The Indian Journal of Occupational Therapy : Vol. 46 : No.
2 (May 2014 - August 2014)
To study the effectiveness of play based therapy on play
behaviour of children with Downs Syndrome.
Author: Preetee Gokhale* (M.O.T.), Co-Authors : Punita V. Solanki (M.O.T.)** , Priyanka Agarwal***
Key Words:
Downs syndrome, Play Behaviour,
Revised knox preschool play scale,
Play based Occupational Therapy
* * Occupational Therapist
Student M.O.T.-III
** Ex-Assistant Professor
*** Occupational Therapist
Institution:
O.T. Training School & Centre,
Seth GS Medical College & KEM
Hospital, Mumbai-12
Period Of Study :
January 2013 - December 2013
Correspondence :
Dr. Preetee Gokhale
Indraprastha, R-31, Dombivili
(East) - 421203
Phone No. :
09819667230
E- Mail :
preeteegokhale@gmail.com
Paper was presented in
OTICON ' 2014 : the 51st Annual
National Conference of AIOTA at
Bhubaneshwar and was awarded
with KEMOT Youth Talent Trophy
for Best Paper.
IJOT : Vol. 46 : No. 2
Abstract
Aims and Objectives: One in every 800 children suffer from Downs syndrome, who lack development of age
appropriate physical, mental, social andpsychological skills therebyaffecting childs play behaviour skills. Aim of
the study was to assess the play behaviour and effect of play based therapy in children diagnosed as Downs
syndrome. Our hypothesis was that the childrens play behaviour improves significantly with play based
Occupational Therapy.
Materials and Methodology: Male and female children diagnosed with Downs syndrome in the age group of
2 - 6 years were randomlyobserved from an outpatient paediatric rehabilitation department of K. E. M Hospital,
Mumbai in this one arm cohort observational study. Each childs neuro-paediatric assessments and play behaviour
assessments on Revised Knox Preschool Play Scale (RKPPS) were done. Children were observed when they
were subjected to age appropriate play based Occupational Therapy intervention in an outpatient department,
for a period of 1 month and were re-assessed on RKPPS.
Results: 10 children were observed (6 males, 4 females). At the end of 1 month of therapy, each child showed
significant improvement in their play behaviour. The results were analysed using Pairedt test. The results
werestatistically significant at the level of P<0.001 and Confidence Interval of (at 99% Confidence interval).
However, factors affecting play behaviour in individual child were variable.
Conclusion: Play based Occupational Therapy was found to be effective in improving play behaviour in a
cohort of 10 children with Downs syndrome.
Abbreviations: RKPPS: Revised Knox Preschool Play Scale
Introduction
1.1 Background
The first few years of a childs life seem spent almost exclusively in play. Nothing gives us more
uneasiness than to see a child who does not play. We consider it a sign of sickness, either of
body or mind. As a result of playing the child grows. Growth is the primary use of play and this
is as true of intellectual growth as of physical. [1-3]
Downs Syndrome is a chromosomal disorder, caused by the presence of an extra 21st
chromosome, which is characterized by mild to moderate mental retardation, short stature, and
a flattened facial profile. It is also called as trisomy21. The incidence of Downs Syndrome is
estimated at one per 800 to one per 1000 births.[8-10]
Through play the child learns to explore, develop, and master physical and social skills. Children
with Downs Syndrome have tendency for more passive play and more repetitive play. Their
play skills are influenced by delayed motor skill development [4] pertaining to manipulation,
cognitive disabilities which implicate hampered capacities to direct and control ones attention
and to regulate ones thinking and behaviour, and inadequate social development affecting
their pretend play and interaction with peers. Since play is such an integral part of a childs life,
it seems only natural that it be used as a method for dealing with these childrens problems in
a therapy setting.
Childrens play is generally described as being spontaneous, purposeful, and involving roles
and relationships, and the use of body space and force in the spatial and material environment
of the home. Such descriptions enable observers to identify and explain deviations from expected
patterns which may be attributable to a variety of environmental factors rather than the childs
own developmental status. [14,15, 21]
Some studies have util ised play categories and their definable developmental features to make
41 May 2014 - August 2014
comparisons between different groups of children, and to arrive Material And Methods:
at prescriptions for intervention. In particular, the relationship
between play and childrens cognitive and language Study Design:
development has frequently involved comparisons of the play Observational Cohort study
behaviour of normally developing and retarded children.Play
therapy [21] is a structured, theoretically based approach to therapy Sample Size:
that builds on the normal communicative and learning processes 10 children diagnosed as Downs syndrome were included
of children. The curative powers inherent in play are used in in the study.
many ways. Therapists strategically util ize play therapy to help
children express what is troubling them when they do not have Study Sample:
the verbal language to express their thoughts and feelings. In Randomised sampling method was used.
play therapy, toys are like the childs words and play is the
childs language. Through play, therapists may help children Inclusion Criteria:
learn more adaptive behaviours when there are emotional or 1) Children diagnosed as Downs syndrome
social skills deficits. The positive relationship that develops
between therapist and child during play therapy sessions can 2) Age group 2 -6 years
provide a corrective emotional experience necessary for healing. 3) Both males and females
Play therapy may a lso be used to promote cognitive
5development and provide insight about and resolution of inner Exclusion Criteria:
conflicts or dysfunctional thinking in the child. 1) Musculoskeletal disorders
Occupational Therapy can play an important role in assisting 2) Other developmental conditions
individuals with Down syndrome from diagnosis to adulthood.
Occupational therapy helps individuals with Down syndrome 3) Other neurological conditions
by creating programs (Play Based activities) to develop and 4) Visual and hearing deficits
utilize skills across the lifespan. This enables them to live life
to its fullest. 5) Untreated seizure disorder

