quiries th a t less allow ance be m ade fo r th e individual child who m ust now fit into group activities and obey group rules. In o th e r words, the child m ust b e aw are o f an d respect the wishes o f others. T his can n o t be accom plished w itho ut previous p eer p articip atio n which provides a child w ith opportunities to learn the con­ sequences of his ow n actions. A s alread y m entioned, the handicapped child m ay n o t have interacted success­ fully w ith his peers an d thus ad ju stm en t to form al schooling m ay be difficult. T he choice o f o rd in ary o r special school is a particularly stressful decision for m any p aren ts o f han d icap p ed children. T h e m a jo r issue th a t needs evaluation is th a t th e child be placed in a situation w here he will experience reasonable success and acceptance fro m his peers. T h e o ther psychological sequelae o f physical handicap, viz. learning problem s and difficulties w ith ab stract th o u g h t have b een well docum ented elsew here (R utter, G rah am & Y ule, 1970). T o sum m arise, th e em otional developm ent of any handicapped child is especially vulnerable. I t is im ­ p o rta n t th a t all professional w orkers dealing w ith the ih ild view him as a W H O L E dynam ic individual. T h ere f r e some salient facto rs w hich com m only prevent thera- 'pists from viewing th e child objectively. W hat these factors m ay be has as yet not been em pirically re­ searched. H ow ever one m ay m ake inform ed guesses as to w hat could prevent therapists from viewing h a n d i­ capped children objectively. W h at follow s is based on m any years of experience of the senior a u th o r as a therapist a t a school fo r cerebral palsied children. T herapists m ay be unaw are of, and tend to deny, th eir own feelings w hen w orking w ith th e handicapped. “R escue fantasies” m ay easily develop in therapists w ith a need to feel superior to paren ts an d other workers. If th e th e ra p ist is unaw are o f h e r own feelings, she m ay do th e child and fam ily a g reat disservice by not allowing them to com e to term s w ith th e limits o f professional help and u ltim ately th e d isability itself. T herapists can p ro m o te the belief in p aren ts th a t the child can becom e n orm al o r nearly so and this m ust be guarded against. T he parents m ust be supported and DECEMBER 1979 93 helped gently to see reality — n o t to ho p e fo r the im possible. T herapists also need to recognise th a t feelings of anger an d disgust m ay be problem s not only fo r the parents of th e handicapped child b u t also for th e m ­ selves. In our culture these feelings are regarded as unacceptable b u t they are ju st as n atu ral as positive feelings. O ften these angry feelings m ay be transferred onto a p articu lar th erap ist or institution. T h e th erap ist m ust understand th e dynam ics involved, refrain fro m retaliatio n , and accept th a t anger is a very n a tu ra l em otion. In conclusion, it is clear th a t th e th erap ist plays a crucial role in aiding the fam ily of a handicapped child in th e successful negotiation of th e m any em o­ tional hazards facing th e child. T h e present pap er has attem p ted to provide th erap ists w ith a w orking guide to the problem s w hich m ay beset a handicapped child and his fam ily. In o rder to assist any fam ily to accept an d deal w ith th e child, the th e ra p ist m u st be aw are n o t only of the problem s facing the chiH , b u t also of herself. References E rik so n , E. H . (1955). C hildhood an d Society. London. Penguin Books. F reem an, R. D . (1967). E m o tio n al R eactions o f H a n d i­ capped C hildren. R ehabilitation Literature, 28, 9. H a rtu p , W. W., G lazer, J. A . and C harlesw orth, R, Peer (1967). R einforcem ent and sociom etric status. C hild D evelopm ent, 38, 1017 - 1026. R u tte r, M ., G rah am , P., Y ule, W . (1970). A N e u ro ­ psychiatric study in childhood. T h e L avenham Press L td., L avenham , Suffolk. Singer, J. L. (1973). T h e C h ild ’s W orld o f M ake- Believe: E x p erim en tal Studies o f Im aginative Play. N ew Y ork. A cadem ic Press. Singer, 3. L. and Singer, D . G. (1976). Im ag in ativ e P lay and P retending in early C hildhood. In C hild P e r­ sonality an d Psychopathology. E d.: A. D avids. V ol. 3, N ew Y ork. W iley and Sons. P H Y S I O T H E R A P Y PLAY IN INFANCY AND APPLICATION IN TREATMENT* D. C O