
in a familiar play environment during a typical playtime as determined by the caregiver. Third,
the child is observed and video-recorded during 15 minutes of free play by an unobtrusive
observer. Finally, the video-recorded free play is scored according to the ToP manual (Bundy,
2010). Researching play or aspects of it comes with numerous challenges. Some of these stem
from the fact that playful behaviour is difficult to define, and that as a contextual behaviour, the
researcher inadvertently plays a part in what will ultimately be captured. Extending from a well
accepted definition of playfulness, and elements that constitute it, Metzger, McNicholas and
Bundy developed the Test of Playfulness (ToP). This test has been refined and validated and has
become the most cited tool for the measurement of playfulness. Although there are other
measurements, what is particularly useful about the ToP is that it provides a measure of
playfulness without penalties for motor skill deficits. Also, unlike the Children’s Playfulness
Scale (CPS), another useful measure, the ToP does not measure cognitive spontaneity as a direct
attribute to playfulness. It therefore may offer some greater potential for use with intellectually
impaired individuals. The ToP however can serve as a useful guide for qualitative researchers in
knowing what elements of playfulness to look for.
Bundy (1999) designed the Test of Environmental Supportiveness (TOES) to compliment
the ToP. This 17 item observational measure assesses both human and non-human elements in
the environment that may influence the child's playfulness in either a positive or a negative
manner. Human environment in this case consists of caregivers, peers, and playmates (either
children or adults). The non-human environment consists of both play items and the setting itself.
Caregivers are scored based on behaviors. Behaviours that ensure the child's safety and provide
play opportunities. Objects are scored on the existing amount, their ability to support play, and
the degree of modification they allow. Space is rated on amount, configuration, safety, and
accessibility. The sensory environment consists of colours, sounds, temperature, and the extent to
which those invite play in the environment. In the administration of both the ToP and TOES,
children are observed for approximately 15 minutes (20-minute videos were used for this study)
and examiners are encouraged, but not required, to use multiple play settings. Children are
videotaped in an indoor setting selected by the parent participating in the video. Parents choose a
location in the family home as the setting for the videotape. The 17 items of the TOES are rated
on a 4 point continuum (-2, -1, 1, 2). Negative scores indicate that an environmental element is
interfering with the child's play; positive scores indicate support from the environment. Bronson
and Bundy (2001) found the TOES useful in identifying 3 levels of separation identifying
supportive environments.
Playfulness and Children with Disabilities
It is widely accepted that any form of disability poses significant limitation to play
behaviour and that disabled children do not have the same play skills as their typically
developing peer. Missiuna and Parlock (1991) suggest that disabled children may experience so
many barriers to play that play deprivation can become a secondary disability. Barriers may be
either within the child or imposed by caregivers, society or the physical environment.
Playfulness as a quality that has been associated with adaptability may be crucial aspect of play
assessment and intervention for children with disabilities.
There have been conflicting research findings regarding the playfulness of children with
physical disabilities. Okimoto et al (1991) found significant differences in playfulness between
young children with cerebral palsy and developmental delays and young children with no
developmental disabilities. This was supported by Hamn (2006) who found that children with
developmental disabilities were less playful than their peers without developmental disabilities.
Harkness and Bundy (1998) on the otherhand, discovered in their study that children with
physical disability were no less playful than their able bodied peers but that the parents of the
disabled participants tended to choose environments that were supportive of their children’s play
needs. This could have created a more positive impression of their playfulness profile than was
probably the case. Howard (1996) puts forward the view that children with physical disabilities
experience less rich play than able bodied children. Children with disabilities tended to spend
more time in the company of adults and had less variety in their out of home pursuits.
Factors Affecting Play Participation
When examining variables that influenced play participation of children with disability,
these studies primarily focused on factors associated with the child. Studies found that level of
function and severity of impairment, rather than diagnosis, were directly related to degree of
participation restriction, (Beckung & Hagberg, 2002; Kerr, Morris, Kurinczuk, Fitzpatrick
&Rosenbaum (2006b) found that social integration was predicted by movement ability
intellectual delay and manual ability. Factors within the family, such as number of children did
not have a strong effect on leisure participation (Ehrmann, Aeschleman & Svanum, 1995;
Lepage, Noreau, Bernard &Fougeyrollas, 1998). Moreover, research on disability shows that not
only child individual characteristics might affect play experience. Social and physical
environments are considered as important mediators of an individual child play experiences
(Bundy, 1997a). A child with a disability such as CP may lack both the abilities and
opportunities for successful play experiences because of limitations posed by physical, cultural
and social environmental barriers (Hamm, 2006; King et al., 2003; Lawlor, Mihaylov, Welsh,
Jarvis & Colver, 2006; Reilly, 1974; Rigby &Gaik, 2007). Gender is found to be a major
predictor of patterns of play participation in children without disabilities (Howe, Moller,
Chambers & Petrakos, 1993; Medrich, Roizen, Rubin & Buckley, 1982). However, gender
effects on play varied in children with CP, (Lepage et al., 1998; Longmuir & Bar, 2000). Boys
and girls participated similarly in formal and informal activities except for more social and skill
based activities for girls and greater intensity of active physical activities for boys (Law 2006).
Based on past research, boys engaged more intensely in active physical activities (and would
enjoy these more and reported higher preferences for this type of activity), whereas girls engaged
more intensely in skill-based, social and self-improvement activities (and would enjoy and prefer
these more than would boys) (King et al., 2006). Sports participation is generally found to be
higher for boys than for girls (Larson & Verma 1999; Medrich et al. 1982), and other evidence
indicate that girls typically are more involved in skill-based, social and self-improvement
activities. As children develop new motor and cognitive skills, they have the capacity to play in
new and more complex ways, and those new abilities are reflected in their choices of more
complex play over time. Infants use object play to explore and learn about the world around
them (Pierce, Munier & Myers, 2009). Relational play with multiple objects is then followed by
symbolic and fantasy play (Pellegrini & Bjorklund, 2004). Outdoor play preferences and the
preferences for rough-and-tumble play has been shown to change with age, as have pretend play