1.2 : Purpose Of Study: Assessment Tools:

The social development and play behaviour of children with
Downs Syndrome in the age group 1-2 years progresses in a
manner similar to their same age typically developing
counterparts. This is the reason that our study includes children
with Downs Syndrome in the age group 2-6 years, as the play
skills acquired by them in these pre-school years lay an important
foundation for further acquisition of school and adolescent life
roles.
Therefore the purpose is to study the effectiveness of play based
therapy on the play behaviour of children with Downs Syndrome
in the age group 2-6years which has future use in the acquisition
of life roles. This therapy is based on the Occupational
Behavioural Frame of Reference.
1.3 : Hypothesis:
NULL HYPOTHESIS (H0 ): There is no statistically significant
improvement in play behaviour of children with Downs
syndrome with play based Occupational Therapy.
ALTERNATE HYPOTHESIS (H ): Improvement in play behaviour
1
of children with Downs syndrome is statistically significant
with play based Occupational Therapy.
Aims And Objectives:
To assess the play behaviour of children with Downs
Syndrome.
To study the effects of play based therapy on play behaviour
of children with Downs Syndrome.
Revised Knox Preschool Play scale: The RKPPS is an
observational measure [13] that allows therapists to evaluate the
play of children ages birth to72 months in their natural
environments[7] . The scale has 12 categories in 4 components
namely Material management, Space management, Pretense-
Symbolic & Participation. Observed play behaviour that matches
the age discriptors is recorded and each factor is scored at the
upper age of age grouping. (For eg. 6 to 12 months is scored at
12 months). Each dimension is scored with the mean of factor
scores and overall play age is scored with the mean of the
dimension scores.
Study Procedure:
10 children with a diagnosis of Downs syndrome coming
to Occupational Therapy; paediatric OPD of KEM Hospital,
Mumbai were selected as per inclusion and exclusion
criteria. Parents of children selected were explained the
purpose and nature of the study. Written consent was taken
from the parents in the language best understood by them.
Any queries regarding the study were explained to the
parents. Four week protocol was administered. Evaluations
were done on the 1st day and at 4th week of Protocol using
RKPPS.
Treatment protocol
Occupational Therapy and Play Based Therapy. Subjects
were called twice a week, each session lasting for one hour.
45 minutes of play based Occupational Therapy was given
followed by 15 minutes of Free play.

