Physio- and Occupational Therapists View of the Place of Play in Re/habilitation: A Swedish Perspective

ABSTRACT The aim of this Swedish study was to explore and describe physiotherapists and occupational therapists’ attitudes and understanding of the place of play in habilitation. This was a qualitative study, using semi-structured interviews exploring ten habilitation professional’s experiences and attitude towards play. Interviews were analysed using content analysis. The analysis of the interviews resulted in four categories (1) Play in the present or exercise for the future (2) Play is a useful tool (3) Play needs different prerequisites (4) Play is a shared responsibility. The categories represent the professional’s attitudes and understanding of play in habilitation. Results demonstrated that enabling play for the sake of play was a low priority in habilitation, despite the acknowledgement that it is a primary concern for children. The professionals focus was mainly on interventions that were remedial: about doing the right thing for the physical body and preparing the child for his/her life as an adult. There is a need to change perspective and incorporate interventions aimed at childhood as well as adulthood. Habilitation professionals need to reframe their anxiety for the future child and reconsider the place of play in practice.


Introduction
The importance of play in children's lives has been well documented for many years and play has been described as a fundamental part of a child's everyday life. There are many different definitions of play but no direct consensus exists due to the diverse disciplinary perspectives involved in researching play. However, play is often described as a complex and multidimensional phenomenon that has a significant role in children's overall wellbeing and cognitive, linguistic, emotional and social development (Piaget, 1962;Sutton-Smith, 2009;Vygotsky, 1967). According to United Nations (UN-CRC) General Comment on Article 31 (UN Committee on the Rights of the Child (CRC), General comment No. 17, 2013), play is a subjective experience of joy and fun that comes from freely chosen, intrinsically motivated, self-directed and meaningful occupations. Although the definition of play differs between disciplines, there is clear evidence showing that play is important for the health, welfare and development of children (Lester & Russell, 2010).
identified that occupational therapists and physiotherapists viewed that the responsibility to teach children to play is with the teachers. However, according to a study by Brodin and Lindstrand (2009) the educators' focus is on learning through play, showing that (similar to habilitation professionals), educators also use play as a means to enable something else. If this is the case, then who can help children with disabilities participate in play just for the sake of play?
Based on the evidence from policy and practice of how important play is for all children and the challenges facing children with disabilities in participating in play, there is a need to find out more about how paediatric habilitation professionals use play and whether enabling play as a right is considered. This knowledge is needed to support the right to participate in play for children with disabilities living in Sweden.
The aim of the study was to explore and describe physiotherapists and occupational therapists' attitudes and understanding of the place of play in habilitation. The objective was not to validate findings from other studies as there were no other qualitative studies to date that have explored play among habilitation professionals in Sweden. Ethical approval was granted from the ethical board in Sweden; 2016/222-31.

Methods
This was a qualitative study, employing semi-structured, individual interviews to explore habilitation professional's experiences and attitude towards play. The interviews were analysed using content analysis informed by Graneheim and Lundman (2004).

Participants
Participants were required to meet the inclusion criteria: a) physiotherapists and occupational therapists who were currently engaged in child and youth habilitation, b) working in northern Sweden, c) with at least two years' experience of working with children with disabilities aged from birth to 12 years.

Procedure
The recruitment of participants was conducted by issuing a letter to all managers in all of the four Children and Youth Habilitation centres in North Sweden, with the request to forward the information to the relevant personnel. The first author received the contact information from the persons who were interested in participating. They were thereafter contacted by telephone to provide information about the study, and verbal consent was gained. A time was established for conducting the interview. Altogether five occupational therapists and five physiotherapists were recruited from the different centres.

Data Collection
Data were generated through individual semi-structured interviews and all interviews were conducted by the first author. The interview started with the question 'Could you please tell me about your understanding of the place of play for children you meet and treat in your work'? The interviews covered different topics and encouraged the participants to talk about their experiences regarding play. The topics covered questions about how they perceived the concept of play in their work in the habilitation centre or at other environments where the child is during the day, like preschool, school or at home. When something was unclear, narration was supported with questions such as, 'can you please explain more?' or 'what happened then?' Each interview lasted about 30 minutes and was audio-recorded and transcribed.

Data Analysis
The verbatim transcriptions were analysed with qualitative content analysis guided by Graneheim and Lundman (2004) to discover the underlying meaning of the text. As a first step, the transcribed interviews were read several times to obtain a sense of the whole. After that, units comprising word or phrases relevant to the study were extracted and each unit was given a code. This process was done independently by the first and last author. The codes that emerged were inductively generated from the data reflecting patterns related to the perspective of the study. Similar codes were then placed into a category. After the authors compared codes and categories and agreed on the content of the categories after some discussion that resulted in minor adjustments. Representative quotations were shown in each category to strengthen credibility. The authors went back to the original text throughout the whole analysis, to validate the findings in the categories. Pseudonyms were used in the quotations to provide confidentiality.