and social play (Pellegrini, 1992).
CHAPTER THREE
RESEARCH METHODOLOGY
Research Design and Methodology
This chapter describes the research design and methodology of the study. The chapter is
divided into five major sections:
(a) the research design and specific procedures
(b) the sampling technique and size
(c) a description of study population
(d) the instruments and measures used and
(e) a description of data analysis.
Research design
This study used survey approach. The participants in the study included all patients whose
parents/caregivers and teachers had given consent and were available for the examination.
Study population
The population for this study are patients who receive therapy at the pediatric out-patient clinic
of occupational therapy department university of Benin teaching hospital Benin city and pupils
of Project Charilove special rehabilitation centre for disabled children.
Sampling technique
The sampling of convenience was used
Sample size
The sample size of this study was 20 physically disabled children, 17 of them was gotten from
paediatric out-patient clinic UBTH, and 3 from Project Charilove special rehabilitation centre.
Procedures
Ethical approval for this study was sought and obtained from the occupational therapy
department university of Benin teaching hospital UBTH. Informed consent of participants was
sought through written letters, phone calls, and one-on-one interaction.
Play took place in outdoor setting with familiar faces and children of similar age. Materials were
items conventionally considered to be play items for children, including colorful balls, sensory
pool, building blocks, postal colours, card board and brushes for finger and foot
painting/stamping. During play sessions each child was observed outdoor. Test of playfulness
(ToP) was used to rate their playfulness, also the Paediatric Functional independence measure
(WeeFIM) was used to access the severity of their impairment and to rate their movement
abilities. In addition, parents of the children participated during play sessions as well as the staffs
and some pupils of Charilove rehabilitation centre. Observation journals were kept and each
participant was also videotaped so that a detailed description of all behaviours and actions were
captured.
Inclusion Criteria
1. Children diagnosed of conditions that leads to only physical disability
2. Children with physical disability between the ages of 6 months and 18 years.
Exclusion Criteria
1. Children with cognitive deficits that prohibits them from playing.
2. Children who in the course of the study develop other conditions other than the
condition(s) in the inclusion criteria
Instrument and Measures
The ToP: The study used the video recordings of free play to measure playfulness. Permission to
use this instrument was granted from the author of the ToP, Anita Bundy, through e-mail. The
ToP Version 4.2 (Skard & Bundy, 2008) was used to measure the constructs of playfulness
through observation in the minutes of free play. The ToP rates 30 items on a 4-point scale from 0
to 3 that reflects extent, intensity, or skill of a child in free play (see Appendix C). Scores from
the video observation were input in the ToP protocol sheet (Appendix C) and then plotted on the
ToP Keyform (see Appendix D) by relative difficulty according to means and standard
deviations. After plotting the scores, a line was drawn through the Keyform (see Appendix D), so
half of the scores were above the line and half below. This resulted in an interval-level
playfulness score to be utilized for statistical analysis (Skard & Bundy, 2008).
Scores on the ToP keyform ranges from -3 to +3 (Bundy et al., 2001). Scores in the negative
direction from zero indicated that the child was not expressing playfulness, and the scores in the
positive direction from zero indicated that the child was playful during the segment of play
(Bundy et al., 2001).
WeeFIM: The Functional Independence measure (WeeFIM) for children is a simple-toadminister scale for assessing independence across 3 domains. it was based on the conceptual
framework of world health organization (1980) of pathology, impairment, disability and
handicap and the burden of care. WeeFIM is an 18-item, 7-level ordinal scale instrument that
measures a child’s consistent performance in essential daily functional skills. Three main
domains (self-care, mobility, and cognition) are assessed by interviewing or by observing a
child’s performance of a task to criterion standards. For this study, this scale was used to observe
the severity of impairment and movement ability in study participants. (see Appendix E)
Data Analysis
The data collected from the study was organized, analyzed and tabulated. Statistical Package For
Social Science (SPSS) version 20 was used in the analysis. Data was presented using prose,
charts, tables and graphs.
CHAPTER 4
RESULTS
This chapter details the results obtained from the study. Their demographic datas are as shown
in table 4.1
Table 4.1 Demographics of study participants
SUBJECTS
AGE
GENDER
NUMBER OF
SIBLINGS
SOCIO-ECONOMIC
STATUS
Child
1
16 years
Male
0
Lower
Child
2
8 months
Female
2
Middle
Child
3
3 years
Female
0
Lower
Child
4
4 years
Male
2
Middle
Child
5
5 years
Male
2
Middle
Child
6
3 years
Female
1
Middle
Child
7
2 years
Female
0
Middle
Child
8
11 months
Male
0
Middle
Child
9
3 years
Female
0
Middle
Child
10
1 year
Female
1
Middle
Child
11
2 years
Female
1
Middle
Child
12
2 years
Female
1
Middle
Child
13
1 year
Male
0
Lower
Child
14
17 years
Male
0
Lower
Child
15
1 year
Female
3
Middle
Child
16
7 years
Male
1
Middle
Child
17
5 years
Female
1
Lower
Child
18
1 year
Female
0
Middle
Child
19
8 months
Male
1
Lower
Child
20
11 years
Female
2
Middle
The mean age was 4.25 ±4.91 years. the range of ages were 8 months to 17 years. eight (40%) of
the respondents were male while 12 (60%) of the respondents were female. None of the patients
were from homes with a high socioeconomic status. Fourteen (70%) of the patients were from
middle socioeconomic status while others were of low status.
Table 4.2 Age grouping.
Age group
Frequency
Valid
<1yr
1-4.9yrs
5 and above
Total
Percent
4
20.0
10
50.0
6
30.0
20
100.0
Paediatric functional independence measure used to scale the clients revealed an average score of
48.05% ±21.11 as shown in table 4.3 below. None of the participants were independent
according to the paediatric functional independence measure. Half of the participants had
modified dependence and the other half were completely dependent as shown in table 4.4
Table 4.3 WeeFIM scale
SUBJECTS
SEVERITY OF
DEPENDENCE LEVEL
IMPAIRMENT
ACCORDING TO WeeFIM
Child
1
74(58.7%)
Modified dependence
Child
2
18(14.3%)
Complete dependence
Child
3
78(61.9%)
Modified dependence
Child
4
66(52.4%)
Modified dependence
Child
5
48(38.1%)
Complete dependence
Child
6
42(33.3%)
Complete dependence
Child
7
43(34.1%)
Complete dependence
Child
8
40(31.7%)
Complete dependence
Child
9
46(36.5%)
Complete dependence
Child
10
68(53.9%)
Modified dependence
Child
11
84(66.7%)
Modified dependence
Child
12
71(56.3%)
Modified dependence
Child
13
29(23.0%)
Complete dependence
Child
14
76(60.3%)
Modified dependence
Child
15
51(40.5%)
Complete dependence
Child
16
90(71.4%)
Modified dependence
Child
17
122(96.8%)
Modified dependence
Child
18
33(26.2%)
Complete dependence
Child
19
33(26.2%)
Complete dependence
Child
20
99(78.6%)
Modified dependence
Table 4.4 Dependence distribution
Frequency
Valid Complete
Percent
10
50.0
Modified dependence
10
50.0
Total
20
100.0
dependence
Table 4.5 ToP Scores
CHILD
DESCRIPTIO
MOVEMENT
RAW
ABILITY
SCORE
MEASURE
STANDARD
DIAGNOSIS
ERROR
N
Child
1
18
50
-1
0.18

