An innovative play environment for handicapped children

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Content INNOVATIV Y ◄NVI 0 FO CHI JD N y anet u·se Taylor T es resented to t .e CULT OF 'IHE G D T CI OOL ITY 0 OUT .uIFO I In ... artial ulfil m nt o the e uire nt r t D re ast r I rts ( hysic 1 Therapy) une 1972 72 UNIVERSITY OF SOUTHERN CALIFORNIA THE GRADUATE SCHOOL UNIVERSITY PARK LOS ANGELES, CALIFORNIA 90007 This the. is rz •ritten by · --- _________ an __ t ______ 9.. ___ t_ ~- '?- _____ . _:,_. --~ --- ----------------- ----'"----- under the dirertion of /1_ __ '£_ _____ Thesis Conunittee, ({lld (lpprrn·"d by all its n1 111bers, has been pre Sl .'lied to and accepted by the Dean of The rrad11tti., rhool, in pr rtial f ulfi/!1nc11t of th., requirenzent. for the de9r e of e · o Dean ' 7 I This th sis i dedicate to my husband, Marvin . ay or vho ave many hour of h · s tim and exp rtise to esi nan con truct t e Thera-play unit in order to serve the spec a chi dren in this tudy M . D. Spec·a1 thanks a e ~iven to who patiently u de me durin 1arraret H. Jones all phase~ of the elopm nt of the environmental unit as well as d r · n the inve ti ation r earch and ritinr, 0f mythes · . Mar aret S . oo serves p cial thanks and appreciation for her inspiration and insi ht . pecial than s are ex~r ss d to Mary Sllberzahn o ave advice and encouragement . inc re appreciation Ls ex r sed tote taff and ar nt Group o the UC Hanct · cap ed Chi dren's ursery co 1 including the teach rs, therapist , tee nic·ans and parents . rateful than s ar~ iven to the V lunte r o ser- v r fro the UC eha ·11tation ervic s Guild who av valuable assistance . Much appreciation· ex res e t riend ho c ntr · ute t me ana mater ·a1s to this pro· ct . ii C OULEDGM ◄NTS • • • • • • • • • • • • • • I I e • e • • • • • • • • • • • • • • • • • • • LIT O P T 1 and CHART • • • • • • • • • • • • Chapter I . T II . D O A A LA T OR H DI- C PD CHILD • • • • • • • • • • • • Introduction • • • • • • • • • • • • • • • tateme t of tle Problem . • • • • • • • • • Imp rtance to Physical Therapy • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • at·onale Limitation Delimitat ·ons Methodology • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • VIEW OF TH• LIT Introduction ... TU • • • • • • • • • • • • • • • • • • • • • • • ormal Developm nt . • • • • • • • • • • • Abnormal Motor Development . • • • • • • • • • • • • • • • Develop nt of Body Ima e Distur anc in Boy Imare e tricted nv·ro m nt • • • • • • • • • • • • • • xpl ration nd Mn · ulation o nv·· r nment by Infant~ an~ Chil r n • • • • • • • iii vi vii 1 1 2 3 7 9 9 12 12 12 16 19 22 23 25 Cha ter Disturbance in Therapy Metho s en ory Inte rat on . r Influencin Motor • • D evelopment and Body I a e • • • • • • 1etho or Intervention • • • • • • • Page 28 32 37 III . D•SC I IO OF TH I P IM~NT L NVIROl 1 T 49 • v. Sett ·n r the tudy • • • • • • • • • xterior of the In · de Pat ay AL he Sul ·ects FO tructure . . • • • • • • • • • • • • • • • • • • T 'STI T UNIT • • • • • • • • • • • • • • • TIO OF D TA • • • • • • • • • • Or ani ati n Data • • • • • • • • • • valuation and Progre s e p r t - -Mary • • ivaluation and eport-- . r ress ay • • •valuat · on and ro res ep rt- -Louise • ·valuation a d ro re s eport-- van • • aluation an ro re s e rt - -Jerry • • valuati n and Pr e;re...,s Report- -Kari • • valuation and ror;res ep rt --George • ◄valuat · on and ?r ress eport --D nnis • valuation an ro re s ep rt - - hawn • ◄valuat n an Prop:re Report--J e h • ◄valuat · on an ro re . eport --Dav d • • va uat · on n r eport--Tan a • • iv 49 52 52 62 62 67 67 71 78 83 8 93 98 101 104 10 1 3 117 22 Ch pter ag 125 135 VI . VII . p Il T .,valuation an ' 'rA TIO r egr ess eport - -Gary ND DI cu SIO OF 1 ULT • • • Ori~ina ob · ctive . . . . . • . . • • 35 Progres w·th Motor kills . • . . • . 