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Taiwanese parents' attitudes toward play for their children with cerebral palsy
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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
TAIWANESE PARENTS’ ATTITUDES TOWARD PLAY FOR THEIR CHILDREN
W ITH CEREBRAL PALSY
by
Wei-Lun Hsu
A Thesis Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF ARTS
(OCCUPATIONAL THERAPY)
May 2002
Copyright 2002 Wei-Lun Hsu
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UMI Number: 1411789
_ ___ __®
UMI
UMI Microform 1411789
Copyright 2003 by ProQuest Information and Learning Company.
All rights reserved. This microform edition is protected against
unauthorized copying under Title 17, United States Code.
ProQuest Information and Learning Company
300 North Zeeb Road
P.O. Box 1346
Ann Arbor, Ml 48106-1346
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U N IV E R SIT Y O F S O U T H E R N C A L IF O R N IA
TH E GRADUATE SCH O O L
U N IV ER SITY RARK
LOS A N G ELES. CA LIFO RN IA § 0 0 0 7
This thesis, written by
W ei-Lun Hsu
under the direction of h Thesis Committee,
and approved by all its members, has been pre
sented to and accepted by the Dean of The
Graduate School, in partial fulfillment of the
requirements for the degree of
Master of Occupational Therapy
rs**. May 10, 2002
THESIS COMMITTEE
C k ,
_____
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iii
ACKNOWLEDGMENTS
I would like to thank Dr. L. Diane Parham, my thesis chairperson, for being my
academic advisor and for her encouragement during the process of developing and
completing my thesis. I also would like to thank Dr. Ruth Zemke and Dr. Mary
Lawlor for serving as my committee members and giving me guidance.
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TABLE OF CONTENTS
DEDICATION.....................................................................................................................................ii
ACKNOW LEDGM ENTS........................................................................................................iii
LIST O F TABLES.....................................................................................................................vii
ABSTRACT............................................................................................................................... ix
CHAPTER
I. THE PROBLEM ...........................................................................................................I
Background o f the Problem ........................................................................................... I
Statement of the Problem ............................................................................................... 4
Purpose of the Study........................................................................................................6
Questions............................................................................................................................ 8
Assumptions.......................................................................................................................8
Importance of the Study..................................................................................................8
H. REVIEW OF THE LITERATURE........................................................................ 10
The Importance o f Play for Children in Occupational Therapy..........................10
Play As A Means to An E nd.................................................................................12
M otor Developm ent.......................................................................................12
Cognitive Developm ent................................................................................14
Language Developm ent................................................................................15
Emotional D evelopm ent...............................................................................17
Play As An Occupational End G oal................................................................... 18
Rule Learning through Play.........................................................................19
Occupational Role Developm ent............................................................... 21
Sum m ary..........................................................................................................22
Play Behavior o f Children with Physical D isabilities...........................................22
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V
Limitations Imposed by Cerebral Palsy............................................................ 23
Physical Lim itations.................................................................................... 23
Cognitive Lim itations..................................................................................24
Environment Barriers...................................................................................26
Studies o f Play Behavior of Children with D isabilities................................ 29
Sum m ary.........................................................................................................31
Parents’ Values toward Play.........................................................................................32
Mother-Child Interaction..................................................................................... 33
Parents’ Attitudes toward Play...........................................................................39
Parents of children with Disabilities........................................................ 40
Parents of Children W ho Are Typically Developing............................43
Summ ary........................................................................................................ 49
III. M ETHODOLOGY..................................................................................................51
Research M ethod......................................................................................................... 51
Subjects...........................................................................................................................51
Instrumentation.............................................................................................................52
Procedure.......................................................................................................................53
Data Analysis................................................................................................................55
IV. RESULTS..................................................................................................................58
Interview Questions in Part I: Demographic Questions o f Parents and Their
Children.........................................................................................................................58
Interview Questions in Part II: Activities at H om e.............................................. 63
Question 1: Who Plays with Your Child M ost o f the Tim e?.....................63
Question 2: During W hat Activities Do Family Members Usually Play
with Your Child with Cerebral Palsy?....................................64
Question 3: Would You Share with Me W hat it is Like W hen You Play .
with Your Child? Maybe You Can Tell Me Stories about
Times W hen You Had Fun Together....................................... 64
Interview Questions in Part IE: Parents’ Attitudes toward Play at Home 70
Question 4: W hy Do You Think Children Play?........................................ 70
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Question 5: Based on Your Concept of Childrearing, Do You Think
Play is Important For Preschoolers Who Are Typically
Developing?................................................................................. 72
Question 6: Do you Think Play is Important for Your Child with
Cerebral Palsy?..................................................... , .........., ......... 73
Question 7: W hat is the Main Reason that You Play with Your
Cerebral-Palsied C hild?.............................................................75
Question 8: If the C hild’s Therapist Recommend that You Play with
Your Child at Home, Will You Follow His/Her
Suggestions?................................................................................ 76
Question 9: If You Do Not Have Enough Time to Play with Your
Child, Would You Ask Someone to Do So?....................... 77
Sum m ary.........................................................................................................................78
V. DISCUSSION.......................................................................................................... 80
Taiwanese Parental Ethnotheories about Play...................................................... 81
Taiwanese Parents’ Attitudes Toward Play for Their Children with Cerebral
Palsy............................................................................................................................... 85
Limitations and Implications for Future Study.....................................................90
REFERENCES........................................................................................................................ 92
APPENDIX
A. Interview Q uestions.................................................................................................104
B. Information Sheet for the Parents.........................................................................108
C. Interview Questions (Mandarin Chinese Version)............................................ 112
D. Information Sheet for the Parents (M andarin Chinese Version).................... 116
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vii
LIST OF TABLES
1. Demographic characteristics of the parents.................................................................... 59
2. Age o f children with cerebral palsy..................................................................................60
3. 2x2 chi-square test of parents’ age and their values about play for children with
cerebral palsy........................................................................................................................ 61
4. 2x2 chi-square test of parents’ educational level and their values about play for
children with cerebral palsy............................................................................................... 61
5. 2x2 chi-square test of parents’ age and their values about play for children who are
typically developing.............................................................................................................62
6. 2x2 chi-square test o f parents’ education level and their values about play for
children who are typically developing.............................................................................62
7. W ho plays with your child most of the tim e?................................................................ 63
8. During what activities do family members usually play with your child?............... 65
9. Types o f story that parents play with their children with cerebral palsy at home..67
10. W hy do you think children play?...................................................................................71
11. The reasons o f why play is important for children who are typically
developing............................................................................................................................73
12. Parents’ attitudes regarding the importance o f play for children............................75
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ix
ABSTRACT
The purposes of this study were to investigate Taiwanese parents’ attitudes
toward play for their children with cerebral palsy, and to explore the reasons behind
their attitudes in relation to the significance of play for their cerebral-palsied children.
An interview designed by the researcher was used as the instrument to investigate the
research questions.
A total o f 45 Taiwanese parents who had preschool-aged children with cerebral
palsy living in 3 urban cities in Taiwan participated in this study. Results show that
43 participants stated that they believed play is important for their children with
cerebral palsy. When asked what it was like when they played at home with their
children with cerebral palsy, 29 parents shared stories that fell into 4 categories
relating to purpose and content of play: amusement, physical activity, skill
development, and social pretend play.
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CHAPTER I
INTRODUCTION TO THE PROBLEM
Background of the Problem
Occupational therapists assume that humans can receive tremendous benefits by
actively engaging in occupation (Reilly, 1962, 1966). Play, work, and activities of
daily life are the major occupations that occupy human lives (Kielhofner, 1985).
For young children, play is considered by occupational therapists to be the primary
type of occupation, in both the United States and Taiwan (Kielhofner, 1985; Pan,
1991; Parham & Primeau, 1997).
Occupational therapists believe that play is very important for children (Reilly,
1974). During play, children develop their abilities by exploring the surrounding
environments. They receive information through their senses, gain knowledge
about the world, and realize the rules of the nature. These skills, in turn, lead to
development of their motor, cognitive, language, and intellectual abilities that are the
foundations o f future achievements (M issiuna & Pollock, 1991). Bundy (1992)
stated that play is a powerful tool through which humans can express themselves.
Thus, play facilitates children’s abilities to function effectively within their
environments.
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Due to impaired ability to explore, master, and interact with the environment,
children with physical disabilities might not have childhood experiences that enable
them to adequately develop their play skills (Mogford, 1977). They may spend a
great deal o f time in medical environments and be excluded from participation in
normal activities (Williams & Matesi, 1988). According to Mogford (1977), two
types of play deprivation may occur when a child has a physical disability. First,
the physical disability will interfere with motor and sensory functioning. Thus, the
child with a disability will be deprived o f some play experiences due to the disabling
conditions. For example, children with cerebral palsy can not directly engage in
play activities that require fine and gross motor abilities. This is called a primary
form o f play deprivation. Another form of deprivation arises secondarily to the
physical disabilities. Because children with disabilities often do not have many
opportunities to experience normal childhood play, they may encounter secondary
social, emotional, and psychological disabilities (Mogford, 1977). An example of
this kind o f play deprivation is the child with visual impairment who cannot play in
outdoor facilities because he might fall.
Families that have a child with a disability such as cerebral palsy may face
numerous difficulties. Because o f the special needs of caring for the child with a
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disability, the family may take on more caring responsibilities, such as spending
more time than usual to feed, dress, and bathe the child. In addition, the family
may be burdened with extra financial demands that are required in order to provide
the child proper medical care, special education and therapy, and suitable adaptive
equipment (Travis, 1976). In addition, these children may be dependent upon their
parents for the rest of their lives for physical assistance and the financial support
(Travis, 1976). Furthermore, families of children with disabilities may also face
challenges that involve family routines. Travis (1976) identified several of these
challenges as sleep interruption, complicated special diet schedule, need for extra
house cleaning, and additional financial burdens for house adaptation. In addition,
families that have a child with a disability may also face psychological and
emotional problems that then affect the parent-child interactions and relationship
(Hanzlik, 1998). Due to the extra burden and psychological stress of caring for the
child with a disability, the parents may not acknowledge the significance o f play and
may not spend much tim e playing with their child.
Hsu (1999) used group interviews and individual interviews to investigate the
difficulties faced by Taiwanese mothers o f children with learning disabilities. The
findings indicated that the common hardships for mothers o f children with learning
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disabilities were classified into seven categories, two o f which are related to the
parent-child interactions. These difficulties involved mother-child interactions and
change of family conditions. In addition, another study executed in Taiwan also
showed that families o f children with developmental delays take on greater burdens
o f caring so that the quality o f family life is affected and becomes worse (Hung,
1998). Perhaps the factors described above influence the attitudes toward play of
Taiwanese parents of children with cerebral palsy. It is not clear to this researcher
what Taiwanese parents’ attitudes toward play for their children are.