Poliomyelitis
Child
2
5
30
-2
0.22

Cerebral palsy
Child
3
18
120
1
0.18

Cerebral palsy
Child
4
14
120
1
0.18

Cerebral palsy
Child
5
8
30
-2
0.22

Seizure disorder
Child
6
6
25
-2.2
0.26

Cerebral palsy
Child
7
5
30
-2
0.22

Cerebral palsy
Child
8
5
30
-2
0.22

Cerebral palsy
Child
9
5
50
-1
0.18
Child
10
11
90
0
0.17

Seizure disorder
Child
11
21
120
1
0.18

Cerebral palsy
Child
12
14
90
0
0.17

Seizure disorder
Child
13
5
30
-2
0.22

Cerebral palsy
Child
14
16
60
0.8
0.175

Poliomyelitis
Cerebral
Child
15
9
25
-2.2
0.26

Cerebral palsy
Child
16
18
100
0.5
0.175

SCI
Child
17
35
150
2.2
0.27

Genus vagus
Child
18
5
30
-2
0.22

Seizure disorder
Child
19
5
50
-1
0.18

Cerebral palsy
Child
20
19
140
2
0.23

Seizure disorder
The movement ability was graded according to the paediatric functional independence measure.
The mean score was 12.1±7.9. the scores range from 5 to 35
Figure 4.1: Graph showing the movement ability plotted against the ToP scores
the above graph in figure 1 shows that the higher the movement ability, the higher the ToPS
score with a high R-squared value of 70.6%.
Figure 4.2: graph showing the number of children plotted against the ToP scores
There seems to be no statistically significant association between the number of children and the
ToPS score in spite of the appearance of the line of fit as the R-squared value is small (8.5%). As
shown above in the graph figure 2.
Figure 4.3: diagnosis of study participants
12
10
8
6
4
2
0
poliomyelitis
cerebral palsy
seizure disorder
Spinal cord injury
Genus vagus
The above graph figure 4.3 shows the distribution of the diagnosis of the study participants,
2(10%) were diagnosed of poliomyelitis, 11 (55%) cerebral palsy, 5 (25%) seizure disorder, 1
(5%) spinal cord injury and genus vagus 1 (5%).
Table 4.6 ToP frequency table
Frequency
Percent
Valid 25.00
2
10.0
30.00
6
30.0
50.00
3
15.0
60.00
1
5.0
90.00
2
10.0
100.00
1
5.0
120.00
3
15.0
140.00
1
5.0
150.00
1
5.0
20
100.0
Total
The above table shows the distribution of the ToP scores of study participant.
Figure 4.4: showing ToP keyform measure scores of participants
The above graph figure 4.4 shows the frequency of the measure scores of study participants
gotten from the ToP keyform
CHAPTER 5
DISSCUSSION, RECOMMENDATION AND CONCLUSION.
The aim of this study was in threefold

