Play is often talked about as if it were a relief from serious learning. But for children, play is serious learning. Play is really the work of childhood.”

Play – the universal language of all children. The tool and means for children to learn and explore the real world.

As a Child Life Specialist who helps children cope in medical settings, I get to witness the extraordinary effect that play has on a child – whether the child is engaging in play as a distraction from a stressful or invasive procedure, playing as a way of normalizing the medical environment they are in or by engaging in medical play for the purpose of familiarizing themselves with medical tools – it is truly amazing .

As Pediatric Occupational Therapists, Christine and I also recognize play as being one of the primary occupations or meaningful daily activities for all children. Play builds confidence in children, fosters creativity and self-expression, and improves social skills, problem-solving skills, fine motor skills, gross motor skills as well as visual motor skills.

For parents or supportive adults like yourself, it is important to encourage opportunities for children to engage in free play, whether it is indoors or outdoors. This blog post will discuss the different types of play, how to play with children to enhance their motor and cognitive skills and ways to support children who may need assistance in engaging in play.

Types of Play

There are several types of play. Most of them are observed to occur at various developmental ages and stages. Some children, especially children with special needs, shy children, and/or children that do not have opportunities to play with other children, may need some support from caregivers to acquiring skills in and/or learn various types of play.

Here are some common types of play:

• Solitary play– this type of play is when children are playing with objects or toys by themselves, and do not seem to be observing or engaging in the environment around them during this play. Ex. Using a shape shifter.
• Onlooker Play – this is when a child is looking at other children playing without the desire to join them Ex a child watching children play on the playground while sitting on the bench
• Parallel play– This is when children are playing near each other, but seem to be doing their own thing, and are not engaged with each other. They may look at each other occasionally but they are not usually trying to influence their peers. Ex. One child is building a block tower at a table while another child is playing with a car on the same table.
• Associative play- This is usually when a child seems to be more interested in their peers and their play. Children are more engaged with each other, and there isn’t usually structure to their play. Ex. Two or more children are building their own block structures in the same area, sharing blocks.
• Imaginative play- Children are imagining worlds, roles, and situations, and encouraging other children to participate in their imaginary situation. Ex. One child is a veterinarian, another child has a sick stuffed animal pet.
• Cooperative play– When children work together for a common goal. Ex. Organized sports, playing board games together, building a sandcastle together.

Helping your child to get the most out of their toys:

Children may not always know how to play or engage with the toys that are given to them. Children that are young, have special needs, and/or have never seen that type of toy before may need an adult to show them how to use their toy to maximize their learning.

While some toys may seem to have limited uses, there are many ways to enhance your child’s learning by using any toy they are given. Here are some examples to do just that:

Language

Using a lot of language while playing any toy is essential in increasing your child’s vocabulary and receptive skills. Teach your child the names and various properties of the toys. For example, “this is a toy car. The colors on the car are red, black, and white. The car is small, feels hard and has a smooth surface; the paint is shiny”. It is also important to narrate your own actions as well as your child’s when playing with the toys. “I am rolling the car up a hill. Vroooom… beep beep goes the horn. I see you are stopping the car from getting across, I will drive around you”. The more language you use, the more you are encouraging your child to understand and/or use language during play.

Promoting Social Skills

Using any and all types of play is great to improve a child’s social skills. Set up situations where your child has to share, and/or ask for toys. Thank them if they let you use the toy. Drawing rainbows? After verbally going over the colors in a rainbow, hold onto the green and purple crayon, that way when they get to those colors in the rainbow, they have to ask you for the crayon.

Following Directions

Play can be a great way to teach your child how to follow one step, or multi-step directions. Whether it is during an organized game, or imaginative play. Start with giving simple, and clear one step directions, and gradually increase the complexity of the directions and number of steps. For example, while playing Simon Says, you can practice one step commands such as “touch your nose” or advance to multi-step directions such as “touch your nose then touch your ears”.  While engaging with blocks, you can have your child place the red block on top of the green block to have them practice following directions.