Statement of the Problem
Children’s play experiences start early in their lives. At the early stage of
infancy, parents’ nonverbal and verbal interactions may be the prim ary form o f play
activity. In these interactions, the infants learn to respond to the parents in motor,
cognitive, and social ways. In turn, the parents reply to their children and then the
infants and the parents mutually contribute to the interaction (Hanzlik, 1989b).
However, for children with cerebral palsy, parent-child interactions are much
different. Due to the physical, cognitive, and language development delays,
cerebral-palsied children may not respond to their parents in a way that the parents
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observing families and interviewing 10 mothers who lived in the southern area of
Taiwan. The study found that the mothers o f children with developmental delays
carried enormous responsibilities in Taiwanese society. They had to care for the
disabled children and simultaneously manage the household responsibilities. In
addition, they struggled with their family conditions. Further, Chang (1996)
reported a case study of a Taiwanese m other’s experience of caring for her child with
severe cerebral palsy. The m other said that rearing a child with a disability
influenced the condition of her family, including the interactions between family
members, economic situation, and living style. All of the literature above
mentioned changes in Taiwanese family lives due to a child with a disability in their
home. Although some o f the researchers described above studied families of
children with developmental delays, they may also indicate the situations of families
o f children with other disabilities, such as cerebral palsy. The factors that affect the
situations o f family lives may influence the parents’ attitudes toward play for their
children with cerebral palsy.
Purpose of the Study
Few studies examine parents’ attitudes toward play for their children with
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cerebral palsy either in the United States or in Taiwan. In this researcher’s personal
experience as an occupational therapist in Taiwan, it appeared that many o f the
parents who had a child with cerebral palsy in Taiwan usually did not have time to
play with their cerebral-palsied children. Some o f them do not think play is an
important activity for their child with a disability, and some o f them actually do not
have spare time to consider the child’s developmental functions beyond motor ability.
This study attempted to investigate Taiwanese parents’ values about play for children
with cerebral palsy and gather parents’ thinking using a self-developed interview.
This researcher believed that most Taiwanese parents who have children with
cerebral palsy do not play with their children frequently and usually they play with
their children only because of the professional’s emphases. It was also believed by
this researcher that the parents who have children with cerebral palsy do not realize
the importance o f play for their children with disabilities.
The purpose o f this study was to: (a) investigate the Taiwanese parents’ attitudes
toward play for their children with cerebral palsy, and (b) determine the reasons
behind Taiwanese parents’ values in relation to the significance o f play for their
children with cerebral palsy. An interview was developed and used to investigate
the opinions o f the Taiwanese parents of children with cerebral palsy.
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Questions
This study addressed the following questions:
1. W hat are Taiwanese parents’ attitudes toward play in the home for their
children with cerebral palsy?
2. W hat are the reasons behind the parents’ values related to play for their
children with cerebral palsy?
Assumptions
This study was based on the following assumptions:
1. Play is an important activity for children to develop cognitive, motor,
language, and psychological functions.
2. The parents’ answers in the interview can represent their real attitudes about
play for their cerebral-palsied children.
Importance of the Study
This study aimed to clarify how Taiwanese parents who have children with
cerebral palsy think about the parent-child play in the home settings. This study
might help the parents o f children with cerebral palsy in Taiwan to realize the
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CHAPTER n
REVIEW OF THE LITERATURE
This chapter provides a review of the literature related to the nature o f play and
the attitudes o f parents with children with disabilities. First, the importance of play
for children in occupational therapy is addressed. Next, the studies of play behavior
of children with disabilities are reviewed. Then, literature on parents’ values about
play within different cultural backgrounds concludes this chapter.
The Importance of Play for Children in Occupational Therapy
Florey (1981) identified six principles of play common to most primary theories:
Play is a complex set of behaviors characterized by fun and spontaneity; play is
sensory, neuromuscular, mental, or a combination of all three; play involves
repetition o f experience, exploration, experimentation, and imitation o f one’s
surroundings; play allows children to rehearse their interpretation o f reality and
fantasy; play functions as a agent for integrating the internal and the external worlds;
and play follows a sequential, developmental progression. Using this perspective,
play provides the chance to allow children to explore and to create new behaviors
that are required o f them for competence in occupation. Also at the same time, play
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offers children the opportunity to consolidate and refine new behaviors that serve as
a foundation for more complex and mature behavior (Vandenberg & Kielhofner,
1982). Play is “a process that produces new behavior forms” and also “is an
organized skill” (Vandenberg & Kielhofner, 1982, p. 26).
For occupational therapy practice, play is a means for enhancing development
and skill acquisition as well as a goal o f intervention (Parham & Fazio, 1997). In
the perspective of play as a treatment modality, or a means to an end, play is believed
to alter occupational behavior, develop environment negotiation skills and culturally
acceptable behaviors (Vandenberg & Kielhofner, 1982), and address common
developmental component goals for infants and toddlers at risk with developmental
delays (Anderson, Hinojosa & Strauch, 1987; Pierce, 1997). It is also a method to
enhance sensory integrative development and adaptation to transitions within school
settings (M ailloux & Burke, 1997; Neville-Jan, Fazio, Kennedy & Snyder, 1997).
In a pilot project using developmental play techniques as an interactional approach
for children with physically disabilities, Sparling, Walker and Singdahlsen (1984)
found that after a 7-week course of intervention, the children’s performances were
enhanced in the developments of cognitive, language, social-emotional, motor, and
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activities of daily life (ADL) skills. This study supports the premise that play is
important in facilitating children’s development.
On the other hand, the perspective o f play as a goal o f intervention focuses on
play as an end in itself. Occupational therapists supply appropriate opportunities
and ways to extend children’s play experiences and to make play become meaningful,
satisfying, and accessible for children with neuromotor disabilities, emotional
disorders, and developmental delay. Furthermore, occupational therapists also
provide strategies to facilitate play within the context of the family that has a child
with a disability (Blanche, 1997; Hinojosa & Kramer, 1997; Holloway, 1997).
Plav As A Means to An End
It is generally agreed that children spend the majority o f their time in play. Why
is play important in occupational therapy for children? The m ost popular view is
that play serves as an arena for children to develop motor, cognitive, language, and
psychological skills. Namely, it supports the development o f the components o f
occupation.
M otor Development
M ovement is the first way that children interact with their environment
(Case-Smith, 1996). A m otor explanation for play emphasizes the neurologic,
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biological, and kinesiologic functions that serve young children to act (Burke, 1998).
Motion and changing sensations that motion produces are the first resources for play
that an infant him self can exploit alone when he is discovering that he has the ability
to control his movement (Garvey, 1990). Play o f infants and toddlers is also driven
by the need to master basic motor skills (Case-Smith, 1996). For example, when
the young child waves a toy to create a sound, he is also performing an action that
requires shoulder control. Engaging in physical activity develops a skillful use of
the body for children. This feeling o f mastery o f body that children gain through
play gives them more and more confidence to explore new behaviors and their
environment (Alessandrini, 1949).
Occupational therapists often use play as a means to facilitate the motor
development o f children with physical disabilities (M orrison, M etzger & Pratt, 1996).
M otor impairment may often interfere with the child’s participation in play (Beers &
Wehman, 1985). Through selection of activities, in accordance with the child’s
interests and capacities, the occupational therapist can design a treatment program
that improves m otor function.
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Cognitive Development
One well-renowned study of play as a basis for children’s cognitive
development is the work o f Piaget. Through the long-term observational study of
his children, Dr. Jean Piaget (1951/1962) developed a set o f stages that he believes
that all children would pass through when they interact with people and objects in
the world. Regardless o f cultural and racial differences, the stages are considered to
be universal. Corresponding to stages of cognitive levels, Piaget (1951/1962)
described three types of games: practice games, symbolic games, and games with
rules. Through the stages, children are expected to progress step by step to
construct their interactional skills with objects and people. During the process of
manipulations o f objects and people, children create an image o f the world and an
understanding o f the ways that all parts around them fit together. Piaget’s definition
of play is “ the act o f bending reality to fit one’s existing level o f cognitive
functioning (1952/1961). Using this perspective, children’s play is considered as
the behavior that is designed to facilitate mastery of reason and thought.
The occupational therapist is concerned with analyzing children’s abilities to
perform in everyday activities (Case-Smith, 1996). Therefore, occupational
therapists seek the goal to improve children’s functional skills, from a unique
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perspective in which performance is analyzed into components o f underlying skills.
The performance components or underlying skills of concern to occupational
therapists include cognitive components, which underlie children’s abilities to
perceive, learn, and problem solve in their environment. Cognitive ability is
essential for children to learn various skills. Thus, using play as a means to
facilitate cognitive ability is critical for occupational therapists (Case-Smith, 1996).
Language Development
The development o f language follows a hierarchical procedure. There are two
phases of infant babbling. The first phase can be characterized as play with the
vocal apparatus used to produce sounds, and the second phase focuses on playing
with and imitating sounds with meaning. Repetitive, rhythmic vocalizations are
associated with pleasurable status for children in the prelinguistic stage, and
infant-parent games are often related to a vocal component (Garvey, 1990).
According to cognitive-interactionist theory, which was based on Piaget’s (1962)
thinking about the stages o f cognitive development for children, the children acquire
the cognitive perquisites for language through actual interactions with the
environment, such as sensory-motor interaction with the environment. These
“hands-on” experiences that interact with environment serve to stimulate the
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competence in social interaction (Vandenberg & Kielhofner, 1982), therefore,
language development is critical for occupational therapy.
Emotional Development
Although Freud (1961) never articulated a systematic theory o f play, he made a
significant impact upon the development of play role in the emotional development
of children (Rubin, Fein 8c Vandenberg, 1983). Freud proposed that play provided
children a way for wish fulfillment which allows the child to escape constraints in
reality and supply a safe context for expressing unacceptable, aggressive impulses.
It is through activity and repetition that the child begins to understand the self and
the environment. A playful context, in which the child is either actively involved or
just a passive observer, helps the child to gain control of himself and fulfill his
wishes. Furthermore, play also can serve as a function for mastery o f traumatic
events by permitting children to take an active role to master situations in which they
were passive victims (Rubin et al, 1983). Through activities and exploration in play,
the child comes to understand his conflicts and painful feelings, thus he or she
replaces unpleasant emotions with happier feelings. In other words, the
psychological function o f play allows the child to remove him self from reality and
express his feelings through play behavior.
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Erikson (1977) used the mastery concept of Freud’s view of play to create ego
development theory and a coping system of play for children. He believed that
children could deal with anxiety through play within a comfortable context, “ ...The
child’s play is the infantile form of the human ability to deal with experience by
creating model situations and to master reality by experiment and planning” (Erikson,
1963). His ideas then led to the foundation of the development and use o f play
therapy to help children with emotional difficulties.