To evaluate the playfulness of children with physical disability using the test of
playfulness

To evaluate the factors responsible for restricting the playfulness of children with
physical disability

To appraise the suitability of the rehabilitation centres in enhancing play in children with
physical disability.
Aim a: to evaluate the playfulness of children with physical disability using the test of
playfulness
The result of the study revealed two themes which were ‘PLAYFUL and NON PLAYFUL.
Using the ToP protocol sheet alongside the ToP keyform, it was revealed that out of the 20
children who participated in the study, 11 (55%) were not playful and 9 (45% ) were playful. The
high scores received by some of the participants on the ToP suggested this were very playful
children. This children did exhibit playfulness according to the element of motivation, internal
control, freedom to suspend reality, and framing that conceptualise the construct of playfulness
in the ToP.
Motivation
This study revealed that participants demonstrated adequate motivation as they were observed to:

Be actively engaged in the play activity

Persist and repeat actions to succeed

Be exuberant

Laughing and shouting
They seemed to be motivated by the presence of familiar adults and peers and the provision of
colourful toys and play materials that added fun to their play session.
This findings has been further confirmed by the study done by Ferland (2005) on The Ludic
Model: Play, Children with Physical Disabilities and Occupational Therapy. 2nd Ed. Canadian
Association of Occupational Therapists. noted that curiosity and sense of humour were retained
in the population of children with a severe physical disability.
Internal control
The children in this study were able to initiate their own play and make free play choices, which
increased their engagement and persistence. The quality of their play however reflected
repetitive choices, imitation of peers, and they engaged in challenging behaviors.
This findings is consistent with the study of ( skar, 2002) on Disabled children's perceptions of
technical aids, assistance and peers in play situations. Scandinavian Journal of Caring Science,
16, 27-33, Again, most of the literature on the play of children with physical disabilities focuses
on the more severely disabled population, finding that the children were more dependent on
adults, restricting the children’s free play choices.
Freedom to suspend reality
It was observed in this study that, children exhibited high level of cognitive ability despite
physical impairment, which suggest that physical impairment does not affect cognitive function/
ability of the play in children with physical disability. they were able to manipulate objects and
play toys no matter how long it took them.
Framing
Participants were skilled at showing they were able to give and respond to other’s facial cues,
and were good at interacting with others in expected ways. For instance, participants were
observed to follow cues from the researcher e.g smiles, or disapproval which made them to
promptly modify or change behaviors.
Aim b: To evaluate the factors responsible for restricting the playfulness of children with
physical disability.
This study assessed some possible factors that could restrict the playfulness of individuals with
physical disability, factors such as severity of impairment, movement ability, number of children,
gender.
Severity of impairment. This study revealed that the diagnosis of the children did not have any
significant impact in the playfulness of the study participants but rather the severity of their
disability. It was observed that two children with the same diagnosis (cerebral palsy), but with
difference in the severity of their impairment tend to play or engage in play differently. The child
with a milder disability engages in play more than a child with severe disability. And this is in
consonant with the study of (Beckung & Hagberg, 2002) on Nueroimpairments, activity
limitations, and participation restrictions in children with cerebral palsy. He noted “When
examining variables that influenced play participation of children with disability, these studies
primarily focused on factors associated with the child. Studies found that level of function and
severity of impairment, rather than diagnosis, were directly related to degree of participation
restriction
Movement ability: this study shows that there is a significant relationship between playfulness
and movement ability. And it was thus observed that most of the study participants scored low in
the TOP protocol sheet which reflected a low playfulness profile on the TOP keyform. Plotting a
graph of the participants movement ability against their TOP scores revealed that the higher the
movement ability, the higher their TOP scores and therefore means that the they were playful,
and the limited the movement ability, the non playful they become.
Number of children: This study revealed that there was no statistically significant relationship
between the number of children and TOP score and thus does not affect the playfulness of the
individual with physical disability. A similar study by (Ehrmann, Aeschleman & Svanum, 1995;
Lepage, Noreau, Bernard & Fougeyrollas, 1998) noted that Factors within the family, such as
number of children did not have a strong effect on leisure participation
LIMITATION
significant limitation of this study is that many of the observations of the children with
disabilities were undertaken in special rehabilitation facilities, where there were restrictions in
the interactions with peers due to the fact that those peers also had physical disabilities, and the
structural layout of the facilities could limit some expression in play.
According to Bundy (2008 ) play observation using the TOP is to be carried out both in indoor
and outdoor settings, so the playfulness of children can be observed both in a familiar setting
without restrictions and in an outdoor setting, but this study only used the outdoor setting.
Another limitation is the relatively small sample size of 20 in relation to the total number of
persons with disability in Edo state.
SUMMARY
Twenty children with physical disability 6months – 18years participated in this study.
Various literatures were reviewed on playfulness and physical disability. The aim of this study
was in threefold
Aim 1; to evaluate the playfulness of children with physical disability using the ToP
Aim 2 : to evaluate the factors responsible for restricting the playfulness of children with
physical disability.
Aim 3 : to appraise the suitability of the rehabilitation centers in enhancing the playfulness of
children with physical disability.
The test of playfulness (ToP) was used to access the playfulness of study participants
which revealed and grouped the participants into two category “PLAYFUL and NON
PLAYFUL.” the WeeFIM scale was used to rate the severity of impairment which grouped the
participants in two “ MODIFIED DEPENDENCE and COMPLETE DEPENDENCE”. Result
from this study revealed that children with physical disability engage in play, and that severity of
impairment and movement ability are some factors observed to restrict the playfulness of
children with physical disability. Following the observations and results of this study various
recommendations has been made.
CONCLUSION
This study has contributed to the knowledge base of the playfulness in children with physical
disabilities, with the findings that cognitive, severity of impairment and movement ability
significantly influence play ability rather than the diagnosis of the child or number of children in the
home. Also, parents of children with physical disability appeared to be over protective of the
children making them not to have time for free play but always in the arms of someone. Therefore,
occupational therapists need to respond to Sturgess’s (2003) challenge to retain play as the primary
occupation of childhood, based on our confidence as a discipline in the evidence backed belief that
children learn through self-initiated, unsupervised, unrestricted time for play. This becomes even
more important for children with physical disability who have the additional overlay of parental
grief and anxiety about their child’s well being. To retain a play focus, occupational therapists need
to use their problem solving expertise to promote solutions to space and time restrictions, reduce
parental anxiety over environmental dangers and time away from learning and their ability to model
and enjoy play (Sturgess, 2003). In order to do this, we need to understand the play of children who
are our client base. This study has made a significant contribution to the knowledge base and can
be used by occupational therapists to support play skill development with the aim of maintaining
play as a primary occupational role in childhood and in children with physical disability.
RECOMMENDATION
The results of this study were based on a small sample size of 20 participants in the outpatient clinic of occupational therapy UBTH, and project charilove, both in Benin metropolis. It
is therefore recommended that future research be conducted in more cities especially in different
states and geographical areas with a larger sample size and among different categories of
physical disability.
Future research should also consider observation of playfulness of children with physical
disability in both indoor and outdoor settings, as that was one of the limitations of this research
work.
The simple materials used in this study are readily available, allowing the children to recreate
playful situations at home, it is therefore recommended that parent should recreate play situations
at home and allow their children play freely without restrictions but should remove
environmental and physical barriers that could inhibit the play behavior of their children.
Rehabilitation centers should create a barrier free environment that can allow free play and
access of individuals with physical disability including those on wheelchair.
Human resources should be increased including training and retention of rehabilitation
personnel in rehabilitation centers.
REFERENCES