Modeling

Since most children are visual learners, it is important to model or show your child how to perform any task you want them to perform with an object or toy. It is also important to note, that you should always try to model how to use new objects, perform new tasks, or play with new toys.

For example, when attempting to brush a doll’s hair, you pick up the doll, place it in front of you, grab the brush, and show your child how you hold the doll with one hand and brush the hair with the other, moving the brush from the top of the doll’s head to the tip of their hair. Then, give the doll and brush to your child and verbally encourage them to do the same. If needed, gently place your hands over or under your child’s hands and perform the action with them. Gradually reduce the amount of help you give them, until they can brush the doll’s hair on their own.

It is also helpful to use toys to model real life activities such as potty training, wearing a mask or going to school. When kids see their favorite toys engage in certain activities with them, it can increase compliance and reduce challenging behaviors associated with those activities.

Facilitate Self-Expression:

It is always great to use play as a means for children to express themselves and showcase any suppressed feelings. For example, after a stressful doctor’s visit, you can play ‘doctor’ with your child to see how he or she may have felt during the visit. When your child is observed to aggressively insert a toy needle into her doll’s arm, that can reflect how she perceived the needle she had gotten. This type of play allows parents an opportunity to address these feelings in a safe space. “Seems like that pinch doesn’t feel too good, but I also see how quick it was to go away!”. Similarly, pretending to play a scene from your child’s day at school or an encounter they had at their friend’s house can be a great way to practice safety, social skills and develop appropriate coping strategies when needed.

Physical Support

Depending on your child’s age and abilities, they may need some physical support when learning how to play with toys. They may need assistance in holding an item, manipulating it, putting it back, and playing with it. When giving physical support to your child, it is important to gradually diminish the amount of support you give them as they become increasingly more independent with the task. Some ways to provide this support is by placing your hand over or under your child’s hand while engaging and manipulating a toy, holding the item or toy for them, verbally reminding your child what to do next with the item, pointing to the object that they need and more.

Check out our ‘Toy Reviews’ tab on more ways to help foster your child’s acquisition of developmental skills with the toys you have at home or with some of our favorite toys that we have used during our therapy sessions. A new toy review will be released each month. Join the email listing to get it straight to your inbox.

And of course, always reach out with questions on specific ways to enhance various skills with your child’s favorite toys.

Is Child Life a subdivision of OT? Is Child Life similar to OT? Why did you become a Child Life Specialist – were you not satisfied with your OT career? – are just some of the many things I’ve been asked.

I get it.

Well to start, Child Life is not a subdivision of OT. In fact, Child Life is an entirely different certification and training. As a CLS I am trained to help children cope with the stress that comes along with any medical experience (ie. a hospital stay, Emergency Room visit, surgery, bloodwork – to just name a few). In efforts to  help children cope and deal with their anxiety in a medical setting, we provide developmentally appropriate education, procedural prep, distractions, medical play, normalization and recreational activities, sibling/family support, non-pharmacologic pain management and even bereavement and end of life support.  

As a Pediatric OT who works to help children with developmental delays gain functional skills, my Child Life training has enriched my work in so many ways. I absolutely love what I do as an OT. But after realizing the significant levels of stress my kids with Autism, ADHD and developmental challenges exhibit on a day to day basis, I wanted to become more skilled in supporting them emotionally before I can tackle any motor skills with them. And that’s exactly what the field of Child Life did for me.

Here’s a littkle break down on how the field of Child Life has enriched my work as a Pediatric OT: 

Coping in Hospitals

I knew that no matter how amazing of an OT I was meant to be or how well thought out my treatment sessions could be, if my pediatric patients are not coping well with being in a hospital setting, then in one way or another my sessions may be lacking. In order for my patients to be more receptive and engaging in a therapy session, they must feel comfortable and safe within the setting and with those they are interacting with.

OT’s who are working in a hospital setting – whether it’s outpatient, inpatient, acute or subacute – should be prepared to deal with children who associate the hospital setting with fear, anxiety and stress. This may be due in part to a past medical experience that did not go as well or perhaps an encounter with a medical staff that was not so pleasant.

