Learn To Play Therapy with Neurodivergent Children & Young People
Over the years it has been heartening and captivating to see play being considered and thought about as an important aspect of children’s wellbeing and quality of life. There are many ways to understand the notion of play as it involves so many different types of play and aspects of emotional involvement. The Neurodiversity Movement has encouraged us at Learn To Play Therapy to deeply consider how we explain our practice and how to respond to misconceptions and misunderstandings about what Learn To Play Therapy is.
For a short Q&A discussion on using Learn To Play Therapy with neurodivergent children see our FAQs page.
What is the Neurodiversity Movement?
The central premise of the Neurodiversity Movement is that variations in neurological development and functioning across humans are a natural and valuable form of diversity, and do not need to be prevented, treated, or cured. While the neurodiversity movement is currently strongest in the autistic community, it encompasses a wide range of neurological experiences.
We see the Neurodiversity Movement as an important shift in attitudes as it no longer pathologises neurodivergent adults and children, but instead recognises their strengths, and focuses on ability and the developing self. Therefore, we are taking this opportunity to explain why Learn To Play Therapy is an ethical neurodiversity affirming therapeutic approach when used as intended.
In our understanding at this time, the values of the Neurodiversity Movement are:
- Variation in neurological development and functioning (neurodiversity) is natural and valuable to human diversity.
- People with neurological differences are not incomplete versions of neurotypical people.
- There is variability in types of brain and cognitive functioning, and all should be accepted. A ‘right’ or ‘normal’ style of neurocognitive function is culturally constructed.
- An unaccommodating environment and interactions within the environment must be considered, with difficulties not solely (or not at all for some people) explained as within the individual.
- Neurodivergent individuals should be accepted and appreciated for who they are and not expected to conform to what is perceived as ‘normal’ in neurotypical circles.
A paper by Leadbitter et al. (2021) discussed the Neurodiversity Movement and implications for early intervention with neurodivergent children. In this paper, they highlighted calls from within the Neurodiversity Movement for changes in language (e.g. identity vs person first) and advocated for interventions within early childhood that:
- do not ‘cure’ or ’normalise’ neurodivergent children
- improve the child’s ‘goodness of fit’ within their social and physical environment
- identify causes of distress and intolerance of uncertainty
- improve mental health
- reduce anxiety, and support resilience, happiness and joy
- improve quality of life and promote autonomy.
How is Learn To Play Therapy Neurodiversity Affirming?
Learn to Play Therapy is a child-centred approach. Contrary to any sense of ‘opposing’ the unique strengths and differences of neurodivergent children, Learn to Play Therapy cherishes neurodiversity by providing support and adaptation that affirm the child’s strengths, rights, and neurodivergent identity. The title ‘Learn to Play’ may presume a stance of teaching due to incompetence, however the opposite assumptions are made in practice. To learn is to actively participate in opportunities to absorb, acquire, and discover new experiences, shaping the unique developing profile of an individual. Learning is fundamental to our daily experience and a key component supporting ongoing health and well-being. Regardless of our name, our intention is not to ‘teach kids how to play’, it is to work with, alongside and in response to the child, so they are able to understand the intentionality of play and choose whether to engage in play independently by themselves or with others.
Choosing not to play with others may be seen as non-compliance, however in Learn To Play Therapy we concur with the Autistic Self Advocacy Network that non-compliance is ‘the ability to evaluate situations and decide’ for oneself, which is a ‘fundamental life skill’ (Autistic Self Advocacy Network (ASAN), n.d., p. 12). Learn To Play Therapy is fundamentally about supporting each child’s unique strengths, and scaffolding the areas they find challenging for continued development of self-advocacy, autonomy, self-determination, and improved quality of life. This supports a sense of connection and belonging in the way that is unique to the child.
Learn To Play Therapy:
is child-centred
The child is seen as capable, accepted and respected as they are
respects
the child's perspective, joins them in play and is responsive to the child
affirms
the child's experience, and provides opportunities for new experiences
works with
the child's strengths and engages them within their sphere of interests
does not
promote masking or teach behavioural responses (this is an inappropriate use of Learn To Play Therapy)
understands
that belonging is a fundamental need which comes from being understood and accepted, not being 'taught' to fit in
knows
that true play is joyful, meaningful and intentional for the child
Because Learn To Play Therapy is a process-oriented relationship-centred approach, it has many complexities (beyond just knowing the play abilities of the child) and these are sometimes overlooked by those who are unfamiliar with it. A key principle of the Learn To Play Therapy process is that the child is able to self-initiate their own play and play ideas. Virginia Axline’s 8 principles on being child-centred (Axline, 1974) are strongly influential in this, as is the work of Vygotsky (Vygotsky, 2016). These fundamental principles have always been central to Learn To Play Therapy. The original Learn To Play book, titled “Learn to Play: A Practical Program to Develop a Child’s Imaginative Play Skills,” published in 1998, was about responding to the child, however the depth of this approach was not fully expressed. Consequently, it may have been utilized for play activities without a comprehensive understanding of these underlying concepts. Such isolated use of play activities might have fostered the misconception that Learn To Play Therapy solely prescribes to a particular way of playing. It is worth noting that this book is now out of print and superseded in its content.