Adebayo, S. (2013). Play participation among children with cerebral palsy.

Adriana Maria Rios Rincon, (2014), Playfulness in children with severe cerebral palsy
when using a robot.
 Aeri, P., & Verma, S. K. (2004). Child’s socialization through play among 2–4 year old
children. Anthropologist, 6, 279-281.

Aleysha, K. Cases (2003), childhood playfulness as a predictor of adult playfulness and
creativity.
 Bandura, A. (1989). Social cognitive theory. In R. Vasta (Ed.), Annals of child
development: Six theories of child development: Revised formulations and current issues
(Vol. 6, pp. 1–60). London, England: JAI.
 Barnett, L. A. (1990). Playfulness: Definition, design, and measurement. Play and
Culture, 3, 319–336.
 Bass, J. D., & Mulick, J. A. (2007). Social play skill enhancement of children with autism
using peers and siblings as therapists. Psychology in the Schools, 44, 727735.doi:10.1002/pits.20261
 Blanche, E. I. (2008), Play in Children with Cerebral Palsy: Doing With-Not Doing to. In
L. D. Parham and L.S. Fazio (Eds.) Play in Occupational Therapy for Children Second
Mosby Elsevier.Edition. pp375-393. St. Louis, MO
 Bowyer, P., & Cahill, S. M. (2009). Cerebral palsy. In Pediatric occupational therapy
handbook: A guide to diagnoses and evidence-based interventions (pp. 97106). St. Louis,
MO:: Mosby.
 Bundy A. (1991). Assessment of play and leisure: delineation of the problem. American
Journal of Occupational Therapy, 47:217-222
 Bundy, A. (1997) Assessment of play and playfulness: What to look for, in Parham LD,
Fazio LS, editors, play in occupational therapy for children, USA; Mosby : (pp. 52-65).
 Bundy, A. (2010) Test of playfulness (ToP) 4.2 manual revised 11/10. Lidcombe,
Australia: University of sydney.
 Bundy, A. C. (1993). Assessment of play and leisure: Delineation of the problem.
American Journal of Occupational Therapy. 47, 217-222.
 Bundy, A. C. (1997a). Play and playfulness: What to look for. In L. D. Parham & L. S.
Fazio (Eds.), Play in occupational therapy for children. St. Louis: Mosby.

