PLAY IN INFANCY AND APPLICATION IN TREATMENT*

The theoretical principles of play according to Piaget are described. Six stages of play up to two years of age are detailed, whilst play relevant to the transition from infancy to childhood is mentioned. The application of play in assessment, parent counselling and treatment is discussed.

The Developm ental Assessment Clinic at the Red Cross W ar M em orial C hildren's H ospital in Cape Town, deals with children who are physically or m entally handicapped as well as those who are socially dis advantaged. Some who are considered to be 'at risk' in infancy continue to undergo comprehensive periodic assessment during their pre-school years.
In order to m ake the assessment procedure pleasureable a play situation, which served as a prelim inary to m ore form al assessment, was created within the clinic setting. D uring these observations it was found that * Originally published in the N ewsletter of the S.A.
N eurodevelopm ental T herapy A ssociation, 2, 3, 2:11 and reprinted by kind perm ission of the editor. play could provide an alternative form of assessment in its own right and, m oreover, serve a useful guide in planning treatm ent and for p arent counselling.
T here are m any ways in which play may be defined. Children, adults and anim als play, and different cultures have their own form s of play. Sheridan's definition, 'Play is the eager engagem ent in pleasurable physical o r m ental effort to obtain em otional satisfaction', is appropriate to the observations th at will be discussed. N orm s of child developm ent used as instrum ents for observation and diagnosis reflect the m aturation of patterns of behaviour in infancy and the integrity of th e neuro-m otor system. These provide a yardstick with which to m easure progress and a guide for tre at m ent, b u t deal very little with play as a natural and spontaneous function.

FISIOTERAPIE
DESEMBER 1979 Sheridan (1977) went a long way to bridge this gap when she supplem ented her scales of 'C hildren's De velopm ent Progress from birth to 5 years', with an interpretive analysis of 'Spontaneous Play' in 'Early C hildhood', but there rem ained the problem o f in sufficient insight into the underlying processes that could explain observations made. A n attem pt was made to find the clarification required and to apply this to the existing needs. Piaget (1951Piaget ( , 1953Piaget ( , 1969) explains m ental functions by their m ode of form ation. He refers to the first two years of life as th e sensori-motor period and b e lieves that it is during the first eighteen m onths that the child constructs the cognitive substructures which serve, as a foundation for his intellectual and perceptual developm ent. C entral to Piaget's description of sensori m otor developm ent are the action-schema, the circular reaction and the role of imitation.

THEORETICAL PRINCIPLES
An action-schema is a co-ordinated pattern of be haviour, involving m ovem ent and perception. As de velopm ent proceeds, every newly established neurom otor perceptual action becomes integrated into an action-schema.
A circular reaction is a behaviour pattern which is repeated for the pleasure of prolonging it or for an interesting result. A circular reaction is self-m otivated and inherently satisfying. Its crucial factor is the active element. T here are three types of circular response. The first or prim ary circular reaction is a behavioural adaptation to an hereditary mechanism or reflex. For example, sucking becomes stronger through satisfaction and repetition. The secondary circular reaction occurs because an accidental occurrence provokes repetition -for example, an object accidentally shaken, makes a noise and is shaken again. The tertiary circular re sponse occurs when an activity can be varied because of feedback. T he infant may m ake several attem pts to switch on a light, using action schemas within his re pertoire, but varying them slightly each time. If he succeeds, he repeats the activity over and over again for the pleasure of m astery of his own power.
Imitation is dependent on the social-affective environ ment. It begins in early infancy and continues through out life. Piaget describes six stages of im itation in infancy.
1. The first sounds a baby makes are self-initiated. The m other responds to these signals with sensitive timing. She repeats the sound which the baby again im itates and thus the 'conversation' is prolonged. Piaget  toire. H e is therefore able to echo new words and im itate simple domestic events which are concerned with his own behaviour. 6. Finally, at the end of the sensori-m otor period, the baby is able to reproduce sounds and move m ents heard previously. In other words imitation can be based on memory. Piaget calls this 'de ferred im itation'. This period m arks the em an cipation from sensori-m otor connections and indi cates the emergence of symbolic activity. The continuing developm ent of language is part of the symbolic process. Piaget considers th at the ap pearance of symbolic behaviour is the crucial point in the interpretation of play. Bruner (1974) believes th at 'm astery play' is crucial for developm ent during the first eighteen m onths and that it consists of extending to new limits already achieved skills. Stated differently, he says th at play consists of pleasure-giving variations of newly acquired routines.
Bruner believes th at initial learning has a large ele m ent of pre-adaptation which reflects species typical; genetic instruction. W ith this in mind, his studies oil com petence in infancy have been prim arily concerned with visually guided prehension and the transition from unilateral to bim anual m anipulation. It is this ability which leads to tool m aking and distinguishes the hum an species from others.
According to Bruner skilled activity specifies an objective to be achieved. T he crucial issue in the regulation of intentional action is the opportunity to com pare w hat was intended with what in fact resulted, using the difference between the two as a basis for correction. H e refers to this as 'internal feedback' which signals an intended action w ithin the nervous system. B runer's description of the m aturation of visual attention in association with prehension and the develop m ent of bim anual activity are of particular relevance to a detailed observation of infant play.
As well as the theoretical principles of Piaget and Bruner and the observations of Sheridan, further analysis of play by Lowe, (1975), Tizard, Philips and Philips (1976), Sinclair (1970) and R osenblatt (1977) have been used.