The 2021 re-write, titled “Learn to Play Therapy: Principles, Process and Practical Activities,” articulates the child-centred approach embraced by Learn To Play Therapy. This updated version explains the concept of creating a zone of proximal development through play and active engagement with the child. Vygotsky explained how the ‘zone of proximal development’ moves a child from their actual development through to their potential development by guidance from adults and more experienced peers (Vygotsky, 1934/1997). By providing support and suitable challenges, the adult/peer acts as a scaffold to facilitate the child to move beyond their current abilities and acquire new skills or knowledge.
Pretend play is a zone of proximal development for children, and children show greater ability and capacity when they engage in self-initiated pretend play. Vygotsky noted that “in play it is as though [the child] were a head taller than him/herself” (Vygotsky, 1966/2016, p. 18). Children express their capabilities, thinking, and interests by playing. All children are unique human beings who bring their life experiences, skills and capabilities into their play sessions. For example, some children are interested in how certain toys work, some children love puppets, some children adore vehicles and some children come with no particular interests.
By fostering a safe, enjoyable, and interactive environment, we encourage the child’s autonomy in play and scaffold the increasing complexity of the play that is meaningful for the child. The ultimate goal of Learn To Play Therapy is for the therapist to become redundant, as the child develops their own unique way of playing, becomes autonomous in how they play, derives pleasure from the process and feels prepared to deal with any play environment.
The Practice of Learn To Play Therapy
Learn To Play Therapy is about joining with the child at their level of play complexity; playing beside the child, responding to the child through imitation, talking about what is happening in the play, co-playing, and co-facilitating the play.
True play is meaningful and intentional to the child.
An example of this is a one-off session when Karen was asked to assess a child:
The session took place in a big gym space, and the child was running around. Karen ran around too.
Her puppet ran and joined the child on the trampoline and looked at the toys in the play shop.
Eventually they moved to a smaller room where Karen’s puppet started throwing blocks in a box. The child threw blocks in the box too. Then, the puppet started throwing the blocks out of the box. The child laughed and started to throw the blocks out of the box too. Then the puppet copied what the child did.
The child was laughing, engaged, trying to trick the puppet. It was fun and it was play.
In the beginning sessions of Learn To Play Therapy, the therapist may introduce play activities.
However, it is the child’s response to the play activity or game that guides the therapist to continue, to change the play, or be responsive to the child if the session requires a different approach.
The updated 2021 Learn To Play Therapy book has over 250 examples of play activities at different levels of complexity, but these are not exhaustive, and they are not to be used as the only way to express play skills – they are a guide.
For example, one child loved cars and his mum would bring a bag of his cars to each session. During the session the child would choose which of his cars to play with and how himself and the therapist would begin to play with them
Another child loved the big character Upseedaisy.
Upseediasy would greet the child in the same way in each session. Then the child would wander around the room looking at different toys and objects set out in different parts of the room. There were just the right number of toys so as not to be overwhelming. When the child chose what they preferred, the therapist would slowly engage in the play using Upseedaisy, who would come over and join the child.
Learn To Play Therapy sessions are paced to the child. For example, if a child likes cars and lines them up, we also line them up. We might move our cars if it increases the child’s interest. We might make a tunnel and put our cars in the tunnel, particularly if the child shows interest and has focussed attention.
For many children, we might be playing while the child watches, and for other children we are watching the children, or we may be interacting with the child through a toy character while we follow the child’s intention in the play.
For example, there was a child who preferred to wander around the playroom.
Karen and his parent would play as he would watch with interest. They would enjoy playing together, and matching their play to the child’s interests and competency level, as much as they could ascertain as he rarely engaged in the play.
One day his parent said, “He talks baby when he goes into the room”.
So they immediately changed rooms, and the play activities were increased to a level of greater complexity. The child still watched but now commented on the play, talked more, and at school he would take out toys and play with them.
Many times he would play on his own, other times he would join in with others. He had friends over to his house to play for the first time. At school or in his neighbourhood street, he found another way to engage with friends rather than using pushing to try to play with them.