To help children with behavior and emotional disorders, occupational therapists
use the context o f play to help the child construct a world that is meaningful. It is
in the play context that children with emotional and behavior disorders can
understand and improve the necessary skills to function in tasks and with others in
school, in the family, and in community settings. This is the major goal of
occupational therapy practice in this area (Florey & Greene, 1996; Morrison et al.,
1996).
Plav As An Occupational End Goal
The second view o f the importance o f play in occupational therapy is that play
serves as an avenue to enable children to develop competencies in the engagement of
occupation. Thus, play is seen as a goal in itself.
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Rule Learning through Plav
The occupational behavior frame o f reference emerged as a contemporary view
of play in occupational therapy. According to the main contributor, Mary Reilly
(1974), play is considered the major activity for children. She believed that play of
children is a primary way of achieving new skills, habits, and abilities, which are a
prerequisite for the competence in later occupational roles in life. Reilly explained
that this is possible because children learn rules through play. Reilly (1974)
described rules as symbols derived from the environment that guide interactions.
Robinson (1977), one of Reilly’s students, further elaborated on how rules are
acquired in the arena of play. She defined the rule as an “internal structure
informing individuals of their constraints o f action learned by acting with objects and
people” (Robinson, 1977, p. 249). The rule is “a map of reality” (Robinson, 1977,
p. 249) that guides children’s actions. During play, children have the opportunity to
discover what effect they can have on the objects and people in the environment and
to develop mental representations as rules that lead to skilled actions accumulates
new and more complicated rules, these serve as new guides o f action and enable
more complex environmental interactions (Robinson, 1977).
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According to Robinson (1977), there were three types of rules, that is, rules of
motion, rules of objects, and rules o f people. The progression of gaining the rules
is: rules of motion, rules of objects, and rules o f people. Rules of motion are
learned in the beginning when children encounter the earliest problems o f moving
their bodies to achieve goals. They repeat the motion over and over again until they
m aster each puzzle. Then children figure out the motion that allows them to
interact with objects so that they can start to have opportunities to interact and
manipulate objects interesting to them. Finally, children discover that the
environm ent not only includes objects, but also includes people around them.
W hile interacting with people, children learn how to exchange information with
others (Robinson, 1977).
These three types o f rules then become the components o f what Robinson called
“subroutines” or actions used to attain a goal. These subroutines gradually combine
together to form skills refined within different contexts with different people. Take
learning to swim for example. First, the child has to learn the rules of how his or
her hands and feet work simultaneously in the water. These rules allow the child to
develop new subroutines, such as floating and swimming in the water. Then he or
she will integrate and link these subroutines to know how to swim while changing
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breath. Finally, the child will consolidate and solidify the skills within a different
environment, such as in the sea or in the lake.
Occupational Role Development
Occupational role is the central concept in the occupational behavior frame o f
reference (Reilly, 1974). Role is defined as “the expected pattern of behavior
associated with occupancy o f a distinctive position in society” (Heard, 1977, p. 244).
On the other hand, occupational role is conceived as “the activity in an individual’s
life that contributes to society and, thereby, defines the person’s societal worth”
(Heard, 1977, p. 244). Occupational roles changes across the lifespan, and there is
an orderly progression from player to student to worker, homemaker or volunteer,
and then finally retiree. Each occupational role transforms and builds on previous
skills, and then enables the individual to develop the new and evolved occupational
role (Heard, 1977).
Every occupational role implies a set o f expectations of behavior (Heard, 1977).
The major occupational role o f infants and young children is the player (Heard, 1977;
Kielhofner, 1995; Parham & Primeau, 1997). For the player role, expectations
come, such as children play in a manner expected by caregivers or parents. The
player role is viewed as a vehicle for learning the rules, skills, and habits that are the
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physical development, as well as cognitive and social skills developm ent (Lindquist,
Mack & Parham, 1982; W illiams & Matesi, 1988). According to Mogford (1977),
most children with disabilities have one thing in common, that is “their ability to
explore, interact with, and master the environment is impaired” (p. 171). Therefore,
children with disabilities may not have the same play experiences as that of typically
developing children (Burks, 1998; Mack, Lindquist & Parham, 1982). The
proposed study focused on children with cerebral palsy. The limitations imposed
by cerebral palsy are reviewed in this section. Specifically, they are physical
limitations, cognitive limitations, and limitations in environmental interactions.
Limitations Imposed bv Cerebral Palsy
Physical Limitations
The physical limitations in the child with cerebral palsy have been extensively
described (Bobath & Bobath, 1975; Levity, 1984). Cerebral palsy is not a
progressive disease, but because o f its influence upon physical growth, it can result
in body deformities. The child often exhibits specific m ovem ent problems that
require higher energy expenditures. Due to this requirement, children with cerebral
palsy m ay appear tired and unmotivated to play (Runac, 1985).
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According to Blanche (1997), the movement deficits imposed by cerebral palsy
have impacts on play in two ways. First, the physical disabilities decrease the
opportunities for children to explore and access their environments. Second, they
influence children’s abilities to actively and spontaneously participate in play when
something interests them.
On the other hand, functional mobility is also a factor that limits opportunities
for social play (Ferland, 1997; Hewett, 1970). In Hewett’s study o f the behavior of
children with cerebral palsy living at home, Hewett (1970) concluded that children
with physical disabilities needed to be taught how to initiate play during social
interactions with people. Additionally, children with physical disabilities may not
be permitted to have chances to play in a nonstructured setting, such as playgrounds,
neighborhoods, and parks because the environmental challenges usually exceed
children’s ability and skills, and may lead to frustration and anxiety (Levitt, 1975;
Stout, 1988).
Cognitive Limitations
Cognitive impairments may often accompany cerebral palsy. Deficits in
cognitive development with below-average intellectual level have been seen in
between 50% and 75% o f children with cerebral palsy. It may range from mild to
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25
profound (Pellegrino, 1997). In the cerebral-palsied child with both severe
movement and intellectual impairments, it appears that cognitive limitation is more
decisive than physical disability (Blanche, 1997). In research on deprivation of
early sensorimotor experience and cognition in severely involved children with
cerebral palsy, Eagle (1985) found that intellectual level had a greater effect upon the
acquirement o f early cognitive milestones than severity o f physical disabilities.
Because the cerebral-palsied child’s knowledge of the concrete world is often limited,
“such children may experience difficulty at the more abstract level of play:
symbolism and fantasy may be slow to develop” (Salomon, 1983, p. 464). Hewett’s
study (1970) o f children with cerebral palsy living at home described the typical
activities of these children and the factors that encouraged them to play. Mothers
were asked what kind o f toys their children liked to play with the most. Eleven
percent of mothers whose children were aged two to seven years and had mental
handicaps or uncertain cognitive abilities answered that the children were interested
in no activity at all. Others replied that they were interested only in baby toys.
Consequently, for the child with cerebral palsy who has both physical and cognitive
deficits, severe cognitive impairments may affect play developm ent to a greater
degree than do physical limitations (Blanche, 1997).
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Environmental Barriers
There are three types o f environmental barriers: social barriers, physical
environmental barriers, and barriers imposed by parents o r caregivers (Burke, 1998;
Okimoto, Bundy & Hanzlik, 2000; Williams & Matesi, 1988). First, children with
physical disabilities, such as those with cerebral palsy, often have low availability of
peers and playmates due to physical limitations and exclusion by their peers
(Okimoto et al., 2000). With decreased opportunities for interactions with peers, it
is difficult for children to develop social skills and friendship, which further
increases their isolation (Burke, 1998; M issinna & Pollock, 1991). For example,
consider the situation o f one child with a disability in a mainstreamed kindergarten.
He or she may not know how to initiate a talk with friends or how to join a group.
Children with disabilities may have poor social skills to interact people and his
environment.
Second, barriers imposed by the physical environm ent may severely limit
accessibility for children with physical disabilities. The barriers may exist in the
home and in the community, such as playgrounds and school (Stout, 1988; Williams
& Matesi, 1988). Besides, the toys, materials, and equipm ent also limit children’s
ability to explore and express themselves (Rubin et al., 1985). Sheridan (1975)
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27
stated that children with disabilities are often excluded from being supplied with
abstract play material, such as pegboards, screw-toys, and nesting boxes. Instead,
they are provided with educational toys to learn basic knowledge. However, these
kinds of toys do not help children with disabilities to extend their language, social
interaction skills, and more complicated types of play. In the study o f the gross
motor skills of cerebral-palsied children in an adventure playground for children with
disabilities, Levitt (1975) found that when children with physical disabilities reach
motor developmental levels o f one year and over, they benefit more from the
playground instead o f structured places, such as therapy room.
The third type o f environmental barriers is from parents or caregivers.
Children need opportunities to initiate and engage in activities in which they can
have freedom to make choices, learn rules, develop functional skills and master their
physical needs. However, parents or caregivers o f children with disabilities
frequently overprotect them and may not allow them to play in normal activities
(Salomon, 1983; W illiams & Matesi, 1988). This is perhaps due to lack of
knowledge o f motor developm ent and the fear of injuries to their child (Levitt, 1975;
Mogford, 1977). Furthermore, parents may underestimate their children’s skills and
capacity (Levitt, 1975). Research evidence suggests that the more assistance
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parents give, the more passive children become (Levitt, 1975). In Levitt’s (1975)
study, the results showed that some children with disabilities tended to use their
charm to obtain help and gradually learned to wait for adults to help them except for
active initiating actions, such as rolling. In addition, a professional’s emphasis on
children’s functional skill development may fail to acknowledge the importance and
need of play for children, therefore, free time is used by parents for therapy or other
activities (Hanzlik, 1989a, 1989b; Kogan, Tyler & Turner, 1974; Mogford, 1977).
Burke (1998) addressed the possibility that parents of children with disabilities may
have unhappy and unsuccessful experiences in raising their children. They may
have experienced a long-term separation from their ill infants and feelings of
discom fort in handling a small infant, which result in difficulties in family role
development. These uncomfortable feelings can affect the parent-child relationship
and then inhibit the parent’s motivation to play with their children (Burke, 1998).
In short, for children with disabilities like cerebral palsy the play environm ent may
reflect “conditions of play deprivation,” such as “sedentary, passive experience
usually in the form of television; a lack o f or limited availability o f raw materials; a
lack o f appropriate models for play; too much emphasis on with small motor or large
m otor actions; too high o r too low parental expectations” (Takata, 1971, p. 283).