STAGES OF PLAY
The following is a sum m ary of stages of play whichis being used as a guide in developm ental assessm ent) Observations have confirmed th at although age levelsL are to some extent arbitary, the sequence is invariable.

Stage I 0 -6 weeks
In the neonatal period innate reflexes are re-inforced by practice. The baby is visually highly distractable, but there is m om entary visual fixation on faces or moving objects. Visual attention is directed towards a stimulus and he is attracted by targets with good visual ground properties. If his head turns his eyes remain fixed on the target.
H and to m outh activity which began as a reflex, is perpetuated by practice and becomes a voluntary act.

-1 6 weeks
Vocal contagion continues. Visual attention can be shifted from one target to another w ithout much interm ediate drifting. (Bruner states th at this is the visual m atrix in which m ovem ent of the hand can be appreciated. The infant not only recognises w hat the hand is, but where it is.) Presentation of a suitable object induces activity of the baby's arms, opening and closing of the hands and m ovem ent of the mouth.

-6 m onths
Sounds previously practised by the baby, if initiated by the m other, are repeated by the baby.
The baby sees an exciting object, moves his limbs, accidentally touches the object and repeats the activity.
H e reaches, grasps, retrieves and mouths single ob jects using one hand at a time. Full visual inspection ^c o m p a n ie s the act. The hand is shaped to grasp as 'h e reaches forward and the m outh opens in advance. H e begins to pass the object from hand to hand, but retains only one object at a time.

-8 m onths
The baby continues to initiate new sounds and gestures which his m other im itates and the baby reimitates to prolong the activity.
M other now can initiate m ovem ent which the baby is able to im itate, if his own movements are visible to him, e.g. clap hands, wave bye-bye. Single objects are shaken, waved and banged. A pleasant result p ro vokes repetition. Shaking, waving or banging schemas are used on all objects. The m outh rem ains as the term inal phase of activity, but this action no longer re quires full visual attention.
A n object can be retained in each hand.

-1 2 m onths
Actions within the baby's repertoire which are not visible to him can now be im itated, e.g. facial grimaces, hand to face movements. X Babbling begins, initiated at first by the baby and Viitated by the m other.
Bim anual activity begins. The baby can now hold an object steadily in one hand and explore parts of it with the other. H e is able to hold two objects and click them together.
A cquired action-schemas can be applied to new events, e.g. objects may be dropped deliberately from varying positions. A n object can be retrieved by moving an obstacle aside if the baby has watched it being hidden. H e still uses only one hand for both moving the obstacle and retrieving the object.

-1 8 m onths
The baby is able to im itate new sounds and gestures not seen or heard previously. Thus he begins to echo new words and im itates new gestures. However, he discontinues if the model for im itation is n o t visible or audible.
Through im itation single object representation begins, e.g. baby dials the telephone or puts the telephone to his ear, b u t does not combine the two, brushes his hair, scribbles with a crayon.
Bim anual activity m atures. Play becomes m ore appro priate to the m aterial and two objects are combined. Thus objects are placed on top of, beside or into one another. Lids are removed and replaced. Long chin objects are placed into holes.
A ction schemas can now be altered because of feed back and a type of trial and erro r for a desired result begins, e.g. switching on a light, turning a knob.
W ith the advent of bim anual activity, m outhing is greatly dim inished.