He joined them in play activities, such as a Christmas street celebration where he played on the bouncy castle and sat with the other neighbourhood children to eat and drink. He was connected, much happier, less anxious, and still his unique self.
An autistic child who does well or appears more visibly engaged isn’t becoming less autistic – they’re simply showing what they are capable of with the right support.
(ASAN, n.d., p.21)
Learn To Play Therapy is beneficial for children who have at least one meaningful word or action, or have focussed attention while they watch the parent or therapist play. It is not appropriate for children who do not have these capabilities in play.
Other approaches such DIR Floortime® or Theraplay® would be more appropriate in this case.
Using Play Assessments with Neurodivergent Children
We respect that neurodivergent children may learn and develop differently, and we recognise that children’s play is unique to their environmental opportunities, social networks, and internal capabilities. Every child is unique with their own set of capabilities. A play assessment provides information on the play capabilities of a child and the underlying skills that a child already has in play. We make no presumptions about a child’s play. An assessment provides information on a child’s strengths in play and areas that may need further assistance to support the child’s personal empowerment to understand play and choose how they play, who they play with, what to play with and if they want to play at all.
The play assessments generally used in Learn To Play Therapy are focused on the quality and complexity of key components of pretend play.
-
Pretend Play Enjoyment Developmental Checklist (PPE-DC)
-
Child-Initiated Pretend Play Assessment-2 (ChIPPA-2)
-
Animated Movie Test (AMT)
The Pretend Play Enjoyment Developmental Checklist (PPE-DC) uses six underlying factors of pretend play in increasing complexity, as represented by age. This sequence of development is cross-cultural and invariant. Within the Neurodiversity Movement this assessment could easily be criticised for comparing neurodivergent children to neurotypical development. However, we recognise that neurodivergent children have strengths across these skills that are unique to them, honouring differing styles of play for every individual. In practice, the complexity of the play is more important than the approximate age of development, as it is the complexity of the play and combination of skills that is the focus of this assessment. All children have their own unique developing profile and there are many possible combinations of play abilities that a neurodivergent child may have. Focusing on complexity, as a developmental framework, aligns with ASAN’s understanding of different developmental tracks: “An autistic child may develop some skills later than non-autistic children, or in an unusual order. While knowledge of developmental stages can be useful in assessing and diagnosing … autism, they are not a roadmap that must be forcibly followed. Therapies and services should be helping autistic children develop skills because they are relevant to their personal goals – not because they are next on the typical timetable.” (ASAN, n.d., p. 23). The framework of increasing complexity of pretend play ability in the PPE-DC provides knowledge on the complexity of a child’s play strengths and, just as importantly, provides insight and appreciation for where we ‘meet’ the child in joyful play to assist with their personal goals.
The Child-Initiated Pretend Play Assessment (ChIPPA2) requires focussed attention of the therapist to observe the process, complexity, style and play themes of a child’s play.
The Animated Movie Test allows time for observation of how a child/young person approaches the complex task of thinking through a story, and that process is again unique to every child.
These assessments target our observations and understanding of play, so a child’s play strengths can be recognised. Play is subtle and many skills that the child has can be missed. For example, the child who is exploring a small character, then leaves it to look at something else, then returns to the character and props it near an object with focussed attention, careful movements, and intention is showing complexity in sequences of play actions, character play and most probably object substitution, which supports flexible thinking abilities. These observations support a developing understanding of the child’s unique thinking process and supports an understanding for how the child might be communicating in a meaningful way.
Why Focus on Pretend Play in Learn To Play Therapy?
Having knowledge of pretend play abilities provides deeper observation and understanding of the competencies children already have in play. Consideration is given to the child’s needs at the time and for some children it may be that assistance in pretend play is not appropriate for the child. Engaging in pretend play can provide joy and pleasure for a child, but it is tiring and requires levels of focussed attention and interest that can move children beyond their window of tolerance. Hence, the therapist may respond by shortening the play session, or introducing play with less complexity.
The developing quality of play for all children is an important consideration and there are children who might identify as neurotypical who also struggle with pretend play, either through their environmental circumstances, opportunities, or for unknown reasons.
Learn to Play Therapy is not imposing pretend play on the child, creating a behavioural response and promoting ‘masking’. This play is damaging and stressful for the child. It is not ‘true’ for the child, nor is it intentional or meaningful, and we do not support this.
Pretend play is unique and brings more than just play to the child. It can be imposed on other types of play, for example, a balance beam can become a bridge, or a tunnel can become a cave, or playing in sand can evolve into playing at the beach or in a desert. It is infinite in possibilities. Pretend play has long been associated with social awareness, self-regulation, divergent problem solving, language and narrative language, understanding story, and more recently with cognitive processes such as counterfactual reasoning (Francis & Gibson, 2023).