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Studies of Play Behaviors of Children with Disabilities
Gralewicz (1973) conducted a study o f play differences between
multihandicapped (half o f them diagnosed with cerebral palsy) and typically
developing children who were 3 to 5 years old. Observations on play were
recorded in the children’s home by their parents. Gralewicz (1973) concluded that
multi handicapped children had fewer play companions, had less interactive playtime
and less variety of play activities than the nonhandicapped children. But when the
therapeutic time was added to their playtime, their composite time was equal to the
time spent by nonhandicapped children in play. In addition, although group
differences were not statistically significant, the multihandicapped children spent
more time engaged in no observable activity at all. In Brown and G ordon’s
research (1987) of activity patterns of children with disabilities, the researchers
found that during activities o f daily life, children with cerebral palsy or spina bifida
spent more time in dependent activities, personal care, and quiet recreation, and were
less engaged in social interactions, active recreation, household tasks, and activities
outside o f home. They concluded that activities o f children with disabilities were
less varied and were frequently related to social events. With age, they seem more
prone to social isolation.
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children with disabilities seemed idler. Their activities were less com plex and less
advanced in cognitive terms than those of their counterpart peers (Jennings et al.,
1988).
Based on the experience o f establishment of Toy Library at Nottingham
University, M ogford (1977) described the abnormal play behaviors o f children with a
variety of disabilities, including children who had cerebral palsy also had mentally
retardation. They consisted of “a lack of sustained attention and rough, destructive
and inappropriate use of objects . . . persistence of narrow and inflexible methods of
exploration . . . marked lack of initiate, playing only when encouraged or prompted
by an adult” (p. 174).
Summary
Due to the physical and cognitive dysfunction and environmental barriers,
children with cerebral palsy often become overly dependent on their parents or
caregivers for help in exploring, interacting and playing in a satisfying way. The
dependence o f children with cerebral palsy is not only from their innate disabilities
but also from the attitudes of their parents or caregivers and the physical
environmental barriers. Especially the parents’ values would facilitate the children
to Ieam to depend upon parents’ helps. The more obstacles they encounter, the
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32
more dependent they may become. In other words, the effects o f the disabilities can
be cumulative and learned (Brown & Gordon, 1987; Mogford, 1977).
Parents’ Values toward Play
Much o f child development depends on active and dynamic interactions
between mother and children (Hanziik, 1989a; Holloway, 1997). Sutton-Smith
(1980) argued that the infant’s developmental skills are derived from the early play
routines between mother and infant beginning in the infant’s second month of life.
Therefore, play has an important role in enhancing positive mother-child interaction
and child development (Florey, 1981). Bronfenbrenner (1986) and Lemer,
M ardell-Czudnowski, and Goldenberg (1981) also argued that parental knowledge
about and attitudes toward play are significant factors in child’s development. Thus,
parents’ values toward play are essential to explore, especially the parents o f children
with disabilities.
Before viewing the parents’ values regarding play in home, it is helpful to
explore the parent-child interactions first to obtain a blueprint o f parents’
understandings of play. The majority o f the parent-child interaction research had
been conducted on mothers. Based on a pilot study designed to assess factors
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related to interactions between occupational therapists and parents o f children with
cerebral palsy, Hinojosa and Anderson (1987) stated that 89% of occupational
therapists worked mainly with mothers, while only 11% worked with both parents.
Therefore, the literature review will focus on mother-child interaction. Through the
mother-child interaction, mothers’ attitudes toward play in home will be illustrated
and elaborated. Then parental values toward play will be viewed within different
culture backgrounds.
Mother-Child Interaction
The importance o f the parental influences on child development has never been
questioned. A child’s development is enhanced by the good interactions between
the mother and child (Hanzlik, 1989a). Playful parent-child interactions promote
the child’s cognitive and physical development (Connor, Williamson & Siepp, 1978).
However, when the child has a physical disability, such as cerebral palsy, the
dynamic interactions between the mother and the child are much different from those
between a m other and a child who is typically developing (Connor et al., 1978).
Hanzlik (1989a) addressed, “if one o f the dyad members is unable to demonstrate or
elicit behaviors that promote joint regulation o f interaction, maladaptive behaviors
may be the result, and the dyad may be at risk for interactive behavioral anomalies
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34
that have the potential to affect the social, cognitive, language, and physical
development o f the infant” (p. 35).
In studies o f dyads between mothers and their children with physical disabilities,
the results have been consistent. Mothers of children with disabilities display more
commanding or directive behavior toward their children, engage in more physical
contact, initiate more interactions, and show more warm affection than the
comparison mothers who have children with typical development. On the other
hand, during mother-child interactions, children with physical disabilities show less
engagement in eye contact, less independent play, and less positive affect than their
counterparts who are typically developing (Barrera & Vella, 1987; Brooks-Gunn &
Lewis, 1984; Cunningham, Reuler, Blackwell & Deck, 1981; Fish-Brown, 1992;
Hanzlik & Stevenson, 1986; Kogan & Tyler, 1973; Lieberman, Padan-Belkin &
Harel, 1995).
These kinds o f directive or controlling behaviors of mothers who have
children with cerebral palsy can be classified into two categories: physical and verbal
guidance. Hanzlik and Stevenson (1986) and Brook-Gunn and Lewis (1984) found
that mothers o f infants with cerebral palsy show more physical directive behavior
than mothers o f children with no delays. These mothers had a tendency to hold
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35
their children. Perhaps it is because some children with cerebral palsy are unable to
easily initiate fine or gross motor movement corresponding to their chronological
ages, that their mothers may try to facilitate more movements for them (Hanzlik,
1998). Also, mothers of children with disabilities engaged in more verbal
directives to m onitor their children’s movement (Hanzlik, 1989b; Tannock, 1988).
They may verbally ask their children to participate in some events that were not
related to children’s focus of attention (Mahoney, Fors & Wood, 1990). These
directive behaviors o f mothers o f infants with disabilities may serve partially to
explain the children’s behaviors and responses. For example, if the mother
continually makes a lot of requests by either verbal or physical commands, the child
with disability will spend more time processing a response, will seem passive to the
mother, comply more frequently to mother’s requests, and engage in less voluntary
responses (Rogers, 1988). Thus, the child’s responses may increase the tendency
for mothers to give more directives.
To a certain extent, maternal directives have a positive effect on child behaviors
during interactions (Tannock, 1988). However, excessive maternal physical contact
and assertive behaviors may decrease the child’s competence and level of
independence in play. According to Beckwith (1976), the excessive physical
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36
contact, such as holding or positioning the child in one posture for a long time
(Hanzlik & Stevenson, 1986), would restrict the child’s chances to explore, and then
decrease the child’s activity level, and they may have a negative impact on the
child’s cognitive development. Besides, as previously mentioned, mothers o f
children with disabilities have a greater tendency to initiate interactions than mothers
o f children with no delays (Brools-Gunn & Lewis, 1984). When children are
constantly directed, they do not have many opportunities to make choices and initiate
interactions with their mothers. Therefore, perhaps they come to believe that they
do not have adequate abilities to affect their environments by themselves and then
become passive recipients (Hanzlik, 1998; McDonald, 1985). These negative
behaviors and concepts may interfere with the ability of children with disabilities to
play independently. Thus, children with disabilities may benefit less from
mother-child interactions. In other words, if the mothers of children with
disabilities could use directives in a supportive way, they would produce a positive
communicative effect for children with disabilities (Davis, Stroud & Green, 1988).
Hanzlik (1989b) implemented an intervention study for mothers o f children
with cerebral palsy to investigate the effects o f maternal instruction on verbal and
nonverbal interactions. The intervention to improve mother-child interactions
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38
and before the interventions, the children were scored on the Test of Playfulness
(ToP). The results showed that the children whose mothers received the
intervention to improve mother-child interactions got significant higher scores on the
ToP after intervention than before intervention. They also found that when the goal
of parents and therapist is to enhance children’s instinctive playfulness, the
intervention to improve mother-child interactions was more potent than the NDT
intervention in enhancing the child’s developmental skills.
In summary, mother-child interaction is essential for young children. Positive
mother-child interaction can enhance children’s developments. However, the
interactions between mothers and their children with physical disabilities, such as
cerebral palsy, tend to be much different than the interactions of mothers and their
children who are typically developing. Mothers of children with disabilities tend to
show directive behaviors to guide their children during play, so the children
gradually learn to engage in less responsive and less independent play. After
interventions to improve mother-child interaction, children with disabilities become
more responsive to their mothers and have more opportunities to explore and play
independently. Therefore, the literature reviewed supports the- premise that parental
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Subramanian, 1996). In the first approach, specific beliefs are received from the
culture and then become internalized with the process of socialization. In the
second conceptualization, different cultural backgrounds supply different qualitative
experiences, from which the individual generalizes to from beliefs. The
intracultural consistency o f experience leads to the appearance o f sim ilar beliefs that
are held by the different members of the cultural group. In the third
conceptualization, culture is made up of knowledge and individual beliefs, as
individuals interact with cultural system of beliefs.
Parents of Children with Disabilities
In M ogford’s (1977) description of her experiences establishing the Toy Library
at Nottingham University, she found that some o f mothers o f children with
disabilities thought their children could not play or explore the environm ent because
of their misunderstandings that children who have physical disabilities do not have
motivation to play. Chiang (1999) used a qualitative study to research a
Taiwanese mother’s experience of having a child with developmental delay.
Chiang (1999) indicated that before the mother knew her child was diagnosed as
developmentally delayed, she had a hard time to simultaneously deal with the care of
the child and the household responsibilities. So in order to save time, she did not
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41
play with her child, although she thought that it was important to do so. However,
after knowing her child was diagnosed with developmental delay, the mother was
told the significance o f exploratory behaviors and cam e to understand that play and
exploratory behaviors are important for her child. Therefore, the mother
encouraged her child to play and designed an appropriate environment for her child
to explore. Although this child had developmental delay without cerebral palsy,
these results may be relevant to this study because it expressed the attitudes
regarding play o f a mother of a child with disabilities in Taiwan.
In Sparling, Walker, and Singdahlsen’s (1984) research, the results are similar.
This pilot study was to study the effect o f educational play as an intervention
approach and was conducted with 14 preschool children with physically disabilities.
A fter the intervention, the children’s performances improved in developments of
cognitive, language, social-emotional, motor, and ADL. In addition, the parents of
these children came to value the importance o f play and use play as an essential
component of the child’s developments.
Research indicates that mothers o f children with physically disabilities spend
more time engaged in physical child care activities (Johnson & Deitz, 1985),
therefore, mothers o f children with cerebral palsy often integrate the children’s home
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42
treatment into their daily routines and interactions, such as family play. Parents
report more positive attitudes toward their children when interacting in play than
when involved in therapeutic activities (Hinojosa & Anderson, 1989; Kogan, Tyler &
Turner, 1974). This finding suggests that parents should be encouraged to grow in
their roles of care giving through new manners in regard to daily child management.