A CLS can help ease the transition to medical settings in various ways. A CLS may debrief with a child regarding their past experiences or encounters, they may engage in medical play for the purpose of developing positive association to medical equipment as well as addressing fears in a safe space, they provide normalization activities to make the hospital environment less frightening, and they provide procedural prep for all events occurring during their stay.

Coping Skills during Anxious times

As a school OT, a lot of the children I work with deal with anxiety in similar ways a child at the hospital experiences anxiety. For my kids in the school setting, the anxiety may be due to a change in routine (such as the teacher being absent and thus having a substitute), unmet sensory needs, challenges in communication skills, pain, etc. I often carry my child life toolkit to help children relieve this anxiety before it escalates. Some things I have are bubbles or a pinwheel for deep breathing, sensory toys, distraction games such as iSpy, a stress ball, fidgets, and glitter wands.

Education

As an OT, part of our essential role during treatment sessions is to provide patient education on how to appropriately and effectively continue treatment at home. How we implement that education for the different age ranges is not something I was give extensive training in as an OT student.

However, as a CLS we are certified and trained in providing education that is developmentally appropriate for each pediatric age group while knowing how to assess which developmental level the child belongs to. Having this training makes it easier to connect with that child and ensure they are understanding the information in a way that best meets their developmental level. 

A child is more likely to continue therapy at home if the education is provided in a way that best suits their understanding through developmentally appropriate language and visual supports (ie dolls, images, videos etc).

Trauma

Stress in inevitable in all children. I’ve had students during my OT sessions who were completely distraught and unable to focus on their work due to what’s happening at home – ie. parents getting a divorce, the loss of a parent/grandparent, the loss of a pet,  moving, etc. This inevitably affects a child’s performance at school and should not be overlooked.

One of my students, who was unfortunately mourning the passing of her dog, was unable to work on her OT goal of writing. Our typical OT session involves writing 2-3 age appropriate sentences with a focus on her letter formation, spacing and alignment in addition to an activity working on her fine motor development (ie. strengthening the small muscles of her hands). Keeping those goals in mind while acknowledging her need to cope, I realized it was more therapeutic for her to write a memoir of her dog as a writing task, or creating a memory box with popsicle sticks for a fine motor activity. That way, although she no longer had her dog, she can still hold on to something tangible indefinitely. These activities not only became a motivating factor for this student to continue working on her OT goals, but they had a huge therapeutic component which was most important of all.

Restoring Family Bonds

As a CLS, we restore the parent- child bond or sibling-child bond when family dynamics change.  Parents often feel guilt from their child’s condition or may even struggle coping with their own stresses. A CLS makes sure to work on the family-child relationship as it affects all aspects of the child’s life.

I had a student for OT who unfortunately did not know her father had passed away a year ago. As any young six year old child, she was eagerly awaiting her father’s return from his ‘travels’. I soon found out that it was mom’s personal decision to keep this secret from her daughter in fear of how she may react. The student, who started to grow worrisome of her dad’s absence and may have gotten an idea of his reason for not returning home from older siblings, started to grow resentment towards her mother.

I spoke to the mother about the importance of telling her daughter the truth and the negative impact this can have on the parent-child trust. The concerned mom knew she had to break the news to her daughter but was struggling with the ‘how’. That’s where my CLS side was able to help. I was able to provide her with appropriate resources as well as information for support groups, leaving the mother full of gratitude and relief.

Had I not had that training as a CLS, I may not have felt comfortable having this conversation with the mom, let alone have those resources at hand.

Coping Skills for Family Members

As mentioned before, a family’s way of coping with a stressful life event inevitably affects the child’s own coping skills as well as their perception of the situation. Since a family’s style of coping is an influential factor to a child’s coping skills, a CLS can help families develop appropriate coping skills to better support themselves and their children.

Play

Play is the natural language of all children and an essential occupation for kids as well. It’s always great to be able to use play as a means to not only achieve pediatric goals as a CLS but as an OT as well. Having a background in Child Life has made me more creative in providing playful ideas when working with the pediatric population in addition to giving me more training in play based therapy approaches.