Stage V I 18 m onths -2 years
Im itative behaviour can now take place in the absence of an im m ediate model. The child begins to reproduce words heard previously and im itate events previously seen.
H e reproduces representational schemas associated with his own behaviour, using two or three objects as props. F or example, he m anoeuvres a steering wheel and pretends to drive, pretends to feed him self using a cup and a spoon, pushes a car making appropriate noises.
Play with a doll, at this stage is still indiscriminate. Bim anual dexterity is sufficiently advanced to solve simple problems, e.g. a lid can be lifted with one hand and an object retrieved with th e other while the lid is held open.
A ccording to Piaget the infant in the sensori-m otor period does n o t have any m ental representations by which he can evoke persons o r objects in th eir absence; th at is, he lacks the symbolic function. H e believes that the appearance of symbolic behaviour is a crucial period in the developm ent of intellectual function. It is the m eans by which the child can assimilate reality t > his own desires and interests. Furtherm ore, the < 'lild's language at this stage is unsuited to express his living experience so th a t he requires a means of self expression suited to his needs. The m eans of selfexpression that he uses is play which may be purely representational or symbolic. P iaget calls the next stage in developm ent the preoperational stage, which continues until the seventh year. This stage is beyond the scope of a discussion on infant play, bu t during the child's third and fourth year specific elem ents of play can be distinguished w hich are relevant to the stage of transition between infancy and childhood.
These are: Practice play -in which the child consolidates his sensori-m otor powers. H e repeats and varies ac quired activities for pleasure and mastery. No repre sentation o r symbolism is involved. Examples of this type of play are filling and pouring, throwing pebbles into water, pushing one object with another, pushing a wheeled toy down a slope.
Constructive com binations -in which the child experim ents with educational toys. Play may be con structive or destructive. Simple objects are placed in lines or clusters, objects are sorted by colour and shape. E laborate constructions may be made for the process alone, and the representational im agination added by exclaiming, 'I 've made a house'.
R epresentational schemas. W hereas in .the sensori m otor period domestic mimicry was related to the child's own behaviour, these schemas are now projected onto som ething else. R epresentational play now becomes sex-appropriate. D oll-related play becomes dom inant using a com bination of appropriate domestic objects. G irls feed their dolls, w rap them up, comb their hair. L ittle boys are m ost likely to recreate schem as in volving m otor cars, accidents or sim ilar incidents, given

FISIOTERAPIE DESEMBER 1979
suitable m aterial. In representational play, using appro priate material the child will "Cook like mum m y" or "Work like daddy" . Symbolic play. This occurs when the child can identify himself as som eone else, e.g. playing th at he is mummy, postman, shopkeeper. If realistic m aterial is unavailable the child can improvise by using substitute items. A chair may be used as a m otor-car and the use of a steering wheel may be mimed.
R epresentational play precedes symbolic play in the developm ental sequence, but it may frequently be indistingishable from it as the child adapts the situation to his needs. Both representational and symbolic play signify the presence of a language process.
Games with rules. These emerge in the slightly older child and increase in im portance as social life is en larged.

APPLICATION IN TREATMENT
The skill of the therapist lies in her ability to adapt her knowledge of norm al developm ent to the needs of the handicapped child. P iaget's theory describes the m eans by which the normal infant improves 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 understanding of objects and his relationship with them and is ready to use newly developed powers of sym bolization. The emergence of symbolic or make-believe play is the culm ination of the experience he has gained in the sensori-motor period.
If Piaget's theory is to be applied in practical terms the following should be kept in mind: The importance of preverbal communication: Piaget believes that in the first few m onths of life it is the infant who initiates a vocal sequence and the m other who reinforces it by im itation. A survey of current research in Britain carried out by Tizard, (1975) indicates that there is considerable evidence to substantiate this.
As vocalising in handicapped and retarded children is often delayed, the baby's signals may be too weak to be recognised. It may be possible to assist the com m encement of reciprocal vocalisation b y 'm a k in g the m other aware o f her need to imitate the sound that her baby makes, even if these seem to be inappropriate for his age. T he therapist can augm ent this process further by im itating the baby's vocal efforts during treatm ent.

The opportunity to learn by imitation:
If every effort is m ade to capture the child's visual attention, early m utual im itation of hand and face movements can be encouraged. It will be remembered that several stages of im itation occur before a child is able to carry the image of an event in his mind and reproduce it spontaneously. Dom estic mimicry is an im portant stage in the transition from sensori m otor to representational play. The handicapped child requires endless opportunity to observe the activities of the household and needs to be given suitable re presentative objects with which to play.

The necessity for active engagement in play:
Action-^result-^feedback-^repetition of the action, are the com ponents of the circular reaction. The child's own actions are the only m eans by which he can dis cover the properties of objects and his effect on them. W hen a child's physical ability is limited or distorted, this poses many problem s. Careful assessment and selection of suitable toys should assist in overcoming these problems.
H andicapped and retarded children may proceed very slowly through each stage of developm ent. At times a change of direction in play may assist in planning the next stage of treatm ent. One example of this is the problem of prolonged m outhing o f ob jects that som etimes, occurs when a child does not develop a firm bilateral grasp. If treatm ent effectively enables the child to retain his grasp in both hands simultaneously, bim anual activity can commence and m outhing is slowly reduced. In the norm al baby bilateral grasp coincides with his ability to pull up and support him self in standing.

CONCLUSION
Successive stages of play with objects in infancy aniR. early childhood have been described. By combining theory and observation an attem pt has been m ade to apply the knowledge gained to the treatm ent of handi capped children.
It is doubtful w hether it is possible to 'teach' 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 permits.