When the parents know that their attitudes toward their children are more important
for enhancing later developments than the minor problems they faced, they may
relax and enjoy their family lives more (Lemer, Mardell-Czudnowski & Goldenberg,
1981).
Based on this researcher’s personal experiences o f being an occupational
therapist in Taiwan, I question whether the parents o f children with cerebral palsy
often do not realize the importance of play for their children. Most o f them care
about children’s functional mobility, intellectual levels, and self care abilities, but
they don’t know that children leam these relevant skills through play behaviors.
Besides, due to the stress of everyday life, the parents can not focus much of their
attention on their children who have cerebral palsy. Perhaps this is because the
researcher’s workplace was in a rural area where parents’ educational levels are not
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43
very high. It was not clear to this researcher how parents of cerebral-palsied
children think o f play in their home.
Parents o f Children W ho Are Typically Developing
Gaskins (1999) reported a case study o f beliefs and behavior o f a Mayan family
and expressed how Mayan parental beliefs effect children’s play. She found that for
the Yucatec M aya, parents don’t highly value play as children’s activity, but they
don’t actively inhibit their children to play. The results indicated that the Mayan
parents feel the main meaning o f play is that it keeps the children busy, occupied,
and content so that adults can work. Further, the parents also believe that it is good
to see young children play because then one knows they are not sick. But play is
not valued to have significant consequences and importance to children’s
developments (Gaskins, 1999).
In a study o f Caribbean immigrant parents’ ethnotheories about the value o f play,
Roopnarine and Hossain (2001) interviewed sixty mothers and fathers with
pre-kindergarten or kindergarten-aged child about their thinking o f play and early
childhood education. Both parents agreed that children receive a wide range o f
benefits of engagem ent in play but they also expressed the importance of academic
focus in early childhood education and then the children can be competent in later
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44
schooling. Although the Caribbean parents value the significant o f children’s play,
they still discourage their children’s play.
Primeau (1997) studied the nature of parent-child play and its orchestration
within the daily occupations o f families. Data were collected from participant
observations and intensive interviews with 10 families o f preschoolers. She found
that parents used two types o f strategies to orchestrate daily occupations within their
families: strategies o f segregation that leads to play interspersed with household
work, and strategies o f inclusion manifested as play em bedded in household work.
In the play interspersed with household work, parents took advantage o f times when
their children were already engaged in play and when they could do their household
responsibilities. In play embedded in household work, parents allow their children
to involve in adult’s work in an appropriate way which is called scaffolding play, or
parents participated in play with their children within different childcare occupations.
This kind o f parent-child play expanded the parents’ opportunities and capacities to
play with their children. Furthermore, in scaffolding play, parents provide chances
that increase their children’s learning and ability to participate in occupations that is
significant for their future lives.
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In a study o f Taiwanese mothers’ attitudes toward play, Pan (1994) used the
Maternal Attitudes toward Children’s Play Questionnaire to investigate mothers who
had child in Taipei private kindergartens. The questionnaire consisted o f two
sections. The first part addresses how mothers think of the function o f play. That
is, does play contribute to children’s cognitive, social, mental, and physical
developments? The second part explored how mothers arrange children’s play at
home. The results revealed that mothers had the highest mean score on the
cognitive domain, followed by the social domain, physical domain, and mental
domain. In addition, most mothers responded that they usually provided children
with a variety of toys, such as functional, constructive, and dramatic toys and they let
children play for an average of one to two hours per day. (Pan, 1994).
For parents of children who are typically developing, Li, Bundy and Beer (1995)
investigated Taiwanese parental values toward playfulness. They used the items
from the Children’s Playfulness Scale as a questionnaire to survey Taiwanese
parents’ knowledge and values toward children’s play and playfulness. When the
parents were asked how important play is to kindergarten-aged children, of the 81
returned questionnaires, 70 considered play to be “very important” (Li, Bundy &
Beer, 1995). The results suggested that play is highly valued by Taiwanese parents.
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47
Exploratory Learning School perceived the value o f play in children’s cognitive
development.
In middle-class Chinese and United States families, the caregivers participate in
the social pretend play with their young children and pretend play is sanctioned in
both middle-class Chinese and U. S. families (Haight, Wang, Fung, Williams &
Mintz, 1999). However, the ways the interaction take place are substantial different
and related to socialization beliefs. In Chinese culture, filial piety is valued,
including obeying and honoring the parents, respecting and submitting to the elder,
adhering to rules, and cooperating (Chao, 1994). In addition, for Chinese mothers,
teaching their children to be a good person is their primary role responsibility, a
expression of maternal love, and a success of parenting (Chao, 1994). Thus, the
Chinese mothers value the importance of mother-children pretend play through
which to teach their children. Compared to Chinese mothers, middle-class
European-American mothers generally endorse a “child-centered” approach to
interact with their children (Chao, 1994). They view play to be important for
children’s developments and engage in play with their children (Haight & Miller,
1993). Although both middle-class Chinese and U. S. families value the existence
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48
o f mother-children pretend play in the families, the manner that take play are various
and related to culture beliefs (Haight, 1999).
In a study of cultural differences in Korean- and Anglo- American preschoolers’
social interactions and play behaviors by Farver, Kim, and Lee (1995), the
researchers found that 47 % of Korean-American mothers thought that the purpose of
play for their children is for amusement, to relieve boredom, and to express curiosity.
In contrast, 84% of Anglo-American mothers believed that play is learning and is
related to children’s development. In another study of comparing the socio-culture
contexts between South Korea and United States, the results are similar (Tudge, Lee
& Putnam, 1998). The researchers found that Korean mothers tended to be
observers when they engaged in children’s play whereas U. S. mothers were more
active participate in children’s play (Tudge, Lee & Putnam, 1998).
Parmar (2000) explored cultural differences in beliefs o f play of Euro-American
and Asian families living in the United States. Data were collected by Daily
Activities Checklist and questionnaire which included open and close-ended and
semi structure interviews. Data were collected at two settings, at home and at
school, from forty-eight parents and teachers o f preschool children from two cultural
backgrounds. The results found that Euro-American parents highly value the
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49
importance of play and regarded play as a vehicle to enhancing children’s physical,
social, emotional, and cognitive developments. On the other hand, the Asian
parents did not regard play in relation to children’s development. They also did not
believe that children can benefit by playing. These studies, which compare the
differences between two cultural backgrounds may relate to the concept o f parental
ethnotheories. Parental ethnotheories about play are influenced by the environment
they live and the customs they have, and are shaped by members of a cultural group.
Summary
Parents’ attitudes toward play are important for children’s developments.
According to the reviewed literatures, the parents of children who are typically
developing have different values about children’s play. It may be in relation to
parental ethnotheories about play. However, for the parents of children with
disabilities, especially for the mothers, attention may be focused more on the deficit
or disability rather than on their children’s play instincts, and parents may not
acknowledge the significance of play. Some research evidence suggests that after
being told or receiving an intervention, parents realize the advantage o f engaging in
play for their children and can change their attitudes toward play. Thus, parents’
knowledge and values toward play is significant for the development o f children
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50
with disabilities. It was not clear to this researcher how Taiwanese parents who
have children with cerebral palsy think about play behavior for their children.
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Instrumentation
The interview designed by this researcher was used as the instrument to
investigate the research questions (see Appendix A). The three parts of the
interview were as follows: (I) demographic questions of children and the parents,
such as child’s age and gender and parents’ age, occupation, education level and the
total family income; (II) three questions designed to provide information about the
child’s play with parents and others at home; and (HI) six questions designed to
explore the parents’ values toward play about their children with cerebral palsy. In
Part II o f the interview, the researcher asked the following questions about the
situation at each child’s home: “Who plays with the cerebral-palsied child most of
the time?”, “During what activities do family members usually play with your
child?”, “Would you share with me what it is like when you play with your child?
Maybe you can tell me stories about times when you had fun together.” The last
question aimed to get a scenario o f family play to get a better understanding of
parent-child play at their home. Part m o f interview consisted o f one open-ended
question o f “W hy do you think children play?” and 5 close-ended questions with two
o r more response options. These close-ended questions were “B ased on your
concept o f childrearing, do you think play is important for a preschooler who is
typically developing?” “Do you think play is important for your child with cerebral
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53
palsy?” “W hat is the main reason that you play with your cerebral-palsied child?” “If
the child’s therapists recommend you to play with your child with cerebral palsy at
home, will you follow his/her suggestions?” “If you do not have enough time to play
with your child with cerebral palsy, would you ask someone to do so?” After the
parents answered each o f the closed-ended questions, the parents were asked to
elaborate on their answer by sharing more details regarding their attitudes to get
further qualitative data.
Procedure
The Interview Guide (Appendix A) and an Information Sheet for the Parents
(Appendix B) were prepared for the potential respondents. The interview questions
and the information sheet for the parents were initially written in English and then
were translated to Mandarin Chinese by the researcher (Appendix C & D). Then an
individual who was unfamiliar with the study translated it back into English.
Approval from the Institutional Review Boards at the Health Science Campus
o f University o f Southern California was obtained before conducting this study.
The study was exem pt from requiring an informed consent form for the subjects. In
this study, subjects were assigned study ID numbers at the time of interview,
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55
parents face to face in a private room in the rehabilitation center. Before starting
the interview, parents were given the Information Sheet for the Parents (Appendix B)
in order to understand the questions completely. For yes/no questions in questions
5 ,6 , 8, and 9, all participants answered easily without long-time consideration.
After the parents answered each o f the questions, the researcher asked the parents to
elaborate on each o f their responses to get more detailed qualitative data. The
reasons for doing this were to obtain a clearer understanding about the parents’
attitudes toward play and to gather information regarding the parents’ experiences
and feelings about caring for a child with cerebral palsy. All parents’ responses
were written and checked by the researcher immediately and also were audiotaped to
serve as a quality check and a backup when the written interview notes were missing
or not clear. The interview took about 45 minutes for each participant.
Data Analysis
The researcher counted the number of parents’ responses to each option for
close-ended questions 1, 2, 5 ,6 , 7, 8, and 9. Then the percentage and frequency
data were generated for each o f these responses. Chi-square tests (2x2) were used
to analyze the effects of parents’ age and educational level on the results for
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56
questions 5 and 6 in Part HI of interview. These questions asked: “Based on your
concept of childrearing, do you think play is important for preschooler who is
typically developing?” and “ Do you think play is important for child with cerebral
palsy?” The goal of the 2x2 chi-square tests was to clarify the associations between
parent’s age, educational level, and their opinions toward play for their
cerebral-palsied children. For the parents’ age, the respondents were divided into
two groups: the younger age group (20 to 30 years old), and the older age group
(over 30). As for educational level, the parents were separated into two groups,
which were low and high education level. Parents who had completed high school
or had less than a high school education were grouped as having a low educational
level, and those with an education beyond high school were grouped together as
having a high educational level.
