Working at Play
The playroom of Kennedy Krieger Institute's Achievements program doesn't look like a typical child's playroom. There are no blocks, books, dolls or trucks lining the shelves or scattered about the floor. In fact, the room seems practically devoid of toys, those things that inspire the imaginations of children but it's not. They're here, stored neatly in clear plastic bins, one to a container, each labeled with a picture and a word describing its contents.
This room at Achievements has been carefully engineered to be easily navigated by children with autism, whose neurological impairments interfere with their natural ability to play. For most children, playing is a spontaneous act, inspiring a host of social and communication skills that are important to healthy development. Children with autism and other neurologically based disorders, as well as traumatic brain injuries, often have impairments that make it difficult to play in traditional ways. But with therapeutic interventions, support and special environments such as the highly organized playroom at Achievements, play for these children is becoming less work and more fun.
Breaking play down into steps
Children with autism disorders have trouble playing because of neurological impairments that interfere with their ability to interact with their environments. These are children who explore their environments in an idiosyncratic fashion, not allowing others to fully participate. They do not play with toys in a conventional way; they must be guided. And that is essentially what Achievements Speech/Language pathologist Emily Tyson is doing when she directs 5-year-old Keith Carter to a small table by the window in the playroom. It is time to play with blocks.
"Shapes" reads the bin on the low table where they sit. Tyson points to the picture beside the word a ball and blocks and she encourages Keith to pick out the triangle block and drop it in the appropriate hole. Not only does she cue him with the picture as she speaks to him, slowly and distinctly, she uses American Sign Language. Though Keith is not hearing impaired, he has difficulty understanding the words he hears; it is as though what he hears is a foreign language that he cannot grasp for his brain does not process language appropriately. But through pictures and signs and a host of therapeutic interventions, Keith and other children like him can develop some capacity for using spoken language.
Much of the therapy that children receive at Achievements is aimed at teaching them how to play, for play requires the very skills that autistic children lack: communication, interaction with peers, the ability to engage in meaningful sequences of activities. Keith may lack the skills to play, but he obviously has the desire. When his teacher produces a big blue pompom, he shakes it, delighting in the motion, and he snaps it in her direction, teasingly, as though he's going to swipe her with it. He chortles with delight at the prospect. But that is where it stops. In spite of the teacher's response and her cueing, the gesture is isolated. What seemed an overture, the beginning of a game, is fleeting and never goes beyond an inclination. "Play requires sequencing and social interaction, and Keith doesn't have the natural ability that unaffected children have for that," Tyson explains. "So we teach him, step by step."
The teachers and therapists at Achievements take children like Keith through the motions, and through their repetition, they learn the sequence. Eventually, they generalize it into their everyday interactions. Keith's grandmother, Diane Armstrong, testifies to that. "Keith has really come out since he came into the program. Before, it was like he was in his own little world. Now he plays - but they've made him do it. I remember he used to be afraid to go up a ladder [to a slide]. His teachers made him do it, step by step, and he learned. But he was just never inclined to do it on his own to explore, like other children."
The staff at Achievements is looking forward to the completion of a new playground, made possible through funding from the Chatlos Foundation and the Goldsmith Family Foundation, that is under construction on Kennedy Krieger's Greenspring Campus where Achievements is located. "It will enable us to provide children with incredible opportunities to acquire the skills they need to play," says Tyson. "The playground provides a highly motivating environment to teach language and play skills through movement." She explains that she will use picture symbols in the classroom that correspond to pictures labeling the equipment outside to plan sequences of activities, such as, "First slide, then swing on the tire, then climb up to the platform." A picture schedule will allow Keith to organize his play, as he will revert to his compulsive, repetitive movement without it. "For Keith, the slide is just the beginning," Tyson says. "There's a whole new playground and world out there for him to explore!"
Inspiring motivation, learning through play
Youngsters at Kennedy Krieger's rehabilitative unit for children and adolescents with brain and spinal cord injuries are, on the other hand, relearning how to play. The purpose of the unit's Child Life and Therapeutic Recreation Department is to improve or maintain children's physical, cognitive, emotional and social functioning through recreational activities. A peek into the game closet in the department's therapeutic playroom conveys the complexity of the challenges that these young patients face. Aggravation, Amnesia, Bonkers! Clue, Memory, Monopoly, Out-Burst! Rage!, Risk, Sorry, Solitaire, Scattergory, Uno, and The Game of Life. In the cases of the children here, the names of these games have literal meaning. A child may engage in a game of Clue, not just for fun, but to help her re-establish the memory and inductive reasoning skills that were lost as a result of a traumatic brain injury.