U R L A N D E R , B.Sc. kjM M A -R Y The theoretical principles o f play according to Piaget are described. Six stages o f play up to tw o years o f age are detailed, w hilst play relevant to the transition fro m infancy to childhood is m entioned. T he application o f play in assessment, parent counselling and treatm ent is discussed. T h e D evelopm ental A ssessm ent C linic a t th e R ed Cross W ar M em orial C h ild ren ’s H ospital in C ape Town, deals with children who are physically o r m entally handicapped as well as those who are socially dis­ advantaged. Som e w ho are considered to be ‘at risk’ in infancy continue to undergo com prehensive periodic assessm ent during th e ir pre-school years. In o rd er to m ake the assessm ent p rocedure pleasure- able a play situation, w hich served as a prelim inary to m ore form al assessm ent, was created w ithin th e clinic setting. D uring these observations it was fo u n d th a t * O riginally published in the N ew sletter of the S.A. N eurodevelopm ental T h erap y A ssociation, 2, 3, 2:11 and rep rin te d by kind perm ission o f th e editor. (Physiotherapy) R and OPSOMMING D ie teoretiese beginsels van speel volgens Piaget word beskryf. Ses stadia van speel tot op twee jaar w ord op- gesom , terw yl speel m et betrekking to t die oorgang van kleinkind to t kind (na twee jaar) genoem word. D ie toe- passing van speel in evaluering, raad aan ouers en behandeling, w ord bespreek. play could provide an altern ativ e form of assessm ent in its own right and, m oreover, serve a useful guide in plan n in g treatm en t an d fo r p a re n t counselling. T h ere are m any ways in which play m ay be defined. C hildren, adults an d anim als play, and different cultures h ave th e ir own form s o f play. S h erid an ’s definition, ‘P lay is th e eager engagem ent in pleasurable physical o r m ental effort to o b tain em otional satisfaction’, is ap p ro p riate to th e observations th a t will be discussed. N o rm s o f child developm ent used as instrum ents fo r observation and diagnosis reflect th e m atu ratio n of p attern s o f beh av io u r in infancy and th e integrity o f th e n eu ro -m o to r system. T hese provide a yardstick w ith w hich to m easure progress and a guide for tre a t­ m ent, b u t deal very little w ith play as a n a tu ra l and spontaneous function. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 94 F I S I O T E R A P I E DESEMBER 1979 Sheridan (1977) w ent a long way to bridge this gap when she supplem ented her scales o f ‘C h ild ren ’s D e­ velopm ent Progress from b irth to 5 years’, w ith an interpretive analysis o f ‘Spontaneous P lay ’ in ‘E arly C h ild h o o d ’, b u t th ere rem ained th e problem o f in­ sufficient insight into the underlying processes that could explain observations m ade. A n attem p t was m ade to find th e clarification required and to apply this to the existing needs. THEORETICAL PRINCIPLES P iaget (1951, 1953, 1969) explains m ental functions by their m ode o f form ation. H e refers to th e first tw o years of life as th e sensori-m otor period and b e ­ lieves th a t it is during th e first eighteen m onths th a t the child constructs th e cognitive substructures which serve, as a fo u n d atio n for his intellectual and perceptual developm ent. C entral to P iag et’s description of sensori­ m otor developm ent are the action-schem a, the circular reaction and th e role of im itation. An action-schema is a co-ordinated p attern of b e ­ haviour, involving m ovem ent and perception. A s de­ velopm ent proceeds, every newly established neuro- m o to r p erceptual action becom es integrated into an action-schem a. A circular reaction is a b eh av io u r p a tte rn w hich is repeated fo r the pleasure of prolonging it or fo r an interesting result. A circular reaction is self-m otivated and inherently satisfying. Its crucial facto r is th e active elem ent. T h ere are th ree types o f circular response. T he first o r p rim ary circular reaction is a behavioural ad ap ta tio n to an hereditary m echanism o r reflex. F o r exam ple, sucking becom es stronger th ro u g h satisfaction and repetition. T h e secondary circular reaction occurs because an accidental occurrence provokes repetition — fo r exam ple, an object accidentally shaken, m akes a noise and is shaken again. T he tertiary circular re­ sponse occurs when an activity can be varied because of feedback. T h e in fan t m ay m ake several attem pts to sw itch on a light, using action schem as w ithin his re­ pertoire, b u t varying th em slightly each time. If he succeeds, he repeats the activity over and over again fo r the pleasure of m astery of his ow n pow er. Imitation is d ependent on th e social-affective env iro n ­ m ent. I t begins in early infancy and continues th ro u g h ­ out life. P iaget describes six stages o f im itation in infancy. 