Results
The analysis of the interviews with the physiotherapists and occupational therapists regarding their approach towards play in habilitation resulted in four categories (1) Play in the present or exercise for the future (2) Play is a useful tool (3) Play needs different prerequisites (4) Play is a shared responsibility. The four categories represent findings that relate to their attitudes and understanding of play in habilitation, and are described in more detail below.

Play in the Present or Exercise for the Future
The first category that emerged during the interviews was how to relate to the child's play in the present versus training for the future.
All participants strove for the child to become as independent as possible in the future and they described how difficult it was, almost like an inner struggle to work with the child here and now but to always have the future in mind: My interventions goals with the children are to make them independent adults in the future so that they can manage themselves as best as possible. I think most of them want to reach their full potential in the future and then you need to focus on training the body, but you disguise it as play. (Jennifer, PT) For this therapist, play was used as a means of ensuring the child was motivated in intervention, but the goal was not a play goal, but a goal for developing independent skills. Therapists viewed this as 'doing the right thing': working on making the children as independent as possible for the future meant that they needed to work on interventions on a body function level.
Regarding play in the present, the concept of participation was highlighted during the interviews. The concept of participation was known to everyone but not so easy to always live up to in the habilitation context: Children's habilitation is an extremely small part of their lives and it is so many other factors that influence on participation, even if you always think in those terms, it is difficult. (Anna, OT) Overall, participants agreed that participation was a central part of daily life beyond the habilitation centre. As one participant said: Participation is a word that is very popular to use. However, if you really think about participation then it is that the children should feel involved with their friends and be able to play with others, and do the same as other children out in the community. (Linda, PT) However, participants identified that the most common way to address participation in the habilitation centre was about choosing toy or deciding on the activity during the therapy session. Interestingly, focusing on participation in play with others was not obvious as a core concern in therapy. One participant talked about changing perspectives of childhood today, where the child has more say on what matters to him/her in the habilitation context. However, there was a general agreement that this was dependent on the child's age and that only older children should have the opportunity to participate in a group with others in therapy: I think that we as professionals need a different perspective on play, how do we think when the child wants to play a game for example or how do we think when the games require motor ability? . . .., then it will be that the child get to practice play, but otherwise I think more the other way . . . we find play or activities that provide benefits to the child to practice motor ability. (Emily, OT) Overall, while play was considered important with regard to participation in decisionmaking in the habilitation centre, it was mostly considered in relation to the future child, and the therapists need to be 'doing the right thing' for maximising potential now to support the child to develop skills for play in the future.

Play Is a Useful Tool in Therapy Practice
Participants talked about different aspects of using play in the habilitation context. For example, play was an essential part of the meetings with the child and family, where play was used as a way to familiarise oneself with the child. Participants highlighted the importance of building a trustworthy relationship with the child. As a participant said: If the child is new to me I just play different things so we get to know each other, so that the next time we meet it feels okay for the child. (Linda, PT) So, for many participants, the aim of the first visit with the child was to use play as a shared way of communicating to build trust.
Observing the child play at the habilitation centre was another approach used that sometimes was enough to assess the child depending on the reason for the visit. One participant described: It happens that I had thought of doing a standardised motor control test but the assessment ended up observing the child play. (Sara, PT) Although all the participants talked about the importance of play it was obvious that the focus was to use play as a means to observe body position, ambulation, side differences, fine motor skills and hand function while the child was playing. When asked if they had a focus on play itself the participants confirmed that their goal was to improve the children's physical conditions instead of their actual ability to play. From these participants' perspectives, training and play was intertwined and it was not possible to separate them. Their goal was to improve the child's body functions through adopting a playful approach with the hope that the child would experience the intervention/training as play. However, participants pointed out that the purpose was not to improve play, it was more of a tool for training, for example, range of motion in some part of the body. As one participant said: I make the training and the treatment in the child's arena somehow and that is what I think is play. (Anna, OT) Participation in activities with other children in relation to habilitation seemed to be a concept all participants had some thoughts about. Participants talked about how difficult it was to balance between interventions and what the child wanted to do. The success of different interventions was dependent on the child's degree of participation in the selected activities. Many of them talked about the importance of not taking the child from his/her natural context to perform interventions. For these therapists, they stated that interventions or training of body functions should never be more important than the child's participation in activities. In contrast, a few thought that some interventions or training was more important than participation.
There are some things one just has to do, that is just the way it is, if you have spasticity in your arm or hand you have to work on range of motion. (Jennifer, PT) So, play was viewed by these therapists who worked in habilitation centres as a method for relationship building, assessment and for maximising the child's motivation to participate in therapy. It was not viewed as an activity or occupation in its own right that warranted specific attention.