Bundy, A. C., Nelson, L., Metzger, M., & Bingaman, K. (2001). Validity and reliability
of a test of playfulness. Occupational Therapy Journal of Research, 21, 276–292.
 Ferland, F. (2005). The Ludic Model: Play, Children with Physical Disabilities and
Occupational Therapy. 2nd Ed. Canadian Association of Occupational Therapists. CAOT
Publications ACE: Ottawa, Ontario. Canada.
 Glanzman, A. (2009) Cerebral palsy. In C. C. Goodman & K. S. Fuller (Eds.), Pathology:
Implications for the physical therapist (3rd ed., pp. 15171531). St. Louis, MO: Saunder
Elsevier.
 Hamm E. (2006) Playfulness and the environmental support of play in children with and
without disabilities. Occupational Therapy Journal of Research, 26(3):88-96.
 Harkness, L., & Bundy, A. C. (2001). Playfulness and children with physical disabilities.
Occupational Therapy Journal of Research, 21, 73–89.
 Hoffman, E.P., Brown, R.H., & Kunkel, L.M. (1987). Dystrophin: The protein product of
the Duchenne muscular dystrophy locus. Cell, 51, 919-928.
 Howard, L. (1996). A comparison of leisure-time activities between able-bodied children
and children with physical disabilities. British Journal of Occupational Therapy, 59, 570574.
 Hughes, F. P. (2010). Children, play, and development. Thousand Oaks, CA: Sage.
 Kirby, R. S., Wingate, M. S., Van Naarden Braun, K., Doernberg, N. S., Arneson, C. L.,
Benedict, R. E., . . . YearginAllsopp, M. (2011). Prevalence and functioning of children
with cerebral palsy in four areas of the United States in 2006: A report from the Autism
and Developmental Disabilities Monitoring Network [Abstract]. Research in
Developmental Disabilities, 32(2), 462469. doi: 10.1016/j.ridd.2010.12.042
 Knox, S. (2008). Development and current use of the Revised Knox Preschool Play
Scale. Test of playfulness. In L. D. Parham and L. S. Fazio (Eds.), Play in occupational
therapy for children (2nd ed., pp. 5570). St. Louis: Elsevier Mosby.
 Knudson, C.M., Hoffman, E.P., Kahl, S.D., Kunkel, L.M., & Campbell, K.P. (1988).
Evidence for the association of dystrophin with the transverse tubular system in skeletal
muscle. The Journal of Biological Chemistry, 263, 8480- 8484.
 Leipold, E., & Bundy, A. C. (2000). Playfulness and children with ADHD. Occupational
Therapy Journal of Research, 20, 1, 61–79.
 McCune-Nicolich, L. (1981). Toward symbolic functioning: Structure of early pretend
games and potential parallels with language. Child Development, 52, 785–797.
 Menkes, J.H. (1995). Textbook of child neurology. Baltimore, MD: Williams & Wilkins.
 Missiuna, C., & Pollock, N. (1991). Play deprivation in children with physical
disabilities: The role of the occupational therapist in preventing secondary disability.
American Journal of Occupational Therapy, 45(10), 882–888.
doi:10.5014/ajot.45.10.882
 Morrison, C. D., Bundy, A. C., & Fisher, A. G. (1991). The contribution of motor skills
and playfulness to the play performance of preschoolers. American Journal of
Occupational. Therapy, 45(8), 687694. doi:10.5014/ajot.45.8.687
 Muys, V., Rodger, S., & Bundy, A. C. (2006). Assessment of playfulness in children with
autistic disorder: A comparison of the Children’s playfulness scale and the test of
playfulness. Occupational Therapy Journal of Research, 26, 159-170.
 Okimoto, A. M, Bundy, A. and Hanzlik, J. (1991). Playfulness in children with and
without disability: Measurement and intervention (pp. 73-82).
 Okimoto, A. M., Bundy, A., & Hanzlik, J. (2000). Playfulness in children with and
without disability: Measurement and intervention. American Journal of Occupational
Therapy, 54, 73–82.
 Parham, D. (2008). Play and occupational therapy. In D. Parham & L. Fazio (Eds.), Play
in occupational therapy for children (pp. 3-39). St. Louis, MO: Mosby.
 Pierce, D., Munier, V., & Myers, C. T. (2009). Informing early intervention through an
occupational science description of infant-toddler interactions with home space.
American Journal of Occupational Therapy, 63, 273-287.
 Power, T. G. (2000). Play and exploration in children and animals. Hillsdale, NJ:
Erlbaum.
 Reed, C. N., Dunbar, S. B., & Bundy, A. C. (2000). The effects of inclusive
programming on the playfulness of preschoolers with and without autism. Physical and
Occupational Therapy in Pediatrics, 19, 73–91.
 Reid, D. (2004). The influence of virtual reality on playfulness in children with cerebral
palsy: A pilot study. Occupational Therapy International, 11(3), 131–144..
 Reilly, M. (1974). Play as exploratory learning: Studies in curiosity behavior. Beverly
Hills, CA: Sage.
 Rigby, P., & Gaik, S. (2007). Stability of playfulness across environmental settings: A
pilot study. Physical and Occupational Therapy in Pediatrics, 27, 27–43.
 Rogers, S. L., Gordon, C. Y., Schanzenbacher, K. E., & Case- Smith, J. (2001). Common
diagnosis in pediatric occupational therapy practice. In J. Case-Smith (Ed.), Occupational
therapy for children (4th ed., pp. 136–187). St. Louis, MO: Mosby–Year Book.

