Q & A on play for children with complex needs

Dr Debby Watson, Researcher Debby Watson

Debby Watson recently completed a PhD study in playfulness and children with profound and complex impairments.

What is playfulness?

Playfulness is one of those things that is really hard to define, but unmistakable when you see or feel it! In children with complex and profound needs, it can be a bit harder to spot because of physical, communication and sensory impairments, but it’s definitely there – in what’s been described in my research as when children ‘shine’. Often, it’s a case of knowing a child really well and being able to recognise their particular expression of playfulness. For one of the children in my study, you could tell that he was excited and playful if his eyebrows went up, his mouth opened wide and he vocalised more, stiffening his body. For others, it would be something different, like increased body movement or the eyes focussing and brightening.  I would say that playfulness in children with complex needs involves several elements: a lift in mood; physical signs; increased awareness; increased motivation and a sense of fun and humour being present.

Why is playfulness so important for children with complex needs?

I think that children with complex needs experience a lot of very mundane interactions. In my study I found that for almost a third of the time that I observed them they were either waiting for something to happen, having physical interventions such as suction or were being positioned so that they could take part in an activity. All of these things are really important, but it means that there is less time for them just to be a child, being naturally playful. Children with complex needs differ from other children in that they often need support to access their playfulness – the playfulness is definitely there but some children need very ‘tuned in’ support in order for it to be recognised and encouraged.

In the five profoundly disabled children in my study I observed that the children who had high levels of active involvement in playful activities also had higher numbers of observed ‘strengths’ such as being able to make choices or anticipate events. Although it is really difficult to say definitively why playfulness is important, there was strong evidence that it may; increase well-being, arousal, communication and responsiveness; make the child feel good and have fun without being judged; help with development; enable the child to be connected to others and may also have educational benefits such as transferring skills, increasing concentration, creative thinking and potentially helping children to entertain themselves. Above all, though, I think that playfulness helps to make children become excited and have fun. In that state, other things such as the motivation to reach out or make sounds will follow.

What are the barriers to playfulness?

It’s remarkable that children with complex needs are playful at all considering the enormous barriers to playfulness that they have! To me, it shows just how fundamentally important playfulness is because it survives barriers such as feeling unwell, being uncomfortable and being misunderstood – in addition to all the more obvious barriers such as not being able to get up and run around, or not being able to hear or see well.

Adult participants in my study were generally agreed that physical impairments were not the main barriers to playfulness.  Instead, they felt that poor attitudes, low expectations and difficulties with communication (for the child and the person interacting with them) were more significant. To me, it’s important to look at barriers and supports at three levels if we want to encourage playfulness: within the child we need to be aware of the child’s preferences, character, communication style and impairments and how these things interact; around the child it’s important to think about attributes in supporters that enable receptiveness to and messages for playfulness and to pay attention to physical and psychological issues such as positioning, allowing time, reducing stress. It’s also really important to spend time preparing for playfulness and focussing on keeping it going; beyond the child with PMLD it’s essential that there is a permissive environment (psychological and physical), where playfulness is encouraged.

Many participants in my study felt that schools were far too focussed on targets and progression, meaning that not enough time or importance was placed on playfulness. Good communication between home, school and services is crucial, as is a positive, ‘can do’ attitude. I think it should always be recognised that families spend huge amounts of time and energy in co-ordinating and managing the services they receive that are essential to keep their children alive, developing and well, and very little energy may be left for being playful.

My personal plea to professionals is, as well as talking to families about all the important, medical aspects of care, to talk about encouraging playfulness really early on when a child is identified as having an impairment. Playfulness for this group of children doesn’t have to be ‘special’, with specialist toys or training; it needs to be as natural and as fun as possible, just encouraged for its own sake, not so that a box on an assessment form can be ticked. Siblings and other children are really good at it and we could learn a lot from them!

How can we support children with complex needs to be playful?

I think it’s useful to see playfulness as a cycle. This means that playfulness isn’t just seen as something that happens solely within the child, but that it needs to be sustained in two (or more)-way interactions, where the child needs some feedback from the ‘play partner’ (another child or, more usually with children with complex needs, an adult) and the play partner needs the child’s responses to gauge what’s making the child feel playful and what’s not getting much response. This can be illustrated from an example from my research involving Harry (not his real name), with his mother and two support workers, in his home. The words in bold are stages in the cycle (you can read more about this on my website www.debbywatson.co.uk