Whether I’m helping a child learn to manage fasteners, buttons and zippers on a toy doll in my OT session or teaching an IV prep on a similar doll during my Child Life session, I’m always appreciative of the fact that I can use this natural medium to help children learn and understand the world.

Creating Sensory Environments

As a means to help children cope in medical settings, a CLS aims to provide a calming sensory environment in what can be a highly overstimulating scenario. With that additional training in creating optimal sensory environments, I am more equipped at helping my children with sensory challenges during my OT sessions as well.

The extensive training in creating optimal sensory environments has helped me tremendously as a CLS as well. As a CLS and advocate for our Pediatric Emergency Department, I am now on the team to create the very first sensory room for our Pediatric ER! I’ve had the pleasure to use my training from both fields to come up with an amazing design for the sensory room that will help destress an anxious child before and/or after their ER visit.

With that being said, I also have the pleasure to be an ongoing guest lecturer for a Child Development Course where I teach Graduate Students of Education on how to create an optimal sensory classroom for their special needs students. Giving my graduate students strategies from both a CLS and OT perspective has been greatly insightful and well received.

Helping Children of Adult Patients  

Although I do not work with the adult population, CLS are also needed there. Not only does a CLS get called to support an adult who has developmental delays but they support an adult patient who may have children that are not coping well with the parent’s illness. Whether the parent has had a traumatic injury, a chronic illness, are in a coma or are preparing for end of life, the CLS can provide developmentally appropriate prep for the children as well as facilitate appropriate bonding activities specific to that child’s coping needs.

End of Life

End of life and bereavement support has always been the most challenging area to address even as a Child Life Specialist – making it that much more vital to our skillset. Having a pediatric patient who may be approaching end of life is something any pediatric healthcare worker should be ready to face. A CLS is trained to support a child and their family during this time and facilitate memory making activities for the families and their loved ones.

Questions?

If you’re a Child Life Specialist, Occupational Therapist, student in either field or someone who is interested in pursuing either career (or hey, both!) please feel free to reach out with questions. I will be sure to respond!

When it comes to our kids with autism, who are anxious at baseline, may be non-verbal and/or have sensory needs, it does not take much for them to reach high levels of anxiety. As a Child Life Specialist trained to support children in medical settings, I wanted to share tips on how best to support your child with Autism before, during and after their doctor’s visit.

Before the Visit

Social Stories
It is always important to talk to your child about their upcoming doctor’s visit, what to expect and why they will be going. Since most kids with Autism are visual learners, you can prep them using a story book or a social story. A social story is a short narrative that helps walk your child through a social scenario. If your child is non-verbal, try using images and language that is familiar to them and adapting the social story to their understanding. A social story can use the following phrases:

–  Mommy is taking me to see a doctor so he can help me with my tummy ache
– When we get there, mommy must sign my name, so the doctor knows I am here
–   I may have to wait with mommy in a special waiting area before it’s my turn to see the doctor. I can play iSpy with mommy while I wait.

The social story can be in first person, like the example above, or in third person using your child’s first name: Matthew is going to see a doctor. This helps them better relate to the scenario.

Incorporating actual images of the doctor’s office into the social story can be helpful so that your child knows what to expect when they get there. When showing images of the doctor’s office and/or reading a book about going to the doctor’s office, avoid pictures or illustrations of children with worrisome or fearful expressions as your child with Autism may pick up on those expressions. Kids with smiling faces are preferred to ensure that they will be okay.

Medical play

Playing ‘doctor’ using items that the child will most likely be seeing in the doctor’s office is a great way to familiarize your child before their visit, leading to a less stressful encounter with their doctor. Some things to incorporate during medical play can include a stethoscope (letting your child feel the coolness of the bell or diaphragm on their skin), a blood pressure cuff  (pretending to squeeze their arm), a thermometer to check their temperature, a scale to check weight, a tongue depressor to look inside their mouth and an otoscope to check inside their ears.