IJOT : Vol. 46 : No. 2 42 May 2014 - August 2014

Occupational Therapy intervention was inclusive of Statistical analysis was done using Students t test. (Paired t
test)
Parental counselling
Test was used to assess the statistical significance of Play based
Normalization of tone
Occupational Therapy intervention in the selected sample.
Facilitation of normal mature motor patterns and Observations were noted pre and post intervention and t value
equilibrium reactions was calculated using following formula.
Therapy for arm-hand control
Play based Therapy consisted of different age appropriate x = Mean, S = Standard Deviation, n = Sample size
play based activities pertaining to the dimensions of RKPPS
scale. Free play was also included as a part of intervention.
Play based activities were inclusive of-
Results and Tables:
SPACE MANAGEMENT:
Table 1
Ball throwing & Catching activity in sitting & standing, Gender wise distribution of sample:
initially with the mother; progressing to Ball throwing &
catching in a group.
MATERIAL MANAGEMENT:
Stacking rings, Building blocks, Perfection board, Bead
stringing activities to improve manipulation, construction,
purpose & attention.
IMITATION AND DRAMATIZATION:
Pretend play with Doll (feeding, dressing the doll etc.),
Doctor set.
Mother-Child interaction to improve Imitation &
Dramatization.
INTERACTION AND PARTICIPATION:
Playing in group of therapist & peers to improve Co-
operation.
Use of expressive language & gestures to improve linguistic
skills of the child.
In play based therapy, following approaches were used-
1) Free Play[3,5] which is intrinsically motivated, fun and is
performed for its own sake. Free play helped childs
inherent potentials to come out and allowed for exploration
and expression of selves.
2) Mother-child intervention techniques [5]-which included
Parent child taking turn during interactions
Face to face interaction
Decrease physical directives
Use of wh questions that continue established topic
of conversation and are developmentally appropriate.
3) Parental modelling which included modelling of required
roles by mothers and imitation of childs behaviour
Home program was also explained to parents.

Data Analysis:
Statistical method used:

IJOT : Vol. 46 : No. 2 43 May 2014 - August 2014

 Table 2
Comparison of means of RKPPS scores- pre and post Play based Occupational Therapy intervention:

Table 3: Comparison of Mean RKPPS scores

Above graph shows that there is 13 % improvement in means

of RKPPS scores pre and post intervention.

IJOT : Vol. 46 : No. 2 44 May 2014 - August 2014

 Table 4
Comparison of Total scores of RKPPS (Pre and Post
intervention)

Table 6
Comparison of scores of RKPPS ( Dimension : Space
management)

Sr No. PRE POST Expected Play Age

1 15 18 30
2 15 18 36
3 12 15 28
4 19.5 23 30
5 18.5 25.5 36
6 19.5 22 32
7 20.5 25.5 36
Table 5
Comparison of scores of RKPPS ( Dimension : Material
8 22.5 26 38
management) 9 18 20 28
10 20.5 23 30

IJOT : Vol. 46 : No. 2 45 May 2014 - August 2014

 Table 7
Comparison of scores of RKPPS ( Dimension : Pretense-
symbolic)

Discussion & Conclusion :

On the basis of above represented data, improvement was
observed in play behaviour of children diagnosed as Downs
Syndrome. There was overall improvement of 13 % in Total
RKPPS score following intervention, t value for which was
8.13 at the confidence interval of (17.95 1.63) to (22.1 1.63).
11% in the dimension of Material Management,t value for
which was 8.6 at the confidence interval of (19.75 1.29) to
(23.2 1.29),10.8 % in dimension of Space Management, t
value for which was 7.6 at the confidence interval of (18.1 1.47)
to (21.6 1.47).13.8% in Pretense-symbolic, t value for which
was 6 at the confidence interval of (17.4 2.39) to (21.9 2.39).
& 14% in dimension of Paticipation,t value for which was
5.47 at the confidence interval of (17.8 2.67) to (22.4 2.67).
More improvement in area of participation can be attributed to
enhancedmother child interaction as a part of therapyprogramme.
Least improvement was seen in area of Space management which
can be attributed to low postural tone, Delayed balance and
equilibrium reactions, Lack of postural control during activity
performance (for eg. Difficulty in maintaining the required
posture during play activities).

Table 8 The improvement in play behaviour was found to be statistically

Comparison of scores of RKPPS ( Dimension : Participation)
significant as the data analysis showed significance at the level
of P < 0.001 .
The results are very much similar to those found in the study
titled MotherChild Play: Children with Down Syndrome and
Typical Development by P. Venuti, S. de Falco, and G. Esposito
and Marc H. Bornstein. In conclusion, they observed essential
maternal contributions to child play development in children
with Down syndrome that seemed to be achieved through
mothers adaptation to their childs limitations and potentialities
alike. Also, the strengths in mother child play that could
represent areas of potential remediation through intervention
for children with Down's Syndrome.
Conclusion:
Thus it can be concluded that play based therapy was
effective in improving play behaviour of children with
Downs Syndrome.