1. T he first sounds a baby m akes a re self-initiated. T h e m o th er responds to these signals w ith sensitive tim ing. She repeats the sound w hich the baby again im itates and thus the ‘co nversation’ is prolonged. P iaget refers to this as vocal contagion. H e describes a sim ilar process of im itation with m ovem ents of the head. 2. A t th e next stage, th e baby becom es able to im itate th e sam e sounds and m ovem ents which are already w ithin his repertoire, if his m other initiates them . A new sound or m ovem ent in tro ­ duced by his m o th er can n o t be im itated a t this stage. 3. A little later the baby is able to im itate a few new m ovem ents if initiated by his m other, bu t his own m ovem ents m ust be visible to him . He thus learns to clap hands and wave bye-bye. 4. L a te r still, he is able to im itate m ovem ents w hich a re n o t visible to him , thereby im itating facial grim acing o r han d to face m ovem ents. The in te­ gratio n o f im itation of sound an d of m ovem ent m ay have som e bearing on the com m encem ent of babbling. 5. T h e bab y now enters a stage at which he is readily able to im itate new sounds and m ove­ m ents which were n o t previously in his reper­ toire. H e is th erefo re able to echo new words and im itate simple dom estic events which are concerned w ith his own behaviour. 6. F inally, at the end of the sensori-m otor period, th e baby is able to reproduce sounds and move­ m ents h eard previously. In o th er w ords im itation can be based on m em ory. P iaget calls this ‘de­ ferred im itatio n ’. T his period m arks the em an­ cipation from sensori-m otor connections and indi­ cates the em ergence of sym bolic activity. The continuing developm ent of language is p a rt of the sym bolic process. P iaget considers th a t th e ap­ pearance of sym bolic beh av io u r is the crucial p oint in th e in terp re tatio n of play. B runer (1974) believes th a t ‘m astery play’ is crucial fo r developm ent d uring th e first eighteen m onths and th a t it consists of extending to new lim its already achieved skills. Stated differently, he says th a t play consists of pleasure-giving variations of newly acquired routines. B runer believes th a t initial learning has a large ele­ m en t of pre-ad ap tatio n which reflects species typical; genetic instruction. W ith this in m ind, his studies oil com petence in infancy have been p rim arily concerned w ith visually guided prehension an d the transition from unilateral to bim anual m anipulation. I t is this ability which leads to tool m aking an d distinguishes th e hu m an species from others. A ccording to B runer skilled activity specifies an objective to be achieved. T h e crucial issue in the regulation o f intentional action is th e o p p o rtu n ity to com pare w hat was intended w ith w hat in fact resulted, using th e difference betw een the two as a basis for correction. H e refers to this as ‘internal feedback’ w hich signals an intended action w ithin the nervous system. B ru n er’s description of th e m atu ratio n of visual atten tio n in association w ith prehension an d the develop­ m en t of b im anual activity are of p articu lar relevance to a detailed observation of in fan t play. A s well as th e theoretical principles of P iaget and B runer and the observations of Sheridan, fu rth er analysis o f play by Lowe, (1975), T izard, Philips and Philips (1976), Sinclair (1970) and R o sen b latt (1977) have been used. STAGES OF PLAY T he follow ing is a sum m ary of stages o f play w hich- is being used as a guide in developm ental a sse ssm e n t) O bservations have confirm ed th a t although age levelsL are to som e ex ten t arbitary, th e sequence is invariable. Stage I 0 - 6 w eeks In th e neonatal period innate reflexes are re-inforced by practice. T he baby is visually highly distractable, bu t th ere is m om entary visual fixation on faces or moving objects. Stage II 6 - 1 0 w eeks M u tu al im itation occurs at th e exact m om ent the sound or m ovem ent is produced. If m o th er stops im itating, baby stops vocalising. H e reinitiates a new sequence him self. V isual a tten tio n is directed tow ards a stim ulus and he is attracted by targets w ith good visual ground properties. If his head tu rn s his eyes rem ain fixed on the target. H an d to m o u th activity w hich began as a reflex, is perp etu ated by p ractice an d becom es a voluntary act. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) DECEMBER 1979 P H Y S I O T H E R A P Y 95 10 -1 6 w eeks V ocal contagion continues. V isual a tten tio n can be shifted from one targ et to an o th er w ith o u t m uch interm ediate drifting. (B runer states th a t this is th e visual m atrix in w hich m ovem ent of th e han d can be appreciated. T he in fan t n o t only recognises w hat th e han d is, b u t w here it is.) Presentation o f a suitable object induces activity of the b ab y ’s arm s, opening and closing o f the hands and m ovem ent of the m outh. Stage I I I 4 - 6 m onths Sounds previously practised by th e baby, if initiated by th e m other, are repeated by th e baby. T h e baby sees an exciting object, m oves his limbs, accidentally touches th e object and repeats th e activity. H e reaches, grasps, retrieves and m ouths single o b ­ jects using one han d at a tim e. F ull visual inspection ^ c o m p a n ie s th e act. T h e hand is shaped to grasp as 'h e reaches forw ard and the m outh opens in advance. H e begins to pass the object from han d to hand, b u t retains only one ob ject a t a time. 6 - 8 m onths T h e baby continues to initiate new sounds and gestures w hich his m o th er im itates and th e baby re- im itates to prolong th e activity. M o th er now can initiate m ovem ent w hich th e baby is able to im itate, if his own m ovem ents are visible to him , e.g. clap hands, wave bye-bye. Single objects are shaken, waved and banged. A p leasant result p ro ­ vokes repetition. Shaking, w aving or banging schem as are used on all objects. T h e m outh rem ains as the term inal phase of activity, b u t this action no longer re­ quires full visual attention. A n o bject can be retained in each hand. Stage IV 8 - 1 2 m onths A ctions w ithin the b ab y ’s rep erto ire w hich are n o t visible to him can now be im itated, e.g. facial grim aces, hand to face m ovem ents. X Babbling begins, initiated at first by th e baby and V iitated by th e m other. B im anual activity begins. T h e baby can now hold an o bject steadily in one h an d and explore p arts of it w ith the other. H e is able to hold tw o objects and click them together. A cquired action-schem as can be applied to new events, e.g. objects m ay be dropped d eliberately from varying positions. A n o bject can be retrieved by m oving an obstacle aside if th e bab y h as w atched it being hidden. H e still uses only one han d fo r b o th m oving the obstacle and retrieving th e object. Stage V 12 -1 8 m onths T h e bab y is able to im itate new sounds and gestures not seen o r heard previously. T hus he begins to echo new w ords and im itates new gestures. H ow ever, he discontinues if the m odel fo r im itation is n o t visible or audible. T hrough im itation single ob ject rep resen tatio n begins, e.g. baby dials th e telep h o n e o r puts th e telephone to his ear, b u t does n o t com bine th e two, brushes his hair, scribbles w ith a crayon. B im anual activity m atures. Play becom es m ore a p p ro ­ priate to th e m aterial and tw o objects a re com bined. T hus objects are placed on top of, beside o r into one another. Lids are rem oved and replaced. Long chin objects are placed into holes. A ction schem as can now be altered because of feed­ back an d a type of trial and e rro r fo r a desired result begins, e.g. sw itching on a light, turning a knob. W ith th e ad v en t of bim anual activity, m outhing is greatly dim inished. Stage V I 18 m o n th s - 2 years Im itativ e beh av io u r can now ta k e place in the absence of an im m ediate m odel. T h e child begins to reproduce w ords heard previously and im itate events previously seen. H e reproduces rep resen tatio n al schem as associated w ith his own behaviour, using tw o o r th ree objects as props. F o r exam ple, h e m anoeuvres a steering wheel and p retends to drive, pretends to feed him self using a cup and a spoon, pushes a ca r m aking ap p ro p riate noises. P lay w ith