Play is defined by the American Occupational Therapy Association (2017) as “any spontaneous or organized activity that provides enjoyment, entertainment, amusement, or diversion” (p. S21). Play is considered a primary occupation of childhood that is essential for development. Through play, children learn to adapt to their environments and ultimately to develop skills for future social, educational, and work settings (Case-Smith & O'Brien, 2015).
The quality of play participation has been operationalized by several authors. The variations of definitions depend on the play collaborators, the context, and the environment in which the play activity occurs. Knox (1997) defined play participation as the amount and manner of interaction with a caregiver in the environment and the degree of independence and cooperation of the child during those play activities. In contrast, Parham and Fazio (2008) defined play participation as the active sharing of a social exchange or an event with others. A variety of attributes and information about a child may be gathered through structured observation of a child in unstructured play (Knox, 1997; Parham & Fazio, 2008; Piaget, 1962). According to Knox (1997), the way that children play shows a range of characteristics that relate to overall childhood development and maturation. This range of attributes includes physical and cognitive abilities, social participation, imagination and creativity, independence and autonomy, and coping mechanisms. These attributes can also demonstrate children's understanding of their roles as well as the roles of their adult counterparts (Knox, 1997). Therefore, play provides a developmental opportunity to practice cognitive and social skills that represent the more stringent demands that will be made later in the child's life (Craighead & Nemeroff, 2010).
Types of Play
The occupational therapy literature includes numerous interpretations of play, but play can be divided into the basic categories of exploratory, constructive, and symbolic (Case-Smith, 2005; Case-Smith & O'Brien, 2010; Knox, 1997).
Exploratory play is first expressed as reflexes, as the child reacts to environmental stimuli (Case-Smith, 2005). This exploration progresses to the use of sensory motor skills, such as poking, prodding, or vocalizations to investigate the environment or cause a reactionary change (Carlisle, 2009; Case-Smith, 2005). Exploratory play supports a child's development by providing rich experiences via sensory stimuli and feedback (Case-Smith & O'Brien, 2015). As children interact with the physical environment, they develop a better understanding of their own senses, the properties and meaning of objects, and their reactions or responses to stimuli (Case-Smith & O'Brien, 2015; Knox, 1997). Exploratory play can also promote motor development through the child's desire to move around to inspect the environment.
Through exploration, the child may begin to create constructions by simply combining objects, such as putting a lid on a snack container or stacking blocks (Case-Smith, 2005; Knox, 1997). Constructive play provides the opportunity for both cognitive and motor development. Children develop problem-solving, sequencing, and decision-making skills as they create, replicate, or test new ideas. Constructive play develops motor skills through an inherent feedback reward for accurate execution of gross and fine motor skills, such as when a child successfully makes a stack of blocks or throws a ball (Case-Smith & O'Brien, 2010; Knox, 1997). Construction can become more complicated as a child builds a Lego house or creates a painting.
The final and most advanced category of play is symbolic, which can involve fantasy play, shared play, or role-play (Carlisle, 2009; Case-Smith & O'Brien, 2015). Examples include dressing a doll and having a tea party. Symbolic play further refines cognitive skills as the child develops an understanding of abstract concepts. Symbolic play begins as replication and imitation and evolves in complexity as the child develops a unique understanding and interpretation of the environment (Knox, 1997). Symbolic play develops social interaction skills as the child uses a verbal dialogue for role-playing characters or interacts with another individual in shared play. Depending on the context, symbolic play also provides opportunities for the child to refine motor skills, such as coordination, fine motor or in-hand manipulation, and ambulation (Knox, 1997).
Purposes of Play
All types of play allow children to develop, practice, and refine skills within a context that is less structured and more enjoyable. Because there is no defined expectation in early play, a child is free to focus on the process of play rather than a specific outcome. Through curiosity and experimentation, children develop cognitive skills associated with processing information, problem solving, and ideation of an action and/or motion (Case-Smith & O'Brien, 2015). Children develop motor skills as they practice repetitive movements or as they are motivated by a goal or by intrinsic curiosity to try new movements, such as pulling up onto a couch to reach a toy. They also develop social skills through shared play experiences as they interact with caregivers or play partners (Case-Smith & O'Brien, 2015; Craighead & Nemeroff, 2010).