IJOT : Vol. 46 : No. 2 46 May 2014 - August 2014

Hypothesis testing:
The alternate hypothesis of the study Improvement in play
behaviour of children with Downs syndrome is statistically
significant with play based Occupational Therapy was accepted
as all the subjects included in the study showed a statistically
significant improvement in their play behaviour following a
month of Play based Occupational Therapy intervention.
The improvement in play behaviour was found to be statistically
significant as the data analysis showed significance at the level
of P < 0.001 .
Thus, Null hypothesis was rejected.
Limitations:
Small sample size
Short studyduration
One arm Cohort Observational Study
Further Recommendations:
Similar study can be carried out on a larger sample after
sample size calculation. This study can be used for sample
size calculation.
Duration of study protocol can be increased so that the
long term effects of the therapy can be evaluated.
Similar study on an older age group can be carried out with
some different assessment tool so as to detect areas of
development which are lacking.
A randomized controlled trial can be conducted to study
the efficacy of play based therapy in comparison to other
therapies.
References:
1. Willard &Spackmans Occupational Therapy; E. B. Crepeau, E.S.Cohn,
B.A.B.Schell; 2003; 10th edition; Lippincott Williams & Wilkins
publication.
2. Willard &Spackmans Occupational Therapy; H.L.Hopkins, H.D.Smith;
1993; 8th edition; J.B.Lippincottcompany.
3. Occupational Therapy for Children; Jane Case-smith;2010;6th edition;
Mosby Elsevier publication
4. Down Syndrome Research and Practice,1994; vol. 2(1); pg 31-35.
5. Understanding play: The Implications for play assessment ,Australian
IJOT : Vol. 46 : No. 2
Occupational Therapy Journal, 2004,vol.51,pg. 3-12.
6. Teaching & Learning, Pamela Sharpe, vol.17(2),pg.87-92.
7. American Journal Of Occupational Therapy,2009, vol.114, no.4,
pg.274-278.
8. National Down Syndrome Congress, www.ndsccenter.com
9. Down Syndrome Educational Trust, ww w.downsed.org
10. Down Syndrome. Com, www.downsyndrome.com
11. Social development for individuals with Down syndrome - An overview,
www.downssyndrome.org
12. Ancy Parry Bledsoe, A Study of reliability and Validity of a Preschool
Play Scale (pediatrics, developmental disabilities, play, research)
AJOT.36.12.783
American Journal of Occupational Therapy, December 1982, vol. 36
no. 12, 783-788
13. Hilda Harrison and Gary Kielhofner, Examining Reliability and Validity
of the Preschool Play Scale With Handicapped Children, American
Journal of Occupational Therapy March 1986, vol. 40 no. 3, 167-173
14. Stagnitti, Karen; Unsworth, Carolyn, The Importance of Pretend Play
in Child Development: An Occupational Therapy Perspective, The
British Journal of Occupational Therapy, Volume 63, Number 3, March
2000 , pp. 121-127(7)
15. Play based Occupational Therapy International Journal of Disability,
Development and Education,Volume 46, Issue 3, 1999.
16. Development of play behavior in handicapped and normal infants,
Topics in Early Childhood Special Education, October 1982 ,vol. 2,
no. 3, 14-27
17. K. E. Wisniewski M.D., Ph.D.*,Down syndrome children often have
brain w ith maturation delay, retardation of growth, and cortical
dysgenesis, American Journal of Medical Genetics, Supplement:
Trisomy 21 (Down Syndrome) ,Volume 37, pages 274281, 1990
18. Barbara H Connolly and Beth T Michael, Performance of Retarded
Chi ldren, W ith and W i thout D ow n Syndrome, on the
BruininksOseretsky Test of Motor Proficiency, Physical Therapy, March
1986 ,vol. 66 ,no. 3 344-348
19. Petrisiamunday hill, Pretend play and patterns of cognition in Downs
syndrome children, Child Development , Vol. 52, No. 2, Jun., 1981
20. A systematic review of the effects of early intervention on motor
development, Developmental Medicine & Child Neurology,Volume
47, Issue 6, pages 421432, June 2005
21. Association for Play Therapy, Carmichael, 2006; Landreth, 2002;
OConnor & Schaefer, 1983,Gil, 1991, Landreth, 2002, Pedro-Carroll
& Reddy, 2005, Moustakas, 1997,OConnor & Schaefer, 1983; Reddy,
Files-Hall & Schaefer, 2005
22. http://www.aota.org/About-Occupational-Therapy/Professionals/CY/
Articles/Down.aspx#sthash.utc9nMrF.dpuf
Appendix - 1 on page no. 16
47 May 2014 - August 2014
IJOT : Vol. 46 : No. 2 48 May 2014 - August 2014