a doll, a t this stage is still indiscrim inate. B im anual dexterity is sufficiently advanced to solve sim ple problem s, e.g. a lid can be lifted w ith one hand an d an o b ject retrieved w ith th e o th e r w hile the lid is held open. A ccording to P iaget th e in fan t in th e sensori-m otor period does n o t have any m en tal representations by w hich he can evoke persons o r objects in th e ir absence; th a t is, he lacks th e sym bolic function. H e believes th a t the ap pearance of sym bolic beh av io u r is a crucial period in th e developm ent of intellectual function. It is th e m eans by w hich th e child can assim ilate reality t > his own desires an d interests. F u rth erm o re, the < 'lild ’s language a t this stage is unsuited to express his living experience so th a t he requires a m eans of self expression suited to his needs. T h e m eans of self- expression th a t he uses is play w hich m ay be purely rep resen tatio n al o r sym bolic. P iag et calls the next stage in developm ent the pre- o perational stage, w hich continues until th e seventh year. T his stage is beyond th e scope of a discussion on in fa n t play, b u t during th e ch ild ’s th ird and fo u rth y ear specific elem ents of play can be distinguished w hich a re relev an t to th e stage o f tran sitio n betw een infancy an d childhood. T hese are: P ractice play — in w hich th e child consolidates his sensori-m otor powers. H e rep eats and varies ac­ quired activities fo r pleasure an d m astery. N o rep re­ sentation o r sym bolism is involved. E xam ples of this type of play are filling an d pouring, throw ing pebbles into w ater, pushing one object w ith another, pushing a wheeled toy dow n a slope. C onstructive com binations — in w hich the child experim ents w ith educational toys. Play m ay be con­ structive o r destructive. Sim ple objects are placed in lines o r clusters, objects are sorted by colour and shape. E lab o ra te constructions m ay be m ade fo r the process alone, and th e rep resen tatio n al im agination added by exclaim ing, ‘I ’ve m ade a ho u se’. R ep resen tatio n al schem as. W hereas in .the sensori­ m o to r period dom estic m im icry was related to the child’s own behaviour, these schem as are now projected onto som ething else. R ep resen tatio n al play now becom es sex-appropriate. D oll-related play becom es dom inant using a com bination of ap p ro p riate dom estic objects. G irls feed th e ir dolls, w rap th em up, comb th eir hair. L ittle boys are m ost likely to recreate schem as in­ volving m o to r cars, accidents or sim ilar incidents, given R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 96 F I S I O T E R A P I E DESEMBER 1979 suitable m aterial. In representational play, using ap p ro ­ p riate m aterial the child will “C ook like m um m y” or “ W ork like d ad d y ” . Symbolic play. T his occurs when the child can identify him self as som eone else, e.g. playing th a t he is m um m y, postm an, shopkeeper. If realistic m aterial is unavailable the child can im provise by using substitute item s. A chair m ay be used as a m o to r-car and the use of a steering wheel m ay be m im ed. R ep resen tatio n al play precedes sym bolic play in the developm ental sequence, but it m ay frequently be in- distingishable fro m it as the child ad ap ts the situation to his needs. B oth representational and sym bolic play signify the presence of a language process. Games with rules. T hese em erge in th e slightly older child and increase in im portance as social life is en­ larged. APPLICATION IN TREATM ENT T h e skill o f the therapist lies in h e r ability to adapt h er know ledge of norm al d evelopm ent to the needs o f the han d icap p ed child. P iag et’s theory describes the m eans by which the norm al in fan t im proves his physical skill and know ­ ledge of his environm ent through practice and im i­ tation. By the end of the sensori-m otor period the child has a basic u n d erstanding o f objects and his relationship w ith them and is ready to use newly developed pow ers o f sym bolization. T h e em ergence of sym bolic o r m ake-believe play is the culm ination of the experience he has gained in the sensori-m otor period. If P iag et’s theory is to be applied in practical terms the follow ing should be kept in m ind: The importance of preverbal communication: P iaget believes th a t in th e first few m onths o f life it is the in