Sarah, E. Fabrizi, (2014), Measuring the playfulness of children with special needs in
occupational therapist LED, caregiver- included community playgroups.
 Scheuerbrandt, G., Lundin, A., Lövgren, T., & Mortier, W. (1986). Screening for
Duchenne muscular dystrophy: An improved screening test for creatine kinas and its
application in an infant screening program. Muscle & Nerve, 9, 11-23.
 Skar, L. (2002). Disabled children's perceptions of technical aids, assistance and peers in
play situations. Scandinavian Journal of Caring Science, 16, 27-33
 Skard, G., & Bundy, A. C. (2008). Test of playfulness. In L. D. Parham & L. S. Fazio
(Eds.), Play in occupational therapy for children (2nd ed., pp.7194). St. Louis, MO:
Elsevier Mosby.
 Smith, S.A., & Swaiman, K.F. (1999). Muscular dystrophies. In K.F. Swaiman & S.
Ashwal (Eds.), Pediatric neurology: Principles & practice, volume 1(1235-1256). St.
Louis, MO: Mosby.
 Stagnitti, K. (2004). Understanding play, implications for play assessment. Australian
Occupational Therapy Journal, 51, 3-12.
 Strain, P. S. (1981). Modification of sociometric status and social interaction with
mainstreamed developmentally disabled children. Analysis and Intervention in
Developmental Disabilities, 1, 157-169. doi:10.1016/0270-4684(81)90029-X
 Strain, P. S., & Danko, C. D. (1995). Caregivers’ encouragement of positive interaction
between preschoolers with autism and their siblings. Journal of Emotional and
Behavioral Disorders, 3, 2-12. doi:10.1177/106342669500300101
 Sturgess, J. (2003). A model describing play as a child chosen activity–is this still valid in
contemporary Australia? Australian Occupational Therapy Journal, 50, 104-108.
 Tyler, R. G. (1996). Girls, boys and a top: Gender/environmental differences and a Test
of Playfulness: Research version 2 (Master’s thesis). Retrieved from
http://www.worldcat.org/title/girls-boys-and-a-top-genderenvironmentaldifferences anda-test-of-playfulness-research-version-2/oclc/37723985
 van Essen, A.J., Busch, H.F., te Meerman, G.J., & ten Kate, L.P. (1992). Birth and
population prevalence of Duchenne muscular dystrophy in The Netherlands. Human
Genetics, 88, 258-266.
 Yang, T., Wolfberg, P. J., Wu, S., & Hwu, P. (2003). Supporting children on the autism
spectrum in peer play at home and school: Piloting the integrated play groups model in
Taiwan. Autism, 7, 437-453. doi:10.1177/1362361303007
Appendix A
Informed consent forms
CONSENT LETTER TO PROJECT CHARILOVE REHABILITATION CENTER
Occupational Therapy Department
University of Benin Teaching Hospital
Benin City
Edo State
27th May, 2016
The Director Project Charilove
Benin City
Edo State
Thro :
HOD, Occupational Therapy Department
University of Benin Teaching Hospital
Benin City.
Dear sir/ma,
PERMISSION TO CARRY OUT MY PROJECT AT PROJECT CHARILOVE
I humbly seek your permission to collect data for my project in your organization. I am a final
year student of occupational Therapy at the Institute of Health Technology, University of Benin
Teaching Hospital Benin City. In the course of my clinical posting, I observed some challenges
in the functional performance of the pupils which I believe can be ameliorated, if given more
time to observe and understand the challenges. Therefore I wish to carry out a research on the
TOPIC: THE TEST OF PLAYFULNESS AMONG CHILDREN WITH PHYSICAL
DISABILITY IN NIGERIA, (a case study of institutional based and community based
rehabilitation centers in Benin metropolis). The objective of the study is to have an in-depth
understanding of their challenges with a view of evolving strategies to overcome them.
I anticipate your favorable consideration.
Thank you.
Yours faithfully
Amadi Promise
CONSENT LETTER TO PARENTS
This check list is intended for the purpose of gathering information for a
research on the play pattern of children with physical disability.
The overall objective of the research is to have a better understanding of
the playfulness/challenges with play experienced by children with
physical disabilities with the view of helping them to overcome such.
Therefore your participation in this study will highly be appreciated as
all the information gathered will be treated with utmost confidentiality.
DECLARATION
I have understood the purpose of your study and hereby give my consent to
participate in you dissertation work.
______________________________
Name of patient
____________________________________
Name/signature of guardian
Appendix B
ToP DEFINITIONS
Definition of ToP items
ITEMS
DESCRIPTION
Is actively engaged
Extent: Proportion of time the child is involved in
activities rather than aimless wandering or other non
focused activity or temper tantrums.
Intensity: Degree to which the child is concentrating on
the activity or playmates.
Skill: Child's ability to stay focused on activity.
Decides what to do.
Extent: Proportion of time during which the child
actively chooses to do what she is doing. Activity does
not have to be purposeful and purposeful activity does
not have to be the child's idea.
Maintains level of safety sufficient to play
Extent: Proportion of time during which the child feels
safe enough to continue to play. If necessary child may
alter environment.
Tries to overcome barriers or obstacles to
Intensity: Degree to which the child perseveres in order
persist with an activity