Play may provide more than just a vehicle for childhood development. Gray (2011) articulated that the decline with the contexts to play in and the opportunities to play (e.g., home, academic settings, physical play spaces, community-based activities) may be correlated to an increase in psychopathology among children and adolescents. Gray identified an increase in anxiety, depression, and narcissism as well as a decrease in the sense of personal control across multiple cohorts of children over the past 40 years. Gray further noted that play supports children's ability to develop interests and competencies and to learn how to solve problems, follow rules, regulate emotions, make friends as equals, and experience basic joy. Developing these skills may provide protective factors against psychopathology in childhood and adulthood (Gray, 2011).
Measurement of Play Behavior and Performance
“Children are designed, by natural selection, to play,” according to Gray (2011, p. 443). With that foundation in mind, occupational therapy practitioners and scientists are interested in play because it is the primary occupation for children. Play is how children learn about their world and develop specific fundamental skill sets. Play encourages curiosity, innovation, and experimentation (Case-Smith & O'Brien, 2010). Activities in play are slightly new or different each time they are performed, encouraging adaptation and transfer of skills (Case-Smith, 2005).
Assessments evaluating play patterns and behaviors have been developed and implemented in occupational therapy practice. These assessments include the Test of Playfulness (Bundy, Nelson, Metzger, & Bingaman, 2001), Revised Knox Play Scale (Knox, 1997), and Play History (Takata, 1974). Each tool has a specific focus and method for assessing play.
The Test of Playfulness assesses a child's intrinsic motivation, internal locus of control, freedom to suspend reality, and framing (i.e., how the child maintains the play scenario and understands social cues within the play context). These categories are assessed through observation and rating of the child's extent, intensity, and skillfulness of play (Bundy et al., 2001; Stagnitti, 2004).
The Revised Knox Play Scale assesses several categories of play, including gross motor skills, exploration, manipulation, construction, imitation, imagination, dramatization, territory, interest, purpose, attention, cooperation, and language. These categories are assessed through observing the child's space management, material management, imitation, and participation. The assessment provides qualitative information about play and generates a play age (Knox, 1997; Stagnitti, 2004).
Finally, the Play History (Takata, 1974) assesses the child's play experiences through a semistructured interview with the care provider. This evaluation investigates forms of play, including sensorimotor, symbolic and simple constructive, dramatic and complex constructive, and pre-game, game, and recreational. These features of materials, action, people, and setting are evaluated through the interview with the care provider (Stagnitti, 2004; Takata, 1974).
Although all of these are valid and reliable assessment tools to support the understanding of play in contextual environments, they do not assess how much time infants and toddlers engage in play or the frequency of their play activities. It is currently unknown how much time children spend engaging in different types of play at different stages of development. This information can help clinicians to understand how play develops and changes over time. The goal of this retrospective pilot study was to document how children's play participation changes over the ages of 8 to 16 months through quantifying changes in the frequency and duration of the use of play objects, play purpose, play type, and play construction.
How does the play participation of infants and toddlers change over the time span of 8 to 16 months of age? Specific considerations include:
What is the frequency of play participation as observed through videorecorded interactions between a caregiver and their infant or toddler at 8 months, 12 months, and 16 months of age?
What is the duration of play participation as observed through videorecorded interactions between the caregiver and the infant or toddler at 8 months, 12 months, and 16 months of age?
The study used a retrospective longitudinal cohort design (Portney & Watkins, 2015). Videorecorded interactions of a cohort of 16 infants and their caregivers were reviewed retrospectively across three points in time when the infants were 8, 12, and 16 months of age.
The observational data originally came from a cohort of 16 parent/infant dyads who participated in a longitudinal research study from 6 to 18 months of age. Inclusion criteria consisted of (a) caregivers who had no significant history of prenatal or perinatal problems; (b) infants who were not at risk for developmental disorders; (c) families who primarily spoke English in the home; (d) families who were able to travel to the study facility monthly; and (e) families who did not expect to move from the area within 2 years of enrollment.
All families had a reported yearly income of $50,000 to $100,000. Of the 16 infant participants, 7 were boys and 9 were girls. One girl was African American, one boy was Asian American (father of East Indian descent and mother of Vietnamese and Hawaiian descent), and one boy was Palestinian.
The children and caregivers came to the Infant Vocal Development Laboratory at Eastern Carolina University at 8, 12, and 16 months of age. Caregivers in each dyad were instructed to play and interact with their infants for 1 hour as they would typically do in a home setting. To facilitate natural interaction, the laboratory environment was designed to simulate a home environment, including stuffed animals, toys, and manipulatives. Interactions were video- and audiorecorded for the 60-minute session, and the middle 20 minutes were analyzed. For the current project, we explored data from infants and toddlers at 8, 12, and 16 months of age, which yielded 48 recordings that were each 20 minutes long. These videos were viewed and coded by three independent coders.
The play participation coding scheme was developed through a literature review that explored play participation of infants and toddlers (Case-Smith, 2005; Knox, 1997; Muys, Rodger, & Bundy, 2006; Parham & Fazio, 2008; Stagnitti, 2007). The coding scheme consisted of the following primary categories: play object choice, play purpose, play type, and play construction (Table 1) (Table A, available in the online version of the article). The primary play categories were operationally defined as follows. Play object choice was the exploration (i.e., visual, auditory, gustatory, tactile inspection) of non-human objects or toys. Play purpose was articulated as the intended outcome of play interactions between the caregiver and the child (Parham & Fazio, 2008). Play type was defined as voluntary activities in which the infants and toddlers interacted with objects or toys that were under their control (Knox, 1997; Parham & Fazio, 2008). Finally, play construction was defined as the use of an object by the infant or toddler, with little attempt to make a product through stacking, taking apart, putting together, or relating objects (Knox, 1997; Parham & Fazio, 2008). The coding scheme was further adjusted and clarified after a sample videorecording was reviewed and a sample coding was performed.
Coding Scheme for Play Pattern
Coding Scheme Description
Datavyu (Datavyu Team, 2014) is an open source research tool that uses a spreadsheet to record observations (i.e., coding scheme/behavior). Codes were entered into cells, and cells were created for each observation at the start and stop time of the behaviors. For this project, the frequency and duration of play participation behaviors (for the infants and toddlers), as defined in the coding scheme, were coded and later quantified.
Three raters (the primary investigator and two graduate research assistants in the master of occupational therapy program at Idaho State University) were trained in the use of Datavyu (Datavyu Team, 2014) software, and each rater participated in multiple training sessions. After the raters completed the training sessions, they performed coding of the play participation data set. Intrarater reliability was 0.90, and interrater reliability was 0.87. As previously stated, the middle 20 minutes of each video were coded for each case at three different sessions (at 8, 12, and 16 months of age). Approximately 45 to 60 minutes was needed to code each 20-minute video, totaling 36 to 48 hours of coding play participation data for one rater. The raters coded all four categories of play for each of the 16 participants.
Data were exported from Datavyu, transformed, and analyzed with Microsoft Excel (2013). Descriptive statistics were calculated for observed frequency and duration of visual and fine motor patterns. For the purpose of this pilot study, statistical analysis consisted of calculating the mean and standard deviation for frequency and duration of the 16 subjects for the coded patterns at each of the three age levels. These patterns were displayed as histograms to provide a visual representation for analysis.
The medical center institutional review board at Eastern Carolina University approved the study, and the human subjects committee at Idaho State University provided exemption. All participants provided written informed consent.
Results and Discussion
Play Object Choice
As seen in Table 2, there was a notable increase in the average time spent exploring nonhuman objects and/or toys as the cohort of infants and toddlers reached 16 months of age. Notably, a decrease was seen in the frequency and duration of play object choice at 12 months compared with 8 months, with a subsequent increase between 12 and 16 months. This difference in means for frequency and duration at 12 months may be attributed to increased focus or proficiency in mobility with creeping to crawling (speed and coordination) and participation with ambulatory skills across the sample of toddlers. Overall, the increase in the duration of behaviors categorized in choice of play object may foundationally be a result of the development of tactile discrimination, fine motor skills, and precision; foundational praxis skills; and increased gross motor mobility (Carlisle, 2009; Knox, 1997; Piaget, 1962). The increase in the duration of behaviors observed between 12 and 16 months of age may also be the result of increased cognitive schemas, engagement in cause and effect, and a general increase in attention span (Case-Smith & O'Brien, 2010; Knox, 1997). Typically, at 8 months, infants can retain two toys and reach for a third. By 12 months, an infant may make specific detours to retrieve a toy and can retrieve toys from a different room by 16 months (Furuno, O'Reilly, Hoska, Zeisloft, & Allman, 2004). As they mature, infants begin exploring and identifying different objects as toys. At 8 to 10 months, children begin to show more sophisticated thinking by searching for objects that have been hidden (Dimitrova & Moro, 2013).