  1. Permission and preparation. The session has been set up for me to observe playfulness, so in this way, playfulness is both expected and encouraged. Harry’s mother is very keen to encourage Harry’s active involvement in play and goes to great lengths to ensure that this happens. His support workers are both engaged, know Harry well and have a very positive attitude. On this occasion, Harry is seated between his mother’s legs, on a swinging platform that has been specially made to swing from the ceiling in the living room. Harry is leaning in towards his mother’s hands, which support him to sit.
  1. Attunement. The support worker is kneeling in front of Harry, making eye contact and holding a big, soft ball so that Harry can see it. Harry’s mum talks gently to him, saying, ‘get, set..’ in a sing-song voice. There is an air of anticipation and Harry is engaged and alert.
  1. Offer of playfulness. The support worker throws the ball in the air and passes it to Harry to feel.
  1. Recognition of signs in child. Harry vocalises, makes happy sounds and smiles. His mouth is wide open and his eyebrows go up.
  1. Co-regulation. The support worker and Harry pass the ball between them.
  1. Playful response. Harry plays with the ball and lets go of it when his mother says ‘let go Harry!’ in a jokey voice.
  1. Reattunement. Harry becomes a bit less excited and mother gently says ‘hello’ to Harry. Mother rocks Harry gently on the platform. Harry is calm, smiling and quiet – ready for the next interaction.

It’s clear from this example that several aspects, at the three ‘levels’ that I mentioned above, had to be right: at the ‘within child’ level, Harry was known well and his particular likes and personality were taken into account. Harry likes a bit of danger (being up high), he likes balls and he was made to feel comfortable and safe. ‘Around’ him he had people who were tuned in to him and went to great lengths to make sure he was in a good position to play. They allowed lots of time for his responses and were tuned in enough to know when Harry wanted to move on to something else, or was tired and needed a break. ‘Beyond’ him was the situation he was in, with a mother who really focussed on encouraging Harry to be playful as an important part of his life, realising that they needed to deliberately make efforts to do this, and needing support in order to do it . Harry’s mother had made great efforts, including training, to ensure that Harry’s support workers focussed not only on his health needs but also on social aspects.

There are lots of ways in which we can support children with complex needs to be playful, but many of them will be very individual to a particular child. However, there are some points which seem to be generally helpful. I think it’s really important that the children have some experience of non-disabled children or physically active children playing, as this often seems to excite and motivate them. This might not always be the case as I realise that some children are only aware of the environment very close to them but it seems that a general atmosphere of playfulness does have a positive effect. I looked carefully at what sort of attributes people need to encourage playfulness and the ‘top three’ things were: knowing and understanding the child well, with trust between the ‘play partners’ being established; being able to model playfulness and be willing to be silly and playful oneself and finally, being patient and persistent, not giving up easily if there seems to be little response, but willing to try different things out.  As mentioned before, it’s really important to ‘tune in’ to a child and go along with the child’s choices as this can work well in encouraging playfulness. For example, a teacher talked about an interaction she had:

‘So I was playing this morning with [child’s name] and we were meant to be doing something else but he was a bit distracted and for some reason he kept wanting to keep touching my lips. I don’t know why, so I started, every time he brought his hand up to my mouth, going ‘phh’ and blowing and he thought it was hilarious, so this sort of game developed. I couldn’t have sat there this morning and planned, for ten minutes, I wouldn’t have known. I think just by trying different things and seeing what the child responds to or doesn’t, what they seem to like and as I say, build upon what you find they like.’

I observed several instances of the children enjoying a bit of ‘slapstick’ humour. They seemed to really like it when a support worker, for example, dropped something and everyone made a joke of it. For some children, just being around people who are having a laugh is enough to make them feel playful. Extending that to providing opportunities for a child to, for example, knock things down is really valuable. The more actively involved a child is, particularly if they can feel they’ve succeeded in doing or operating something, the better! This is when I witnessed more incidences of the children being highly excited than for anything else.

What is a play passport and how could it be used to enable play?

I said earlier that when you know a child well, it’s relatively easy to spot what makes them feel playful. However, if your child is going somewhere like a play scheme or short break facility and the support workers may not know the child so well, it might be useful to provide some hints and prompts. Passports often cover important aspects such as communication and health issues, but playfulness is not generally given much attention other than a section on likes and dislikes. That’s why I developed, alongside parents, professionals and academics, a Play Passport that sets out who or what excites a particular child, what frightens them, how to make them comfortable, what the physical signs are when they are playful and other factors that contribute to them being playful. It’s an A5 size leaflet at the moment and can be completed as a Word Document or a PDF and a photo can be added of the child being playful. I hope it will be developed it into something that could be easily accessed from a mobile phone or iPad.

Children have clear preferences when it comes to their playfulness and it’s useful to know whether they like, for example, loud or soft noises or whether they like a strong tickle or a tiny one. The Play Passport also has some reminders on it: that it’s useful to spend time observing a child before wading in and trying things, that it’s really important to tune in to what the child is enjoying and not to be in a rush to move on to the next thing.

Playfulness is such an important aspect of all of our lives, but for children with complex needs it can get lost in a world of assessments, health scares and exhausted carers. I hope that by promoting playfulness as a vital aspect of life, my research will go some way to putting it higher up the list of priorities. After all, it’s not as if it’s not fun!

Dr. Debby Watson is a researcher with special interest in playfulness and children with profound and complex impairments


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