Play Needs to Be Addressed in Context
While play was used in therapy in these varied ways outlined above, participants felt that habilitation settings were not the right place to focus on play and that it was more natural to focus on play when the child was at preschool, at home or in other more natural environments. One participant said about visiting other settings: One still looks at body functions in play but at the preschool one looks foremost at how the child function in a group. (Lisa, OT) This practice of visiting the play context of the child's life was something therapists had experienced. However, participants also reported that due to recent changes in the organisational procedures, children were required to come more frequently to the habilitation centres and fewer meetings and interventions took place at home and in the school.
Consequently, participants talked about the importance of being able to advise the family on play and how to enable play at home and school. For example, opportunities to get out during the school break and be together with other children were noted as an important aspect. As one participant said: You have to make sure that the child can come out on the break and can be with other children. (Lisa, OT) In addition, the physical environment was noted as an important part of making play possible for children with disabilities. It was also an area of concern to these therapists due to their expertise in adapting environments to enhance function. An accessible schoolyard that made the child able to move around on equal terms was seen as a positive for improving the possibilities for play. Furthermore, the right assistive device was also a factor considered crucial for the child's opportunity to perform play activities with other children. Assistive devices to compensate or give the child opportunities to participate in the playground were central and something wished for by parents because their children were becoming too heavy to carry. Like one participant said: Of course this is where you sort of weave it together, the assistive device is an intervention to promote play. (Amanda, PT) Another participant gave a further example of how children can react on the introduction to a walking aid that would make it possible for a child to move to the other children and get involved in play with other children: One knows that a walking aid would be good for the child but some children do not want to use one. In other cases, a walking aid could put a smile on the child´s face and the child can participate with others in the preschool, so in some cases I think it is clear that this is the right device. (Amanda PT) This participant also mentioned the difference a stair lift to a slide could make for the child's opportunity to participate in play on the same terms as the children without impairment. So although these therapists identified that play in therapy does not address play for the sake of play, they all talked about ways they worked with families to explore play solutions for home and school contexts, specifically related to environmental adaptions and assistive devices.

Play Is a Shared Responsibility
All participants highlighted the value of play for the children, and play was seen as a human right and the natural activity for a child. They talked about providing the child with opportunities for play, yet they did not see play as the primary goal of their work in the habilitation centre but more as the responsibility of the parents and teachers. So, play itself was viewed as being somebody else's responsibility, such as the parent's responsibility at home and the teacher's responsibility at preschool and school. However, participants also reflected on how much the child should be able to decide whether to play or practice on the things that the habilitation professionals had recommended for them.
Sometimes it can take six months before the children wants to participate and understand what the purpose with the intervention are. (Sandra, OT) Participants held the view that training rather than play was necessary for some situations because play would not provide enough training of the abilities they felt were necessary for the child to practice. However, much of the training becomes the parent's responsibility and the parents do not always want to fight with their children about training. Therefore, the child was often allowed to decide what he/she wanted to do, and it could mean that it 'just' became play.
In this context, participants, therefore, felt that they had more of a consulting role regarding training and play, giving advice to other persons like parents, assistants and school staff. Mostly the advice was about training but suggested to be done disguised as play. One participant talked about giving support and advice to parents about how to play with a child with a neurodevelopmental diagnosis. She gave examples of suitable games that would suit the individual child. She also talked about making a schedule to clarify for both the child and the parents when certain activities should take place: You make a schedule, here you build a puzzle and then he can sit on his I-pad and then you can do this and that, you help them come up with different activities both in-and outdoors. (Anna, OT) With regard to teaching play skills, participants stated that the teachers or special educators were also the professionals who should teach the children to play: Yes, play is a part but more for the special educator on our team, she works with this participation, cooperation part. (Christina, PT) The participant's visits at preschool gave different perspectives compared to when the child comes to the habilitation centre: To be at preschool is to be a part in the child's life somehow compared to when they come to my work at the habilitation center so I think it can be easier when you are meeting the child at home or in preschool. (Lisa, OT) Some participants talked about the advantage of training and exercising at home due to the availability of fun toys, for example. But they also mentioned the downside or training at home; 'It is not easy and it demands that the parents do a lot'. Throughout the interviews, the participants talked about cooperating with parents and with personnel at school and preschool, which was seen as an important part of children's habilitation.