The results of the close-ended questions served as a foundation to attain a
blueprint o f Taiwanese parents’ values about play. For open-ended questions and
parents’ elaboration of close-ended questions, the responses of parents were analyzed
and coded by identifying primary categories which emerged from parents’ responses.
The researcher counted the number o f parents who mentioned information that fell
into each category for each o f the questions. Questions 3 and 4 asked, “Would you
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57
share with me what it is like when you play with your child? Maybe you can tell me
stories about times when you had fun together” and “Why do you think children
play?” Parents’ responses were coded according to the type o f activity parents’
reportedly played with their children at home (question 3), and according to the kind
of reasons parents gave for why children play (question 4). Thus, parents’
elaboration o f close-ended questions and responses for open-ended questions
provided further clarification o f Taiwanese parents’ beliefs about play for their
children with cerebral palsy.
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58
CHAPTER IV
RESULTS
In this chapter, demographic information of subjects and their children are
described. Next, associations between participants’ age and education level and
their attitudes toward play are provided. Finally, parents’ responses to each
question in the interview are presented and summarized.
Interview Questions in Part I: Demographic Questions of Parents and Their
Children
A total of 45 Taiwanese parents who had preschool-aged children with cerebral
palsy participated in this study. The researcher interviewed parents who met the
inclusion criteria and took their cerebral-palsied child to therapy sessions. O f the
45 participants, 34 were mothers and II were fathers. The prim ary work of 28
parents was taking care of children at home, and 27 of these parents were mothers.
M ost o f the participants ranged in age from 31 to 40 years and had completed
education at the level of senior high school. In addition, over half o f the
participants had 2 children, one with cerebral palsy and a second who was typically
developing. For children with cerebral palsy, 15 were girls and 30 were boys. The
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mean age was 3.46 years for girls, 3.80 for boys, and 3.69 for all children (See Tables
1 and 2).
Table 1
Demographic Characteristics o f the Parents
Fathers
( n = 11)
Mothers
( n = 34)
Characteristic
M
SD
M
SD
Age (years) 36.63 3.93 34.62 5.19
Education 3.55 0.52 3.09 0.79
Number o f children 2.27 0.79 1.82 1.21
Family yearly income 3.27 1.27 2.35 0.81
Note.
Education: 1 = below junior high; 5 = over college.
Family yearly income: 1 = below NT 300,000; 5 = over NT 2,000,000. (1 US Dollar
= 34.5 NT Dollar)
To examine whether respondents’ expressed values toward play were affected
by their educational level and age, 2x2 chi-square tests were calculated for these
demographic variables and questions 5 and 6 in Part HI o f the interview. In
questions 5 and 6, parents were asked their attitudes toward play for children who are
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Table 2
Age o f Children with Cerebral Palsy
Group Mean age (in years) SD
Girls 3.46 1.25
( n = 15)
Boys 3.81 1.16
( n = 30)
Combined 3.69 1.18
( n = 45)
typically developing and for their child with cerebral palsy. Results o f chi-square
tests are presented in Tables 3, 4, 5, and 6. No statistically significant associations
were found between parents’ educational level or age and their expressed values
toward play for their children with cerebral palsy or for children who are typically
developing.
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Table 3
2x2 Chi-Square Test o f Parents' Age and Their Values About Play
for Children with Cerebral Palsy
Age
Response Younger Older
Play is important 5 38
Play is NOT important 1 1
Note. N = 45; p > 0.10
Table 4
2x2 Chi-Square Test o f Parents’ Education Level and Their Values About Plav
for Children with Cerebral Palsy
Education level
Response Low High
Play is important 28 15
Play is NOT important 1 I
Note. N = 45; p > 0.10
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Table 5
2x2 Chi-Square Test of Parents' Age and Their Values About Plav
Age
Response Younger Older
Play is important
Play is NOT important
6 38
0 L
Note. N = 45; p > 0.10
Table 6
2x2 Chi-Square Test o f Parents' Education Level and Their Values about Plav
Education Level
Response Low High
Play is important 28 16
Play is N ot important 1 0
Note. N = 45; p > 0 .1 0
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Interview Questions in Part II: Activities at Home
Question 1: W ho Plavs with Your Child Most o f the Time?
In question 1, parents were asked who plays with their children with cerebral
palsy most o f time at home. As can be seen in Table 7, for most children, the
mother played with the children with cerebral palsy most o f the time, with siblings
the second most frequent playmate at home. In this question, parents were
permitted to check more than one option, so that the total percentage across all
categories exceeds 100%.
Table 7
Who Plavs with Your Child Most o f the Time?
Responses Frequency ( % of total sample)
M other 28 (62%)
Father 12 (27%)
Grandparents 7 (16%)
Sibling 18 (40%)
Caregiver 5(11% )
Note. N = 45
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Question 2: During W hat Activities Do Family Members Usually Plav with Your
Child with Cerebral Palsy?
The most common type o f activity that family members played with children
was an activity that involved being close to the child, followed by therapeutic
activity related to motor function, and cognitive activities (See Table 8). There
were eight parents whose responses were “others.” Three of these parents
mentioned that they played pretend play with their children and one of these parents
stated that he played ball with his child with cerebral palsy. Furthermore, two of
these parents said due to limited time at home, they did not have spare time to play
with their children. The other two parents who chose “others” mentioned their
children could play alone so they did not need to play with them. In this question,
parents were allowed to choose more than one option, therefore the total were greater
than 100%.
Question 3: Would You Share with Me W hat it is Like When You Plav with Your
Child? M avbe You Can Tell Me Stories about Times When You had Fun Together.
Parents were asked to share their stories about times when they had fun with
their children in order to provide a more detailed picture of parent-child play at
home. Initially, some parents did not understand this question very well, so the
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66
parents to have fun. After given this example, these parents realized what this
question meant in order to answer this question.
O f the 45 parents, 29 shared some stories about how they played with their
children at home. To code these stories, the researcher wrote down every activity
that came up then grouped activities with common content or purpose. For
example, once parents mentioned “to amuse child” “role play or pretend play” “play
related to children’s skill development” and “exercise or physical play”, their
answers were grouped together in a category. The researcher double-checked the
rules for coding to make sure that every activity was included. The stories that
parents shared with the researcher were classified into four categories relating to
amusement, physical activity, skill development, and social pretend play (See Table
9).
Amusement
When parents were asked what it is like when they have fun with their children,
14 parents said that they make their child laugh. The ways that parents amused
their children were diverse and many o f them mentioned that they were the only ones
who knew how to amuse their children with cerebral palsy. The ways that parents
amused their children were special and unique. For example, one parent related:
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Table 9
Types o f Story that Parents Plav with Their Children with Cerebral Palsy at Home
Category__________Features o f story________________________________________
Amusement Parents make their children laugh in a unique way.
Physical activity Parent-child play involves children's gross motor activities.
Skill development Parent-child play relates to child's skill development.
Social pretend play Parents engage in social role play with their children.
I know my child likes to listen the sounds of a bear. It is a bear with a button
on its belly and we can press it to listen the bear’s laughter. M y child really
likes the sound. Every time she listens to the bear’s laughter, she laughs too.
So we often play the bear together. Besides, we also have a “yuan yuan’s
song.” It is just a common nursery rhythm, but we call it “yuan yuan’s song.”
Yuan yuan is my child’s nickname that we usually call her. She likes the song
and usually asks me to sing this song. If she is irritable, I sing this song to
comfort her and amuse her.
Physical activity
Two parents stated that they usually play physical activities with their children
with cerebral palsy. Physical play was activity that involved children’s motor
functions, such as crawling and tumbling. When parents were asked to share what
it was like in their physical play, both o f them mentioned that the fathers usually
played this kind o f play with their children. For example,
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My child likes to play ball with me. I throw the ball and he catches it. But
sometimes he can’t catch the ball and just runs around in the living room to find
the ball. It is an interesting activity for him. And I know that he really likes
it.
Skill development
Eight parents stated that they would facilitate their child’s developm ent during
parent-child play, some o f them focusing on children’s motor skills, and others on
cognitive development. For example,
We play “who is the tallest child” to facilitate my child to practice standing. If
we just ask him to practice standing, he doesn’t want to do it. But he likes the
game. In this game, he just remembers not to be shorter than his brother so
that he stands as straight as he can. He not only plays the game but also
practices to stand at the same time.
I feel play is really helpful for this kind of child. My husband and I try to
understand how to help our child. We read a lot of books so that we know it is
important for my child to learn from daily activities, especially from play. For
example, we use chairs to let him practice to stand or use a competition to
motivate him to learn how to wear his socks. And it really works! He learns
quickly during play.
My child’s kindergarten teacher in Montessori School teaches me how to play
with my child. D uring play, my child can practice to control his hands and
legs. We usually play on the bed. I pretend to fall down from the bed and he
needs to save me like in a story, saying that a small mouse is going to rescue his
partner in danger. So during this kind of play, he uses his right hands and legs
unconsciously. And it is our goal to let him practice his affected side.
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Social pretend plav
When parents were asked to share what it was like when they had fun with their
child with cerebral palsy, five parents mentioned role play or pretend play. In role
play, parents and children played various roles, such as the child pretended to be a
m other and the mother pretended to be a baby. Children often were provided with a
set o f toys for pretend play, such as dishes for a table setting. An example o f such
social pretend play is as follows:
She often asks me to play pretend play with her. She likes to pretend as a
person who works in the gas station and wants me to be the person who
refuels the car with gasoline. We usually use her bicycle as a car that needs
gasoline. Afterward she tells me how much I need to pay and gives me a
receipt to keep.
Out o f 45 parents, 16 mentioned that they did not spend much time playing with
their children. Most of them were busy with their work and they often asked
someone to take care o f their children, such as grandparents o r babysitters. Parents
with longer working hours stated that they seldom even had the chance to see their
children play. One parent said:
I do not have much tim e staying at home cause I am too busy. It is 9 pm when
I go home and my child is already sleeping. How can I play with him or carry
out the home program?
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Some parents also said they did not have patience to play with their children,
especially after work. Others indicated that they did not give much attention to
their children due to the stresses o f work and household responsibilities. In
addition, a small number of parents mentioned they would carry out the home
programs without playing with children. For example, one parent said:
Now my child attends kindergarten so he doesn’t have time to play. Neither do
I. So I always finish his home programs as soon as possible. Just stretch his legs
only! I would not do the exercise and play with him at the same time. It is
time-consuming and non-efficient.
Interview Questions in Part III: Parents’ Attitudes toward Play at Home
Question 4: W hy Do You Think Children Plav?