fan t who initiates a vocal sequence and the m other w ho reinforces it by im itation. A survey of current research in B ritain carried o u t by T izard, (1975) indicates th at there is considerable evidence to sub stan tiate this. As vocalising in handicapped an d retarded children is often delayed, th e b ab y ’s signals m ay be too weak to be recognised. It m ay be possible to assist the com ­ m encem ent of reciprocal vocalisation b y 'm a k i n g the m other aw are o f h e r need to im itate the sound th a t her baby m akes, even if these seem to be in ap p ro p riate fo r his age. T h e therapist can augm ent this process fu rth er by im itating th e bab y ’s vocal efforts during treatm ent. The opportunity to learn by imitation: If every effort is m ade to cap tu re the ch ild ’s visual attention, early m utual im itation of han d and face m ovem ents can be encouraged. It will be rem em bered th at several stages o f im itation occur before a child is able to carry the im age of an event in his m ind and reproduce it spontaneously. D om estic m im icry is an im p o rtan t stage in the transition from sensori­ m o to r to rep resen tatio n al play. T h e handicapped child requires endless oppo rtu n ity to observe the activities o f the household and needs to be given suitable re­ presentative objects w ith which to play. The necessity for active engagement in play: A ction—̂ result—̂ feedback—̂ repetition of the action, are the com ponents of the circular reaction. T he child’s own actions are the only m eans by w hich he can dis­ cover the properties of objects and his effect on them . W hen a child’s physical ability is lim ited o r distorted, this poses m any problem s. C areful assessm ent and selection of suitable toys should assist in overcom ing these problem s. H an d icap p ed and retard ed children m ay proceed very slowly thro u g h each stage of developm ent. At tim es a change of d irection in play m ay assist in planning th e next stage o f treatm ent. One exam ple o f this is th e problem o f prolonged m outhing o f ob­ jects th at som etim es, occurs when a child does not develop a firm bilateral grasp. If treatm en t effectively enables the child to retain his grasp in both hands sim ultaneously, b im anual activity can com m ence and m outhing is slowly reduced. In the norm al baby bilateral grasp coincides w ith his ability to pull up and support him self in standing. CONCLUSION Successive stages of play w ith objects in infancy aniR . early childhood have been described. By com bining theory and observation an atte m p t has been m ade to apply the know ledge gained to the treatm en t o f h a n d i­ capped children. It is doubtful w hether it is possible to ‘teac h ’ a child to play but, given suitable conditions and careful m anagem ent, every child should be able to play as effectively as his handicap perm its. Acknowledgement: These observations were p a rt of an ongoing study of in fan t play in norm al and h an d i­ capped children in C ape T ow n un d er the direction of D r C. M olteno, who is th anked fo r his interest and assistance. References 1. B runer, J. (1974) Skill in infancy, in Beyond the in fo rm atio n given. Ed. J. A nglin. L ondon. G eorge A llen and U nw in L td. 2. Lowe, M. (1975) T rends in the developm ent of representational play in infants from one to three years — A n observational study. J. C hild Psychiatry, ( , 3. Piaget, J. (1953) T h e origin o f intelligence in th V child. L ondon. R outledge and K egan Paul. 4. Piaget, J. (1951) Play, dream s and im itation in child­ hood. L ondon. H einem ann. 5. Piaget, J. an d Inhelder, B. (1969) T he psychology o f the child. L ondon. R outledge an d K egan Paul. 6. R osenblatt, D. (1977) D evelopm ental trends in in fan t play, in T h e biology o f play. Clinics in D evelopm ental M edicine, 62. L ondon. H einem ann. 7. Sinclair, H . (1970) T h e tran sitio n fro m sensory- m o to r behaviour to sym bolic activity. Interchange 1, 119. 8. Sheridan, M. D. (1977) Spontaneous play in early childhood: from birth to six years. W indsor, N F E R . 9. T izard, B., Philips, J. and Philips, J. (1976): Play in pre-school centres, I: Play m easures and their relation to age, sex and I.Q. J. C hild P sychology and Psychiatry 17, 21. 10. T izard, B. (1975) P aren t-in fan t interactions in early childhood education. W indsor, N F E R . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )