Play therapy for children with physical disabilities
Karla D. Carmichael
Play therapy allows children with physical disabilities to discover what they can do and who they are. This paper focuses on person-centered play therapy for children with physical disabilities. The suggestions are included for the rehabilitation counselor who may wish to work with children or who may need clarification for referral purposes.
While rehabilitation counselors usually work with adult clients, some rehabilitation counselors may have an interest in working with children or may be called upon to make referrals to a child therapist. Familiarity with play therapy for children with physical disabilities may become an important tool for rehabilitation counselors who work with children.
Play therapy, the use of toys and creative arts in therapy, is a technique that can be readily adapted to accommodate children with physical disabilities. No reason exists to believe that play therapy cannot be applied to children with disabilities. Nevertheless, the counselor would be naive to use play therapy without adaptation of special needs and characteristics of children with disabilities (Li, 1983).
Emotional Needs of Children with Disabilities
Williams and Lair (1991) have stated that lack of mobility, over-protective parental attitudes, preoccupation with treatment, authoritarian treatment climate, limited personal responsibility, and lack of decision-making experiences often result in children with disabilities perceiving themselves as less than competent. Children with disabilities may extend their perceptions of physical limitations beyond those imposed by the disability. Because these children have less control over their lives, they may not develop self-confidence (Williams & Lair, 1991). Play therapy provides opportunities for children with physical disabilities to gain self-confidence, to take advantage of their abilities, and to accept and overcome the limitations associated with their disabilities.
Feelings of inadequacy and rejection by others are among the greatest challenges faced by children with disabilities (Li, 1983). These feelings of inadequacy and rejection come from sources external to the children. Williams & Lair (1991) suggested that because children with disabilities cannot engage in all activities in which their age mates participate, they may be perceived as incompetent, helpless, unproductive, and dependent. Children who are considered different or unattractive may be avoided and considered to be less deserving and less desirable than their age mates without disabilities (Williams & Lair, 1991). Williams and Lair (1991) indicate that counselor acceptance of children with disabilities leads these special children toward self-acceptance.
Lack of self-acceptance and feelings of inadequacy are minimized by providing children with disabilities with a warm and supportive environment (Williams & Lair, 1991). The accepting environment provides an insulator against the rejection that the child may experience. One method to accomplish a warm, supportive and accepting environment is through person-centered play therapy.
Person-Centered Play Therapy
Person-centered play has been described by Landreth (1991) “as a dynamic interpersonal relationship between a child and a therapist…who provides selected play materials and facilitates the development of a safe relationship for the child to fully express and explore self…”. Person-centered play therapy does not have specific activities for the child. The child spontaneously plays with a selection of toys representing household objects, transportation, wild and domestic animals, aggression toys, doll family, community helper dolls, puppets, creative art supplies, and throwing toys. The therapist provides the core conditions of empathy, warmth and genuine respect for the child. The therapist reflects the feelings expressed by the child’s spontaneous, free play. The therapist is careful not to make judgmental statements about the child or the child executed products. For example, when the child shows the counselor an art project, the counselor would not comment on the quality of the work, but rather reflect and explore the child’s feelings about its production. The therapist does not actively play with the child, but rather participates as an observer, encourager, and reflector of feelings (Axline, 1948; Landreth, 1991).
The person-centered approach is focused on the child’s growth and development and his/her ability to know what is best for himself or herself. According to Williams & Lair (1991), lack of comparison to others makes person-centered play therapy an appropriate method for working with disabled clients. Person-centered theory provides a framework for empowering the individual to seek the highest level of ability possible (Axline, 1948; Landreth, 1991; Williams & Lair, 1991). The primary goal of person-centered play therapy is to encourage independence and integration of the child’s growing personality. Through the growth process, the child develops the confidence to cope with life’s challenges (Corey, 1991).
Procedural Accommodations and Adaptations
Salomon (1983) suggested that procedural adaptations may be necessary in person-centered play therapy for children with disabilities. Traditional play therapy described by Axline (1948), Ginott (1961), and Moustakas (1959) does not include parents or a treatment team. Inclusion of a treatment team leads to the first adaptation and modification in the procedure, Procedural modification has two suggested elements: interdisciplinary team and family support. The interdisciplinary team consists of all the persons providing services to the child (Salomon, 1983; Landreth, Jacquot, & Allen, 1969). Information from the team will help the play therapist to provide reasonable accommodations and expectations for the child. The interdisciplinary team can provide the therapist with comments on the effectiveness of the intervention and its transfer to other settings. In exchange, the therapist can provide information that will improve the client’s interaction with other team members. The liberty to express fear, anger, and grief in play therapy may make it easier for the child to contend with disabilities while receiving services in other settings.
The second procedural modification concerns support of the parents (Salomon, 1983), According to Salomon (1983), the family’s need for support and information far exceeds that of the family of a child without disabilities. Parental support includes regular consultation and parenting training for the parents. Supportive individual, group, family and marital therapy may also be found useful to the parents and treatment of the child.
Li (1981) has suggested a further departure from traditional play therapy by including the parent or parents in the play room or observing behind a one-way glass. The parents may even be allowed to view video tapes of sessions during consultation pertaining to the child (Li, 1981).
Traditionally, the therapist does not touch, hold or play with the child (Axline, 1948; Ginott, 1961; Moustakas, 1959). Children with disabilities may require the therapist to touch, hold or help, as the child may require assistance in arranging the toys or to move about the room.
Gene, a child with multiple disabilities, sat on the floor on the therapist’s lap, while the therapist moved toys under Gene’s direction. Sara, a child with spina bifida, walked with leg braces. A large desk placed near the toys afforded a place to play and provided a strong support to help balance Sara. Sara was always within the reach of the therapist in case she lost her balance.
Adaptation of the toys or toy selection aids the child with physical disabilities to become more independent and confident in the play room. Salomon (1983) suggested that children, who may not be able to grasp objects, have paint brushes taped to hands or elbows to paint in play therapy. Musselwhite (1986) suggested attaching sponges from foam curlers to brushes to make the brushes easier to hold. A special glove could be devised by gluing Velcro or magnets to it so the child might handle mental or textured items more easily. Dress up items can be chosen with the child with physical disabilities in mind. Items such as purses, hats, and scarves are easier for children with disabilities to manipulate. Bean bags may be preferred over balls for throwing, as bean bags do not roll away from the child’s reach (Salomon, 1983). The author has bean bags shaped like frogs that are very popular with all children.
Suggested toys for children with cerebral palsy include: activity boards with beads, sliding panels, bells, wheels, and lights; a rummage box with a variety of toys, textures, sizes and shapes; sandbox or tray; musical instruments such as bells, tambourines, drums, triangles, and wooden sticks (Darbyshire, 1980). A board with a collection of locks and latches has provided a very popular toy in the author’s collection. These suggested toys are equally worthwhile for other special populations.
Palumbo (1988; 1989) designed a puppet to be easily used by a child with a profound disability. The puppet had a weighted base, a rod covered with a costume and a head. The puppet could be rocked back and forth making it animated. The puppet was easily used by children with physical or cognitive disabilities.
A second way to accommodate a child with a physical disability is through changes in the setting. Traditionally, the toys are arranged on shelves and the child may see the total selection at one time (Axline, 1948; Landreth, 1991). Bradley (1970) suggests that the toy selection be limited and introduced one item at a time to children who do not have the requisite skills to play or who have difficulty exploring their environment, e.g., visually disabled, motor disabled.
Darbyshire (1980) describes environmental accommodations for children who have cerebral palsy. The child can be placed over a wedge or pillow with the toys within the child’s reach. Other suggestions were that children who use a wheelchair have a variety of places to be moved from their chairs that will encourage different positions. Examples are bean bags and foam wedges (Darbyshire, 1980). The therapist might incorporate large stuffed animals as effective support for the child. One child found a large stuffed gorilla useful by placing the child in front of the gorilla and using the gorilla as support; another child found that lying across a large green frog provided the elevation necessary for playing while lying on her tummy.