Discussion
The aim of this study was to describe physiotherapists' and occupational therapists' attitudes and understanding of the place of play in habilitation. Participants described that they wanted to give the child a 'good start' and maintain or improve body functions to avoid future complications and also support the child to become as independent as possible in the future. Therefore, play was primarily used as a motivator to perform other activities, including assessment and training. According to these participants, play was primarily seen as a valuable tool to make an assessment or for establishing contact between the child and the clinician. Play was also used as a means of concealing exercise or training with the aim to increase the child's motivation to participate and consequently to improve the child's body functions. Yet play was also considered from the perspective of participation in home and community contexts. The results showed that therapists did consider they had a role in consultation and advice on play in the physical environment at home and school, and assistive devices were important to support play in naturalistic contexts. However, supporting the children's possibility to play was not the primary goal for the professionals. They pointed out that the main responsibility was with the parents and teachers.
Both physiotherapists and occupational therapists had very similar ways of discussing their approach to play. It was clear across all the interviews that play had a central part in their work mainly as a way to train/work on improving body functions disguising it as play. This is in line with findings from previous studies in North America and Europe that play is used to achieve other goals (Lynch et al., 2017;Miller Kuhaneck et al., 2013). Even with the biomedical perspective in physiotherapy Bjorbaekmo, Stendal Robinson, and Engebretsen (2018) suggest that in work with children with disabilities the therapy should be enriched if the physiotherapist saw the child as a competent 'human of knowledge'. That could have an impact on how the therapy should be designed. According to Ray-Kaeser and Lynch (2016) occupational therapy has moved away from the biomedical model to a practice more orientated towards participation in occupation, with the influences from the ICF (World Health Organization, 2001) and (World Health Organization, 2007). However, the structure and concepts in ICF were well known to the professionals in this study, yet this did not seem to have much influence on their clinic-based therapy approach. Results showed that even though the professionals aimed to focus on participation almost all of the interventions described were focused instead on training different body functions. According to Verschuren et al. (2011), treating body functions like muscle strengthening is still one of the most common interventions for children with CP even though the evidence is insufficient and according to Wright, Rosenbaum, Goldsmith, Law, and Fehlings (2008) the connections between exercise and the functional outcomes of those changes are limited. Besides the focus on body functions in the present, the professionals in this study appeared to preserve and enhance body function for the future benefit of the child. According to Rosenbaum and Gorter (2012), the future is important -but this needs to be considered equally important as the current needs of the child and family, without ignoring the child and family's realities. The child's current reality in childhood is play and connecting to peers.
Independence and participation were two concepts that arose in the interviews. The professionals talked about doing the right things in the present as a means of ensuring that the child has the best chance to be independent in the future. These thoughts are in line with the results from an interview study with children and their parents regarding standing and exercise by Nordstrom et al. (2014) where the parents were afraid of not doing the best for their child. Do we as adults think mostly of the future and sometimes forget about the here and now, about the child's opportunities to participating in, for example, play? Ray-Kaeser and Lynch (2016) pointed out in their study that play could be initiated from both extrinsic and intrinsic motivation. This coincides with the results of our study where we could see that play often was extrinsically motivated, namely arose from the therapists as a tool to create contact, conduct assessment and to hide training of body functions. Intrinsically motivated play where play was a goal for an intervention was only mentioned in a few cases related to school activities and social activities. The results are in line with Chiarello, Huntington, and Huntington (2006) who stated that occupational therapy and physiotherapy focus primarily on body functions and activity.
The importance of a permissive environment was central in the interviews. The environment should be adapted for the assistive devices or the assistive device should be adapted to the environment. Creating an enabling environment is according to Crawford, Stafford, Phillips, Scott, and Tucker (2014) one of the main strategies within habilitation to promote participation in play. Other equally important strategies were toys that promoted cooperative play, a facilitating adult and the need to work client-centred (Frey & Kaiser, 2011). In this study, only strategies regarding the physical environment were mentioned.
This study explored the place of play in the work of habilitation professionals in the North of Sweden. Similar to a study (Lynch et al., 2017), of occupational therapists' experiences of play in Sweden, Ireland and Switzerland the habilitation therapists in our study valued play as part of a human rights issue for children, yet, as health professionals, they prioritised the use of play as a strategy to enhance intervention. Although all participants were familiar with the concept of participation, the most common way the participants described participation was when they let the child decide which toy to use during the habilitation session. Looking at how participation is described in the ICF (World Health Organization, 2001) and also in relation to play it is somewhat surprising that not more effort was put into working on trying to involve the children more in play with others, in therapy and natural settings. In our study, there was no discussion about habilitation that would benefit the children to increase their play opportunities or their possibility to participate in play with others. Instead, play was part of habilitation training that aimed at the future child rather than the present one. One can wonder how much children's habilitation should focus on the future. Perhaps we need to change perspective and have more of our interventions from the child's viewpoint and not from the professions anxiety of destroying the opportunities for the child to be independent in the future.