We have observed that children decrease in their anxiety as their capabilities in play become more complex, their autonomy increases, and they express their personal empowerment through play. Learn To Play Therapy is about building a child’s understanding of the intentionality of the play for themselves and to recognise the intentionality of the play in others. Children then transfer these capabilities to other environments where they can recognise play in others and choose whether or not to engage, or how to respond when another child comes to join them in play. Playing brings with it a deeper sense of self and a means to express oneself. Increasing these capacities in childhood supports the child to have broader options for social connection if this is something they wish for themselves now and in social-emotional connections later in life.
While many children create scenes and stories in their pretend play, others show their mathematical reasoning and process. The adult in the zone of proximal development in Learn To Play Therapy is the person who has recognised the child’s play capabilities and has a deeper knowledge of how to maximise and support the child’s potential in play. This is achieved through responding to the child, playing with the child, and supporting the child’s decisions in play.
To Finish
We recognise neurodivergent children bring their own competencies in play and in pretend play. We play beside children and respond to their play, imitating their play, co-playing and facilitating play so the child’s play is authentic, intentional, and meaningful for them.
The child initiating their own play and taking play activities where they choose to take them is the joy in Learn To Play Therapy.
Neurodivergent children have many skills in play that are often not recognised.
In Learn To Play Therapy, we value the play of neurodivergent children and the many different expressions that play takes. Playing can be exhausting, so the play activities in a Learn To Play Therapy session also vary in complexity and type of play in response to the child. Our evidence base, including both qualitative and quantitative understandings, have highlighted that children become much happier and joyful, and less anxious as they increase in their intentionality of their own play.
One last word – play is joy!
If a child is not experiencing pleasure, interest, or joy, then the therapist needs to change what they are doing to be more responsive, otherwise the interaction is not considered play.
References
Autistic Self Advocacy Network (ASAN), (n.d.). For whose benefit? Evidence, ethics, and effectiveness of autism interventions. https://autisticadvocacy.org/wp-content/uploads/2021/12/ACWP-Ethics-of-Intervention.pdf
Axline, V. (1974). Play therapy. New York: Ballantine Books.
Francis, G. A., & Gibson, J. L. (2023). A plausible role of imagination in pretend play, counterfactual reasoning, and executive functions. British Journal of Psychology, 00, 1-22. DOI: 10.1111/bjop.12650
Harter, S. (2012). The construction of the self. The Guilford Press.
Leadbitter, K., Buckle, K.L., Ellis, C. & Dekker, M. (2021). Autistic self-advocacy and the neurodiversity movement: implications for autism early intervention research and practice. Frontiers in Psychology, 1 – 7. Doi: 10.3389/fpsyg.2021.635690
Vygotsky, L. S. (1966/2016). Play and its role in the mental development of the child. International Research in Early Childhood Education, 7 (2), 3 – 25. https://files.eric.ed.gov/fulltext/EJ1138861.pdf
Bibliography - neurodiversity
Baron-Cohen, S. (2019). The concept of Neurodiversity is dividing the autism community. It remains controversial but it doesn’t have to be. Scientific American. Blog. https://blogs.scientificamerican.com/observations/the-concept-of-neurodiversity-is-dividing-the-autism-community/
Costandi, M. (nd). Against neurodiversity. The movement has good intentions, but favours the high-functioning and overlooks those who struggle with severe autism. https://aeon.co/essays/why-the-neurodiversity-movement-has-become-harmful
Dallman, A. R., Willians, K. L. & Villa, L. (2022). Neurodiversity-affirming practices are a moral imperative for occupational therapy. Open Journal of Occupational Therapy, 10(2), 1-9, Doi: 10.15453/2168-6408.1937
Fagan, A. (2020). Neurodiversity: the Movement. Psychology Today. https://www.psychologytoday.com/au/blog/the-elusive-brain/202004/neurodiversity-the-movement
Happé, F., & Frith, U. (2020). Annual research review: looking back to look forward – changes in the concept of autism and implications for future research. Journal of Child Psychology and Psychiatry, 61 (3), 218-232. doi:10.1111/jcpp.13176
Kapp, SK. (Ed.)(2020). Autistic community and the Neurodiversity Movement. Stories from the frontline. Palgrave MacMillan. https://link.springer.com/book/10.1007/978-981-13-8437-0
Sonuga-Barke, E., & Thapar, A. (2021). The neurodiversity concept: is it helpful for clinicians and scientists? The Lancet Psychiatry, 8, (7). Doi:10.1016/S2215-0366(21)00167-Xfile.