Having toys that resemble the actual tools are ideal in helping your child better make the association when encountering them in the doctor’s office. Playing with these items beforehand not onlyhelps them to be familiar with the tools and their purpose but also helps them associate these items with joy and comfort.

Medical play also gives you an insight as to how your child may be feeling about the visit. When your daughter tells her toy doll that the ‘thermometer won’t hurt’, that reflects her own understanding of the instrument. On the flip side, if she’s stabbing a needle in her doll’s arm, that too can reflect how she thinks needles feel. At that point it is best to address her concern during the play session, letting her doll know ‘you will feel a pinch but it’s quick to go away!’.

Be honest
Be honest when communicating to your child about their doctor’s visit. Avoid lying to your child by saying ‘we are going to the ice cream store’ instead of saying doctor’s office to avoid a stressful car ride. This can result in mistrust between the parent and child and may lead to an even more difficult transition to the doctor’s office the next time. Rather, be honest and let them know why it is important to go. “We will go see a doctor so he can let mommy know how to better take care of the tummy ache that’s been bothering you”.

Validate their feelings
It is important to let your child know that she is allowed to feel the emotions she is feeling saying things like: ‘it is okay to feel nervous or scared’. Avoid phrases like: ‘don’t be afraid’ since that may prevent them from opening up to you about their emotions. Validating their emotions helps them to feel understood which will lead them to be more transparent when talking to you about their concerns. This also builds trust between the parent and child.

Explain their role
Let your child know exactly what their role would be at the doctor’s office. Avoid saying: ‘don’t cry’ since crying is a natural and healthy coping mechanism for all children. Rather, validate their emotions and give them explicit instructions on what to do: “it is okay to be scared, but it’s important that you hold still so the doctor can listen to your heart and understand how best to help you”.  

During the Visit

Bring comfort items
Make sure to bring your child’s favorite toys, any sensory item that can help calm them downor a familiar item that helps to destress them. If there was a social story or book that was used to prep them for their visit, you can bring that along and continue to read it to your child as he or she goes through each step of the visit.
 
Communication Device
It is very important that your child is able to let you know exactly how he or she is feeling before, during and after their doctor’s visit so you know how best to support them and which concerns to address. If your child requires a communication device, make sure to bring it to their visit and use it intermittently to assess their feelings.

Give choices
Children cope better when they have more control over a situation. Whenever possible, give your child choices during their doctor’s visit: let them decide which chair to sit on, which arm to let the nurse take their blood pressure on, or which snack they will earn when they are all done with their visit.

Use language that sounds less frightening to your child
Using honest yet appropriate language with your child is key in helping your child feel more comfortable at their doctor’s office. Language that sounds less frightening will help you child better cope with the experience. For example, if your child is about to have her blood pressure taken, you can tell her that the machine will give her arm a nice tight hug rather than saying the machine will squeeze her arm.

After the Visit

Reward
Give your child a reward for their bravery! Regardless of how the visit went, they got through it and a prize is well deserved. It is best to let them know beforehand that they will earn a reward at the end of the visit, even giving them choices as to what they would like. The prize should be novel and exciting to them to encourage motivation.

Debrief
Always talk with your child afterwards, asking them how they felt the visit went. For our kids with autism, using a visual emotion scale is helpful in assessing how they feel after the visit. It is important to know what they liked and did not like to better support them the next time. This is also a great time to address any concerns and answer any questions they may have. You can even have your child explain to someone else (perhaps a sibling or friend) as to how their doctor’s visit went, to better understand their perspective of the experience.  

More Medical Play
You can always follow up with more medical play when you get home. If your child is non-verbal or is not as expressive with their words when telling you how they felt, they will be sure to express their emotions though play, the natural language of all children. Through medical play, you can have the childre-enact the visit, observing how they think the visit went. Your child may say things like ‘it’s okay to be scared, you just have to hold still’ which tells you they were able to internalize what was expected of them. If your child continues to show aggression, then they may still have fears that need to be addressed. That would be great opportunity to address concerns that may still be bothering your child for a smoother visit the next time.