35 rma Group . • • • . • • . . . • . . 137 Pr gre s of ~ubject --Body Ima e . . • • 137 Chil r n 1 1th Behavi ral ?r ble s • • • ensory Mural • • • • • • • • • • • • • Per anal - ocia Devel pm nt and peech . Problems 1 ncountered in •xperimenta Te t · n of tle Unit . . . . • ..• 138 140 1 l • • • • • • • • • • • • • • • • COl CLU IO ·DIX • • • • • • • • • • • • • • • • • • BIBLI G PHY • • • • • • • • • • • • • • • 41 145 47 156 V LIST 0 TAB S able Pa e • Indiv ·dual e ort of IVIary • • • • • • • • • 76 2 . Indivi ual p rt f Kay • • • • • • • • • • 81 3. Indi idual eport of Louiue • • • • • • • • 86 4. Indiv · ual eport f ,an • • • • • • • • • • 92 5. Indiv: 1 port of J rry • • • • • • • • • 97 6. Indivi ual eport of Kar . 00 • : • • • • • • 7 . In ividual eport of G orge • • • • • • • • • 103 • Ina · idual eport of Denn · s • • • • • • • • 107 9. Indiv dual epo· t of Shawn • • • • • • • • 112 10 . Indi . ual eport of Jos ph 116 • • • • • • • • • 11 . In ivi ua e ort of David • • • • • • • • • 120 12 . Individual port of Tanya • • • • • • • 24 13 Inct ·vi ual eport of Gary • • • • • • • • • 128 14 . easurement of Grose-, Motor Sl ill Us ·n Crip- led Children erv . ces 1 valuation 29 • • • • 15 . uantitat · ve nalysis of Motor Activity- - c1·m . n 31 • • • • • • • • • • • • • • • • • 16 . Quant1tat ·ve Analys · s of otor Activity - - lid n • • • • • • • • • • • • • • • • 132 17 . Quantitative nalyr--i 0 •1otor ct vity- - Hal in • • • • • • • • • • • • • • • • 133 18 . uant ·tative Ana ysis of \IJotor ctiv ·ty-- l • tt O n • • • • • • • • • • • • • • 34 Vi LIT OF PLAT 1 S late Pa e I . Interior View Thera - l ay • • • • • • • • • 50 II . Thera -play Unit Central Bo ~l • • • • • • 51 III . Thera -play ntry Vie • • • • • • • • 5J-t- IV. T era -play un ·t-Sli • • • • • • • • 55 v. Entering Central Bov 1 • 0 • • • • • • • 58 VI . Inc ine Central BoJl • • • • • • • • 60 VII . Crippled Children Services Groi•1th an De - elopment Scales • • • • • • • • • • • 148 VIII . Teacher Observation Form • • • • • • • • • 152 LIT OF CHA TS Chart Pa e 1 . Descripti e Chart 0 rogress- - ary • • • T7 2 . De cri tive Chart of rogress-- ay • • • 2 3. Descriptive Chart f rogre s --Louise • • 87 4. D scri tive Chart of 0 ress - -Dav · a • • • 21 vii TH N ◄ ◄ D O A AF , P Y 'NVIRONM N 0 HANDICAP ·D CHILDR 'N Introduct·on The basic purpose of th s ~tudy is the creation and investi ation of a novel environment to prov ·de hana · capped ch·l ren 1th a safe mot·vatin area or the velo ment of body ·ma e, perceptua motor ability, and balance . Statement o the Problem If the chil had delayed motor develo ment , he may have ct ·sturbed body ·ma e . If a child 1ith poor balance an muscle eakness is fri htened y allin on a ard ~urface he may become fearful o movement and w"thdra fr m act·ve part · cipation . In ependence in the use of the ro· cted safe sensori-motor st ·mulatory env ·ronmental unit encourages the chil to practice actively the skills ~fuich th therapist is teaching . The ch ld w th v sual roblem nee a meanin f'u safe