Descriptive Statistics for Play Object Choice
This pilot study operationalized the category of play purpose patterns as the intended outcome of play interactions between the caregiver and the child (Parham & Fazio, 2008). A limited difference in the average frequency of behaviors related to play purpose was seen across the cohort's age points (Table 3). However, a difference was seen in the duration of behaviors for this category between 8 and 12 months.
Descriptive Statistics for Play Purpose
Between 8 and 12 months, the average duration of this category almost doubled from 33 seconds per episode to more than 1 minute. This observed increased duration may be attributed to development of the fine and gross motor voluntary movements needed to respond to stimulation and communication from a caregiver (Piaget, 1962).
For the purpose of this pilot study, the play type category was operationalized as voluntary activities in which the children interacted with objects or toys that were under their control (Knox, 1997; Parham & Fazio, 2008). A gradual decrease in the average duration of behaviors in this category was noted across all three age points (Table 4). The frequency of the behaviors was similar across the age points. The decreased duration may be attributed to the developed mobility from creeping to crawling to standing and walking, which made the infants and toddlers more efficient when moving around in the study space and enabled them to seek, obtain, and play with a greater variety of toys, objects, and furniture (Carlisle, 2009; Knox, 1997). Additionally, following a typical developmental trajectory, the infants and toddlers showed an increase in communication, conceptualization, and ideation that could result in more time spent executing more complex motor plans as a part of play (Papalia, Olds, & Feldman, 2007).
Descriptive Statistics for Play Type
The category of play construction behavioral patterns was operationalized as the use of objects in an attempt to make a product through stacking, taking apart, putting together, or relating objects (Knox, 1997; Parham & Fazio, 2008). The average frequency of behaviors in this category gradually increased across the three age points. A significant increase in the duration of play construction behaviors occurred, with almost double the average duration between 12 and 16 months (Table 5). These findings are similar to those for the play object choice category. Specifically, engagement in play construction may be attributed to the increased development of sensory discrimination, fine and visual motor skills, praxis, attention span, and gross motor skills, coupled with independence in ambulation to obtain and engage with more interesting toys (Case-Smith & O'Brien, 2010; Knox, 1997; Piaget, 1962).
Descriptive Statistics for Play Construction
Implications for Clinical Practice
The findings of this pilot study established a first attempt to evaluate play patterns across an 8-month period in a cohort of 16 infants and toddlers at three distinct age points. As previously stated, the behavioral patterns of play observed in this study can be directly related to the development of cognition, communication, and sensorimotor and gross motor skills that occurred as the children matured. The method of observing infants and toddlers play during a 20-minute free play session created an opportunity to quantify the frequency and duration of play patterns as the children matured. This pragmatic approach to evaluating play among typical or at-risk children may add additional insight, especially when paired with other current developmental screening and standardized norm-referenced assessments. Although more research is needed to better capture the temporal aspects of play patterns in infants and toddlers, there are some pragmatic recommendations that relate directly to clinical practice.
The process of developing and implementing an observational coding scheme to better observe how play emerges and changes over time yielded anecdotal implications that are valuable for pediatric occupational therapy practice.
Observing play in a structured fashion in as little as 20-minute sessions may help to capture the development of the contributing domains of development (e.g., sensorimotor, communication, cognition) that make up the core occupation of play in infants and toddlers.
Routine observation of typically developing infants and toddlers and how play evolves over time will help occupational therapy professionals to include play within intervention plans, parental coaching sessions, and home programs.
Parent and caregiver training should include a discussion that, based on the age of the child, different toys, objects, and environmental adaptations may be needed to accommodate higher levels or diversity of play skills (e.g., transition from sensory motor play to imitation and dramatized play).
Several limitations may be noted in the design and implementation of this pilot cohort study. During the original data collection, research technicians in the room may have initiated stimuli or opportunities that may have generated inconsistent responses. Some of the observation sessions included different caregivers (e.g., mother, father, grandmother, aunt, older sibling) in the room, altering the consistency of a single caregiver across each observation and case. The data were retrospective, and the initial goal of data collection was not to capture play participation. In addition, the coding scheme did not account for some behavioral variances of the infants and caregivers.