On this day, 9-year-old Da'Naisha Cox hoots and hollers her way through a rousing game of air hockey with her therapist, Sharon Borshay. Da'Naisha is lithe, possessing of that special gracefulness held by all natural athletes. Da'Naisha was an athlete in the making before the seizures caused by Lennox Gastault Disorder, a form of epilepsy, became severe. According to her grandfather, she walked at 9 months, and he proudly recounts how she rode her bike around the entire perimeter of Fort McHenry Park, without training wheels, when she was only 5. But following a prolonged seizure a month ago, Da'Naisha is now challenged by difficulty with speech and movement. As she sweeps her arm across the board to intercept the puck and keep her opponent from scoring, the motions are inexact, and her commentary through the course of the game slurred beyond recognition. But the desire is there, the desire to play. Caught up in the spirit of competition, she reaches further with her arm than she otherwise would, and her attempts at communication are persistent for after all, she must know who is winning and what's the score. Da'Naisha has challenges to overcome, and play will be a major tool in the rehabilitative process. "Play is what engages children," says Borshay. "In this department we use play, games, toys and humor to motivate the kids and keep them learning. Play is how we get kids to cooperate, to take part in their recovery, to go the extra mile."
Creative environment heightens children's senses
Meanwhile, in a highly specialized setting at Kennedy Krieger affiliate, PACT: Helping Children with Special Needs, play is being taken to a whole new level. In the recently completed multi-sensory playroom, made possible through a grant from the Garth Brooks Foundation, children with a wide variety of neurologically based disorders are given opportunities to experience sensory stimulation that their disabilities would otherwise preclude. Toys and objects specially designed to provide high contrast colored light are perceptible to children with visual impairments. For children with hearing impairments, there are cushions that vibrate with the pulse of music, giving them a means to experience the sound. The special equipment in the multi-sensory room gives the children at PACT tools that enable them to play, and through their play, to develop cognitive skills that might otherwise be unattainable.
The stimuli in the room can be controlled to meet children's individual needs. For a child who is unable to filter stimuli from the environment, and therefore is prone to becoming too distracted to concentrate and learn, the lighting can be dimmed, soothing music played, and his attention turned to a toy or a game that targets development of specific skills. For a child whose impairments cause sensory deprivation or lowered motivation, the room can be transformed into a highly stimulating environment. On the occasion of 2-year-old Terrance Ridley's therapy session with his speech/ language pathologist Holly Gardiner, the room takes on the atmosphere of a discothèque.
As Terrance sits in Gardiner's lap, he watches a floor-to-ceiling Plexiglas column filled with bubbling, colored water, and he is wide-eyed with amazement. Gardiner guides his hand to the big blue button on a switch box she has placed in front of them and presses his hand to the button. The water turns blue! Clearly excited by the effect, Terrence raises his eyes to take in the full length of the bubbling tube, in itself an achievement for this boy who is challenged to use a full range of vision. Terrance's visual impairment is but one manifestation of the cerebral palsy that his limits range of motion, muscle control and strength, impacting his ability to sit, walk, reach and speak. But over the course of this session, Terrance reaches for and presses the button, sits with less support than he generally requires and uses his right hand, that which is most affected by excessive muscle tone problems and which he seldom favors.
The contrast between light and darkness provided by the bubble column and other apparati in the room provides useful visual opportunities for 3-year-old Quanir Johnson, as well. Quanir is visually impaired and has cerebral palsy and serious cognitive deficits. In the multi-sensory room, Qaunir is held in a supported position by his occupational therapist, Dan Eisner. His speech/language pathologist, Nancy Solomon, is nearby. When presented with long, plastic spaghetti-like strands of light, Quanir holds up his head and his eyes move, tracking them. Solomon is pleased to see him responding to the environment and encourages him to imitate the vowel sounds she makes the beginnings of communication. Not today. Quanir is so relaxed by the experience that he is falling asleep. His therapists are very pleased with his accomplishments and a discussion ensues as to how they can use the room to achieve therapeutic goals of other children in their care.
"Play, whether it is constructive play, such as Legos, or symbolic play, such as playing house, requires sophisticated planning, organizing, language and understanding of basic rules of social interactions," says June Goodman, clinical director of the Center for Autism and Related Disorders.
"Teaching play is fundamental. It gives children the building blocks for engagement in the real world."