Table 10 presents parents’ responses to the question o f why children play.
The categories listed in the Table 10 emerged from parents’ responses to this
question. Almost all parents stated more than one reason why children play, so the
total percentage is higher than 100%.
Almost 45% of parents thought children play because o f their curiosity about
everything new around them. Another common response was that play for
children is a kind o f instinct (38%). Additionally, seven parents felt play was
children’s main work, whereas others said children have nothing to do so that they
play, and still others believed the purpose o f children’s play was to imitate adults’
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Table 10
Why Do You Think Children Plav?
Category Frequency ( % o f total sample)
Curiosity 20 (44%)
Instincts 17 (38%)
Learn 9 (20%)
Nothing to do 7(16% )
It is children's work 7 (16%)
Imitate what adults do 7 (16%)
Fulfill their satisfactions 5(11% )
Explore the environment 4 (9%)
Children play because they can not quiet down 3 (7%)
Obtain sense o f achiecements 2(4% )
Afraid o f loneliness 1 (2%)
Note. N = 45
behaviors. The belief that children learn from playing was maintained by nine
parents, who mentioned skills such as learning how to play different roles, how to
use chopsticks, and how to use their bodies during play. But most parents just
mentioned that children learn general skills through play. A very small number o f
parents mentioned other reasons, including fulfillment o f children’s satisfaction,
exploration o f the environment, inability to quiet down, a sense o f achievement, and
fear o f loneliness.
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Question 5: Based on Your Concept of Childrearing. Do You Think Plav is Important
for Preschoolers Who Are Typically Developing?
All but one parent in the study considered play to be important for typically
developing children. The parent who didn’t believe that play is important said
that if her children play too much, they do not put their attention on their academic
activities. This parent hoped her children could just sit quietly and prepare for
elem entary school study.
A summary of reasons o f why the participants believed play is important for
children who are typically developing is provided in Table 11. These reasons came
from the researcher’s coding o f interview responses to this question. Almost all
parents addressed more than one reason o f why play is important for preschoolers
who are typically developing, therefore the total percentage exceeds 100%.
As can be seen in Table 11, most o f the reasons given by the participants are
related to the functions o f play, specifically learning, developing cognitive skills,
developing social skills, understanding the concept o f right and wrong, and
understanding the importance o f safety. On the other hand, 14 parents valued play
as important because they believed if their children could not play well, there might
be something wrong with them. These parents said they like to see children play so
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Table 11
The Reasons o f Whv Plav Is Important for Children Who are Typically Developing
Reason__________________________________________ Frequency ( % of total sample)
Learn through play 14 (32%)
Could be something wrong if children can't play 14 (32%)
Facilitate children’ s cognitive development 14 (32%)
Facilitate children's social skills 8 (18%)
Understand the concept o f right and wrong 4 (9%)
Understand the concept o f safety and danger 4 (9%)
Note. N = 45
that they don’t need to worry about the children’s health. O f 44 parents who
thought play is important, 14 valued play because they thought children learn from
play. For example, a parent mentioned that it is relevant for children to learn
through the way of play. She also indicated that children could gain more
knowledge from play than from direct teaching. O ther parents emphasized the
significance o f play because they assumed that children could realize the concept of
right and wrong as well as the issue o f safety through the context o f play.
Question 6: Do You Think Plav is Important for Your Child with Cerebral Palsy?
Parents’ feelings about the values o f play for their children with cerebral palsy
are presented in this section. As summarized in Table 12, forty-three parents (96%)
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74
indicated that play is important for their children with cerebral palsy. Only two
parents stated that play is not important for their children with cerebral palsy. A
parent who did not value the importance o f play indicated that the significance of
play for children with cerebral palsy would depend on the child’s cognitive level.
This parent thought that if the child does not have cognitive limitations, it would be
easier and helpful for him or her to learn from play. But because o f poor cognitive
function o f her child with cerebral palsy, she believed her cerebral-palsied child
could not gain much benefit from the context of play. Therefore, this parent said “I
don’t think play is important for my child.” The reason o f the other parent who did
not value play was related to environmental safety. This parent did not encourage
her cerebral-palsied child to play in unsafe environment. She felt that no
environment around her child is safe enough, even at home. Therefore, if her child
were playing, she would need to keep an eye on her child and would not feel free to
do anything else. “I just hope she can sit there and watch TV.”
For parents who valued play, reasons that they believed play is important for
their children with cerebral palsy were shown in Table 13. The reasons listed in
Table 13 were coded from parents’ elaborations o f the open-ended question of why
they think play is important for their children with cerebral palsy. As can be seen in
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Table 13
The Reasons o f Why Plav Is Important for Children with Cerebral Palsy
Reason Frequency ( % o f total sample)
Practice motor functions 16 (37%)
Motivation to do therapeutic activities 15 (35%)
Facilitates cognitive functions 11 (26%)
Facilitates brain development 7 (16%)
Note. N = 45
with their children with cerebral palsy, 34 (76%) parents answered because they
thought their children could gain benefits from play. In addition, therapists’
suggestions were mentioned by 17 parents. For those who answered “others”, the
reasons included being afraid to let children feel bored, helping them learn how to
play safely, responding to the child’s request to play with him or her, feeling
responsible as a parent, and playing with children without any other reasons (See
Table 14).
Question 8: If the Child’s Therapist Recommend that You Plav with Your Child at
Home. Will You Follow His/Her Suggestions?
W hen the researcher asked, “If the child’s therapist recommends that you play
with your children with cerebral palsy at home, will you follow his/her suggestions?”
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78
physical safety issues (n = 4), and fear that their children with cerebral palsy might
be emotionally hurt by someone’s insensitivity (n = 3). Two parents gave no
reasons for not asking anyone else to play with their children with cerebral palsy.
Summary
As can be seen in results described above, of 45 parents who were interviewed,
43 stated they believed play is important for their children with cerebral palsy and 44
mentioned that they considered play to be important for typically developing
children. The stated reasons why parents believed play is important for their
children with cerebral palsy were because they believed their children can benefit
from play, for example through practicing motor functions and facilitating cognitive
development. Although 43 parents stated that they valued the importance o f play
for children with cerebral palsy, only 40 o f them said that they would follow
therapists’ suggestions to play with their cerebral-palsied children at home. The
other three parents stated that they would do so only if they have spare time at home.
However, after analyzing parents’ responses to question 3, which asked parents to
share what it is like when they played with their children at home, only 30 parents
were willing to share stories about how they play with their cerebral-palsied children.
The remaining 15 parents indicated that they did not play with their children very
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often due to limited time at home or busy schedules either for children or for
themselves. For those parents who shared stories about parent-child play
interactions at home, the stories were classified into four categories relating to
amusement, physical activity, therapy goals, and social pretend play. The
inconsistency of parents’ responses will be discussed in next chapter.
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Taiwanese Parental Ethnotheories about Play
The results o f this investigation indicated that most o f these Taiwanese
participants valued the importance o f play for their children who are typically
developing. Compared to other studies related to Taiwanese parents’ attitudes about
play, the results are very sim ilar (Chang, 2001; Li, Bundy & Beer, 1995). However,
there are some differences across these studies. In Chang’s (2001) research, most
o f the Taiwanese parents tended to choose a kindergarten that would help their
children prepare for the next level o f education. Chang (2001) felt that most
Taiwanese parents highly value the importance o f education and the academic
performance o f their children. In her study, parents who chose Efficient Learning
School (an academically-oriented school) for their children did not acknowledge the
significance of play in learning. In Li, Bundy, and Beer’s (1995) study, most o f the
Taiwanese parents stated that they believed play to be important, but some o f the
parents who were interviewed explained that they discourage exploratory or
adventurous activities for their children due to very limited space in which to play.
However, in the present study, most parents stated that they believed and valued the
role o f play for their children who are typically developing. It is the researcher’s
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82
opinion that the parents in this study may be influenced by therapists o f their
children with cerebral palsy.
All the children with cerebral palsy in this study were receiving occupational
therapy at the time. When working with a child with cerebral palsy, the
occupational therapist may give the child fine motor tasks requiring the use o f both
hands to increase fine motor skills in the affected hand. This is play for a child, but
to a therapist the activity helps the child reach developmental milestones in fine
m otor skills. The parents of children with cerebral palsy may learn about
developmental benefits of play from therapists and be unconsciously influenced to
encourage their children to play. This may be the reason why the parents in this
study acknowledged the function and importance o f play not only for children with
cerebral palsy but also for children who are typically developing. In contrast,
parents who do not have a child with a disability may not think o f play as having a
developmental benefit. They m ay not even be aware o f developmental milestones
as acutely as parents o f children with cerebral palsy. Thus, parents o f children with
cerebral palsy may attain a better understanding o f the significance of play in relation
to child development.
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84
play outside due to safety issues. Therefore, sedentary activity, such as a puzzle, is
provided and encouraged by parents.
On the other hand, the social function o f play was also highly valued by the
respondents. This is not surprising because traditionally collectivism and mutual
dependence (rather than individualism) have been encouraged in Chinese society
(Yang, 1981). Parents in this study mentioned that they like to see their children
play harmoniously with others’ children, especially with someone who is younger
and in need. Cooperation, sharing with friends, and attention to consideration of
others in a group is important in Chinese culture. Children are encouraged and
expected to help others during the context o f play. Similarly, the results in Li,
Bundy, and B eer’s (1995) study also showed that social spontaneity was regarded as
the m ost important dimension o f playfulness by the parents.
One interesting point to be mentioned is that the parents in this study thought
that children learn the concept of right and wrong as well as issues o f safety in the
context of play. During play, children can easily learn the idea o f what is right to do
and what is wrong to do as well as the concept of safety and danger. From parents’
interviews, the concept o f right and wrong may result from their interactions with
peers, knowledge o f nature, and moral issues. The ideas that emerged from parents’
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85
perceptions o f why children play may be closely intertwined with Chinese culture.
Chinese culture has been influenced by Confucian thought for a long time (Chao,
1994). Thus, filial piety is highly valued in Taiwanese society. A high value is
placed upon social harmony, which is obtained through obeying, respecting, and
submitting to elders; adherence to rules; and cooperation. It is the parents’ role and
responsibility to discipline and discuss daily problems with their children and
especially teach them how to behave with people (Chao, 1994). That may support
why parents thought that children could learn the concept o f right and wrong through
play.
Taiwanese Parents’ Attitudes Toward Play for Their Children with Cerebral
Palsy
The associations between parents’ education and age and their attitudes about
play for their children with cerebral palsy are discussed in this section. In addition,
Taiwanese parents’ perceptions about play for children with cerebral palsy are
discussed.