Collaboration and communication with research peers for validation was necessary in this pilot study. Because not all components of the coding scheme were objective, some subjectivity occurred with coding. Value was not placed in the context or function of the behavior, but rather in the behavior itself. Each child had unique characteristics that were not evaluated for client-centered practice. In addition, the study did not address parenting style or the child's response to that style. The study did not examine the tendency of the infants and toddlers to gravitate toward certain toys at certain age points. Although the controlled study space attempted to mimic a natural play environment, the controlled space may have had a strong influence on the observed behaviors. Finally, the demographics of the cohort were very homogeneous, which prevents speculation as to how socioeconomic status, race, or ethnicity may affect the frequency and duration of play among infants and toddlers.
Future research is needed to build on the findings of this study by observing behaviors within a daycare environment, with the presence of other children (e.g., siblings or age-matched peers), and with infants and toddlers who were born prematurely. Expanding the age range for observations is also warranted.
The primary occupation of children is play. To support children and their occupations, pediatric occupational therapy professionals must develop an understanding of typical play as a foundation for treatment. This study provides a snapshot of play participation. This understanding allows occupational therapists to develop a baseline of typical child play development that may aid in the identification of developmental delays or limitations. The findings confirmed that as infants and toddlers mature and develop, their engagement in behaviors that constitute play occupations also develops. Developmental skills are necessary for play participation and reciprocal interactions. Yet, without play, these children may experience barriers in maturation and the development of skills that encompass play. Current literature identifies developmental benchmarks for age-appropriate behaviors and skills. This study begins the dialogue to consider identifying changes in play participation as another indicator and measure of age-appropriate behaviors and skills.
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Coding Scheme for Play Pattern
|Play type||Play construction||Play purpose||Play object choice|
|Sensory motor (sm)||Combines (com)||Cause/effect (ca/ef)||Searches/locates (se/lo)|
|Dramatization (d)||Places (pl)||Relational play (rp)||Selects/chooses (se/ch)|
|Imitation (i)||Stacks (st)||Trial/error (tr/er)||Restores (re)|
|Transition of object (too)||Communication (co)|
|Takes apart toys or objects (tato)|
Descriptive Statistics for Play Object Choice
Descriptive Statistics for Play Purpose
Descriptive Statistics for Play Type
Descriptive Statistics for Play Construction
Coding Scheme Description
|Play type: voluntary activities in which children often interact with objects or toys that are under their control (Parham & Fazio, 2008; Knox, 1997).
imitation (i): Imitates observed actions, emotions, sounds, and gestures not part of repertoire, patterns of familiar activities. Imitates simple actions, present events and adults, novel movements, imitates simple schemas (i.e. puts person in car and pushes it) dramatization (d): Beginning with pretend using self (i.e. feeds self with spoon), pretend on animate and inanimate objects w/o a direct model.
sensory motor (sm): Exploration of sensation and movements that involve physical objects (may be human or nonhuman), may or may not involve manipulating and relating actual or symbolic objects, involves physical interactions with the environment, is not limited to physical objects, involves a greater use of space, actions are done purely for the pleasure or feeling of.|
|Play construction: Using objects with little attempt to make a product through stacking, taking apart, putting together, and relating objects (Parham & Fazio, 2008; Knox, 1997).
combines (com): Combines related objects (i.e. touching or banging two blocks together), relates two objects appropriately (i.e. lid on pot)
places (pl):putting objects into a container, or placing objects together (i.e. placing rings on a pole)
stacks(st): places objects one on top of the other
transition of object (too): focusing or moving to another toy or object
Takes apart toys or objects (tato): deconstruction of toys or assembled toy creations
Play purpose: Intended outcome of play interactions (Parham & Fazio, 2008).
cause/effect(ca/ef): a basic action to produce effect
relational play (rp): combining (see above definition), placing, taking apart, stacking, sorting, or deconstructing objects.
trial/error (tr/er): using different approaches of doing something to determine a successful method to explore and solve a problem (more advanced cause/effect)
communication (co): using play to communicate needs, wants, emotions, feelings, and for the purposes of social interaction with others
Play Object Choice: Exploration (visual, auditory, gustatory, tactile inspection) of nonhuman objects or toys.
searches/locates (se/lo): looks for and finds toys or objects
selects/chooses (se/ch): selects, prefers, or chooses primary object or toy from multiple choices
restores(re): puts away toys or objects in appropriate places|