to overcome obstacles to continuing the activity.
Modifies activity to maintain challenge or
Skill: Ease with which the child actively changes
make it more fun
requirements/ complexity of the task in order to vary
the challenge or degree of novelty
Engages in playful mischief or teasing
Extent: Proportion of time during which the child is
involved in teasing or razzing or minor infractions of
the rules. Neither mischief nor teasing is done out of a
spirit of meanness.
Skill: The adeptness with which the child creates/
carries out the mischief or teasing.
Engages in activity for the sheer pleasure
Extent: Proportion of time during which the child
(process) rather than primarily for the
seems want to do the activity simply because he or she
outcome.
enjoys it than primarily for the outcome. rather than to
attain a particular outcome
Pretends
Extent: Proportion of time during which there are overt
indicators the child is assuming different character
roles, pretending to be doing something, pretending
something is happening that is not, or pretending an
object or person is something other than what it
actually is.
Skill: The degree to which the performance is
convincing
Incorporates objects or other people into play
Extent: Proportion of time during which the child (a)
in unconventional or variable and creative
uses people into play in novel, objects commonly
ways.
thought of as toys in ways other than imaginative,
unconventional, those the manufacturer clearly
intended, (b) incorporates objects not classically
thought of as toys into the play (e.g., bugs, jars, cans,
table legs), or (c) uses one toy or object in a number of
different ways.
Negotiates with others to have needs/desires
Skill: Ease and finesse with which the child verbally or
met.
nonverbally asks for what he or she needs.
Engage in social play
Extent: Proportion of time during which the child
interacts with others involved in the same or similar
activity.
Skill: The level of social play.
Supports play of others
Skill: Ease with which child supports play of others
(encouragement, scaffolding)
Enters a group already engaged in an activity
Skill: Ease with which the child does something to
become part of a group already engaged in an activity;
the action is not disruptive to what is going on.
Initiates play with others
Skill: Ease with which the child initiates a new activity.
Clowns and jokes
Extent: Proportion of time during which the child tells
jokes or funny stories or engages in exaggerated,
swaggering behavior (usually for the purpose of
gaining others' attention) .
Shares (toys, equipment, friends, ideas)
Extent: Proportion of time during which the child
allows others to play with toys, personal belongings, or
playmates or on equipment the child is currently using
or shares ideas.
Gives clear understandable cues (facial and
Extent: Proportion of time during which the child acts
body) that say, "This is how you should act
in a way to give out clear messages about how others
toward me.
should interact with him or her.
Responds to others' cues in a way that furthers
Extent: Proportion of time during which the child acts
play.
in accord with others' play cues and the response
results in play.
Demonstrate positive affect during play
Intensity: degree to which player’s affect is positive;
ranges from mild enjoyment to real exuberance.
Interacts with objects
Intensity: the degree to which players get involved with
objects .
Skill: the ease with which players interact with objects.
Transitions from one play activity to another
Skill: the ease with which players move from activity
with ease
to activity when has ended or is evolving and another is
available
Anita Bundy, ScD, OTR, FAOTA
Department of Occupational Therapy
Colorado State University
OT Building
Ft. Collins, CO 80523
Appendix C
ToP protocol sheet
Test of playfulness (ToP) (version 4.0-5/05)
EXTENT
INTENSITY
SKILLFULLNESS
Child (#): ___________________
3
?
Almost always
3
?
Highly
3
?
Highly skilled
Age: ______________
2
?
Much of the time
2
?
Moderately
2
?
Moderately skilled
Rater:
1
?
Some of the time
1 ? Mildly
1
?
Slightly skilled
In out video life (circle)
0
?
Rarely or never
0 ? Not
0
?
Unskilled
NA
NA
NA ? Not applicable
ITEM
EXT
Is actively engaged
Decides what to do
Maintains level of safety, sufficient to play
Tries to overcome barriers or obstacles to
persist with an activity
Modifies activity to maintain challenge or
make it more fun
Engages in playful mischief or teasing
Engages in activity for the sheer pleasure
of it (process) rather than primarily for the
end product
Pretends (to be someone else, to do
something else, that an object is something,
that something else is happening).
Incorporates objects or other people into
play in unconventional or variable and
creative ways
Negotiates with others to have
needs/desires met.
Engage in social play
Supports play of others
Enters a group already engaged in an
activity
Initiates play with others
Clowns or jokes
Shares (toys, equipment, friends, ideas )
Gives readily understandable cues (facial,
INT
?
Not applicable
SKILL
?
Not applicable
COMMENTS
verbal, body) that say. “this is how you
should act toward me”.
Responds to others’ cues
Demonstrates positive affect during play
Interacts with objects
Transitions from one play activity to
another with ease.
Appendix D
ToP keyform
Appendix E