First, as described in results, no significant associations between parents’
educational level and age and their attitudes about play were found. But Wang’s
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86
(1994) research about characteristics of families with young intellectually
handicapped children in Taiwan showed that families with young children with
disabilities, compared with those o f children who are typically developing, have
poorer parenting skills. A total of 720 families participated in his study.
Furthermore, Wang (1994) also indicated that the severity of children’s disabilities
and the age, and educational level of the mother were found to be the critical factors
which effected family characteristics of functioning, including the attitudes about
rearing a child with a disability. Mothers who had a higher educational level had
more confidence to nurture their children with disabilities and provide appropriate
toys and activities to facilitate their children’s motivations for learning. However,
in the present study, no significant associations between parents’ educational level
and age and their attitudes about play were found. It may be that the sample size
was not large enough to show statistical significance. In addition, the places where
data were collected may be a factor. The hospitals where the researcher collected
data are in urban cities in Taiwan. People living in urban cities may have more
opportunities to receive information about caring for a child with a disability. It is
also more convenient for parents living in the city to find a rehabilitation center so
their children can receive therapy. Thus, parents in urban cities may have more
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87
chances to be exposed to helpful information for their children which may change
their attitudes toward childrearing, including play.
Second, as reported in chapter four, 43 out o f 45 Taiwanese parents who
participated in this study believed that play is important for their children with
cerebral palsy. But only 29 o f them carried out therapists’ suggestions and played
with their children at home. Sixteen parents indicated that they did not have much
time to stay at home and pay attention to children’s play. If parents believe that
play is essential for development for their children with cerebral palsy, what factors
affect parents’ play with their children and the carrying out o f therapists’ suggestions
in daily life? Jaw, Kao, and Yeh (1998) conducted a study o f the perception of
Taiwanese parents caring for their children with serious chronic illness. Ten
couples participated in the study, six o f whom had children with cerebral palsy. The
results revealed that seven parents realized the importance o f rehabilitation for their
children and were willing to cooperate with therapists. But the other three parents
mentioned although they understood the significance o f therapy for their children,
they could not take their children regularly to the hospital to receive therapy due to
economic burden, poor health conditions o f parents, and the locations o f hospitals.
This may reflect the real condition o f Taiwanese parents who have children with
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89
for their children all day long, even sleep with children. In such cases, it would be
these babysitters that know the children best and carry out therapists’ home programs.
From interviews, some parents said if they hired someone to care for their children,
they could handle other responsibilities and would not feel so stressed in their daily
lives. Although these parents would ask babysitters to do therapeutic activities and
play with children for therapeutic reasons, how often the babysitters carry out is
uncertain. For example, one parent had just about one hour per day to see his child
at home so he asked the babysitter to play with his child and care for him. This
parent also said:
I do not know my child very well. I need to ask Jessie (the babysitter from the
Philippines) about his condition and progress.
However, the results also revealed that 29 out of the 43 (67%) parents who
acknowledged the value o f play for children with cerebral palsy stated that they
utilized time to play with their children with cerebral palsy at home. This result
surprised the researcher because she expected to find that Taiwanese parents who had
children with cerebral palsy did not value play, based on the researcher’s working
experience in rural areas in Taiwan. But this finding is good news for rehabilitation
teams, and especially for occupational therapists. Parents learned to use the
knowledge and techniques that therapists used during the treatment sessions and
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91
play in Taiwanese culture to examine how parents’ perceptions of play are influenced
by cultural heritages and child-rearing practices.
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104
APPENDIX A
Interview Questions
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Interview Questions
105
Part I: Demographic questions of children and the parents
1. Child’s age (in years): 2. Child’s gender:
2-3 girl
3-4 boy
4-5
5-6
3. You are the child’s: 4. Your occupation:,
mother
father
5. Your educational level: 6. Your age:
below junior high school ___ 20-25
junior high school___________________ ___26-30
senior high school______________________ 31-35
college ___ 36-40
graduate school_____________________ ___ over 40
above graduate school
7. Number of children per family: 8. Family yearly income:
_______ ___ Below 10000
is/are typically developing 10000-20000
is/are cerebral palsy 20000-33000
33000-66000
Over 66000
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106
Part II: Activities at home
1. Who plays with (your child with cerebral palsy) most of time?
a. Mother
b. Father
c. Grandparents
d. Sibling
e. Caregiver (babysitter)
2. During what activities do family member usually play with ?
a. Child-care activity (such as grooming, feeding, and dressing activity)
b. Cognitive activity (such as shape, color, and letter activity)
c. Therapeutic activity related to motor function (the activity that the
therapists suggest)
d. Activity to be close to the child (such as holding and sing songs to
child)
e. Others_____________________________________________________
3. Would you share with me what it is like when you play with ? Maybe
you can tell me stories about times when you had fun together.
Part III: Parents’ attitudes toward play at home
4. Why do you think children play?
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107
5. Based on your concept of childrearing, do you think play is important for
preschoolers who are typically developing?
Yes
No
Why or why not? _______________________________________________
6. Do you think play is important for (CP child’s name)
Yes
No
Why or why not? ______________________________________________
7. What is the main reason that you play with your cerebral-palsied child?
a. Therapists suggest you to do so
b. Play is what children do
c. Child can gain benefits from play activities
d. Others ______________________________________________
8. If the child’s therapist recommends that you play with at home, will you
follow his/her suggestions?
a. _____ Yes
b. _____ No
Why or why not? ___________________________________________________
9. If you do not have enough time to play with , would you ask someone to
do so?
a. Yes, who and why? _________________________________________
b. No, why not? ______________________________________________
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108
APPENDIX B
Information Sheet for the Parents
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109
Inform ation Sheet for the Parents
TITLE OF PROJECT:
TAIWANESE PARENTS’ ATTITUDES TOWARD PLAY FO R TH EIR
CHILDREN W ITH CEREBRAL PALSY
PRINCIPAL INVESTIGATOR: Wei-Lun Hsu
DEPARTMENT: Occupational Science and Occupational Therapy
24 HOURS TELEPHONE NUMBER: 886-4-22060695
PURPOSE OF THE STUDY:
You are invited to participate in a research study of Taiwanese parents’ attitudes
about play for their children with cerebral palsy. The following information is
provided in order to help you make an informed decision whether or not to
participate. We hope to learn how Taiwanese parents who have children with
cerebral palsy think about play and how they play with their cerebral palsied
children. You are invited as a possible participant in this study because you
have a child with cerebral palsy who is developmentally functioning like a 2 to 6
year old child. About fifty subjects will take part in this study.
PROCEDURE:
If you decide to participate, I will give you an interview for about 45 minutes.
Before the interview, I will ask you some personal information about you and
your family. Next, I will ask you nine questions about your attitudes toward
play for your child as well as the activities at your home. I will give you a paper
with the questions written down so that you can follow the questions that I will
ask. Some questions will allow you to share your feelings and attitudes about
the questions. The interview will take around 45 minutes in a private room in
the Rehabilitation center. In addition, the interview will be audio taped to serve
as a quality check and also your responses will be written and summarized
immediately after you answer each of the questions.
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110
RISKS:
There is no risk involved in answering the questions except the inconvenience or
discomfort may occur when the researcher interviews you. The interview will
take about 45 minutes. You child will not be observed and will not participate in
any way.
BENEFITS:
You and your child may not gain direct benefit from participating the study.
However, after finishing the interview, you may attain a deepen understanding of
activities that you do with your child.
ALTERNATIVES TO PARTICIPATION:
You may choose not to participate in the study.
CONFIDENTIALITY STATEMENT.
Neither your name nor the name of your child will be recorded in writing or on
audiotape at any time during this study. You will be assigned a study
identification number which will be recorded on interview notes and audiotapes,
but this number will not be linked with your name in any way. Interview notes
will be kept confidential to the extent provided by law. The information from
this study may be published in scientific journals or presented at scientific
meetings but your identity will be kept strictly confidential. All interview data
and audiotaped records will be held in strictest confidentiality during the study,
and will be destroyed when the study is completed. You have rights to review or
edit the audiotapes at any time, and these tapes will not be reviewed by anyone
else besides the principal researcher. No data collected will be released to any
person.
OFFER TO ANSWER QUESTIONS:
Your participation will be supervised by the Ms. Wei-Lun Hsu at (04) 22060695
who you may contact with any questions or concerns regarding to your
participations. If you have any questions regarding your rights as a study
subject, you may contact the Institutional Review Board Office at
002-1-323-2232340. You will be given a copy of this form to keep.
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I l l
VOLUNTARY PARTICIPATION AND WITHDRAWAL STATEMENT:
Your participation in this study is voluntary. Your decision whether or not to
participate will not interfere with your right to health care or other services to
which you are otherwise entitled. You are not waiving any legal claims or rights
because of your participation in this study. If you do decide to participate, you
are free to withdraw your consent and discontinue participation at any time.
INJURY STATEMENT:
In the unlikely event that you or your child should suffer an injury as a result of
participation in the study, the financial responsibility for medical care and other
such care will be yours.
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112
APPENDIX C
Interview Questions
Mandarin Chinese Version (for use in Taiwan)
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2-3
3-4
4-5
5-6
4. ?
5. &5EJt&W§Jg:
____
^ 0 4 *
6. M j* N S :
20-25
26-30
31-35
36-40
40 & _ t
7. I W « I : 8 . m t p z p & s m x :
3 0 S U T
30-60 M
60-100 M
100-200 M
200 M U L t
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114
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b . g g
c . mwmmw& mm
d . R M im w .
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b .____mmmmm m m m a x , m & ,
c . c fc m ffiffim & K im m fm )
d .___ m 'pw m m tm m m mm^m,
e ._____ ___________________________________________________________
3. { m
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4 .
5 . m n i & m w ' m w M i t , •
t i
s f t e ? ____________________________________________
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a . _____
b . _____
c . _____
d . ____ n m _______________________________________________________
#
______
B f + J S ? _________________________________________________________
9. K S I_____ -i© 5 c ’
J 'F #
B f+JS?
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m m m A m m & m m • & w @ m m •
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Asset Metadata
Creator
Hsu, Wei-Lun
(author)
Core Title
Taiwanese parents' attitudes toward play for their children with cerebral palsy
Degree
Master of Arts
Degree Program
Occupational Therapy
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
health sciences, rehabilitation and therapy,OAI-PMH Harvest
Language
English
Contributor
Digitized by ProQuest
(provenance)
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c16-294966
Unique identifier
UC11336669
Identifier
1411789.pdf (filename),usctheses-c16-294966 (legacy record id)
Legacy Identifier
1411789.pdf
Dmrecord
294966
Document Type
Thesis
Rights
Hsu, Wei-Lun
Type
texts
Source
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Access Conditions
The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...
Repository Name
University of Southern California Digital Library
Repository Location
USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA
Tags
health sciences, rehabilitation and therapy