Adaptations to toys must be made to create a safe and accessible environment. C-clamps can be used to stabilize a dollhouse on a table. Dolls placed on elevated trays can be helpful to the child needing minimized distances or range of motion. Musselwhite (1986) also suggests suspending toys on a frame over a chair or bed for children.
Through adaptations of toys and accommodations of the environment, the children achieve a degree of independence and competence not always available in other settings. The play room or setting becomes “user friendly.”
Conclusions and Recommendations
Person-centered play therapy provides children with challenges with opportunities to express themselves in an environment of empathy, warmth, and respect. As Musselwhite (1986) has indicated, symbolic play helps these children to develop creative and independent thinking through their play scenarios; to understand others through the exploration of feelings and roles; and to “come to terms with the self”.
The play therapist makes a valuable addition to the treatment team by helping the children express their feelings and frustrations in a safe, nonjudgmental environment. The play therapist can relay to the team the fears and concerns of the children. The amount of contact between the treatment team and the therapist needs to be determined by the individual needs of the child and the overall treatment plan.
Parents need to be included in the treatment plan. Parents need to be provided with opportunities for therapy and parenting skills training. Communication between the therapist and the parents is necessary for effective progress of the child with a disability.
Therapy appears to be dictated by the developmental maturity of the child and the nature of the disability. Specific adaptations may have to be made, demanding flexibility and creativity from the therapist. Play therapy cannot provide solutions to all the needs listed by Williams and Lair (1991). However, in such an environment, the children are nurtured to maximize their independence and expand their individual goals and aspirations.
Axline, V. (1948). Play Therapy. New York: Ballantine Books.
Bradley, B. (1970). The use of the playroom in education of mentally retarded children. Rehabilitation Literature, 31, 103-106.
Corey, G. (1991). Theory and Practice of Counseling and Psychotherapy. (4th Ed.) Pacific Grove, CA: Brooks/Cole Publishing Company.
Darbyshire, P. (1980). Play and profoundly handicapped children. Nursing Times, 76, 1538-1543.
Ginott, H. (1961). Group Psychotherapy with Children. New York: McGraw-Hill.
Landreth, G. (1991). Play Therapy: The Art of the Relationship. Muncie, IN: Accelerated Development.
Landreth, G., Jacquot, W. & Allen, L. (1969). A team approach to learning disabilities. Journal of Learning Disabilities. 2, 82-87.
Li, A. (1981). Play and the mentally retarded child. Mental Retardation, 19, 121-126.
Li, A. (1983, December). Play therapy with mentally retarded children. Association for Play Therapy Newsletter, 2(4), 3-6.
Moustakas, C. (1959). Psychotherapy with Children: The Living Relationship. New York: Ballantine Books.
Musselwhite, C. (1986). Adaptive play for special needs children: Strategies to enhance communication and learning. San Diego, CA: College-Hill Press.
Palumbo, A. (1988). Special puppet designs for profoundly handicapped children. Journal of Rehabilitation, 54(2), 41-45.
Palumbo, A. (1989). Puppetry adapted to special needs players: Puppetry practice of Dr. Silly. B. C. Journal of Special Education, 134(3), 225-234.
Salomon, M. (1983). Play therapy with the physically handicapped. In C. Schaefer & K. O’Connor (Eds.), Handbook of play therapy. (pp. 455-456). New York: John Wiley & Sons.
Williams, W. & Lair, G. (1991). Using a person-centered approach with children who have a disability. Elementary School Guidance & Counseling, 25(3), 194-203.
Karla D. Carmichael, The University of Alabama, College of Education, Box 870231, Tuscaloosa. Alabama 35487-0231.
COPYRIGHT 1994 National Rehabilitation Association
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