area for explorat · on . T1e atypical child ith autistic or other ehavioral pro - lemn need some m t ·vatin orce to lead him away from ~el -st ·mulat · n activities to more n rrnal exploration o his environment For th )hy jca ly ha a · capped ch "l 1 an attract·ve, ut mulatory env ronm nt o fers po t.ve sensor·-motor exper ences . Importance to hysical Therapy 2 In such a un· t, a chil would not require special nstruction or as istance to use the equ · pment ut w uld b motivated to move and balance by the variety and chal len e in th esi n . The sa e, res 11 nt sur aces would al ow the child to become bolder n h·s att ·tude to ard han 1 n f his ody in exploration of thee v~ronment. Very young ch ldren often cannot tolerate the exercise and regimen designed to help them t s·t, stand, or ·al . herefore, the therapist may utilize equipment an, furn · sh n s to assist the ch· ld in perform n functional activi ties. Often the therap st must im rov se the equ pment or furniture to su t th needs of the ch· d . If an environ mental un·t were esi,ned for developmental act v ties balance ocomot · on, and the pract ce o r s motor sk"lls the chil cou d ben fit while plain . A non- t reatening, pleasant play area may all w the ch· t ut lize skill ana motor ability without tens ons or stress . Jhen the child s act ve y explor n he may attempt new sk 11s . 3 Hypothes·s The bas·c inquiry of th s thes s wj b to inves- t ate an environment as a means o rov din t e chil w·th a safe, mot·vat·n area forte evelopment f body mage, s n or·-motor abil ty and balance. Snee this s an observat·ona tudy, only a tentative hypothes s ·s ffered: It ·s poss· le to improve alance and ro s moto act·vity by means o a specially planned en ironmen for ch ldren. Rat onale rmal D ment It i iven that Gesell's scales for nredicted a es of gross motor skil an developmental milestones ·n normal chi ren are commonly accepted s andar s. T these Gesel standar scales e can compare the c il with delayed sen ri-motor development for a motor age. For ·n tance, th aev lo ment f u ri ht oc mot on s a complicated process wh·ch ·nvolves many previous sta es. The ch·1a would normally walk at 3 months of a e (23:124). 1he chil 1 s bas·c enet·c ndowment to ether w·th th envir nm ntal st·muli and o portunit·es for xper··mentation determ·ne his phys·cal a el a mental and emot onal development. Th"s development i influenced y epr·vat on ore r · chrent f resources an env·ronment ( 26: 3 1 - 35) . nvironmental Influences on Cl · ld' s Development 4 Witen i r reporte that ch· dren earn ross an ne m tor control by repet·t·on of mov ments. The ch 1- dren s e bserved pract·ced to refin motor control ·nan experimental nv·r nment d s· ned fr hana·capped chi dren. Her esi n utilize re ilient surfaces an ·nter st·n forms, contours an ·vis o s of s ace. There as oppor- tunity fr practice of dynam·c an st t·c balance, spat·a1 relationships, ody sc ema, b lateral coordinat· n, and motor ann ng ( 41 : 2 5) • 'oln·t and Provence co ent on the child's mastery of hi boy during play and exploration to ach eve ental i a ges. Body _ma e ·s part·cularly acquired thr ugh ac t ons f exploration, m·tat·on an play (34:580). Sutton- mith observes that a child uses stren th and ag"lity to test h s maneuverability the environment. The ch 1 s testin the env ronment and discovering ways he can ·nteract w th it by t n, tu[.g n, pushin, puling clim in and craw1·ng ·nto th n s (37:57). Dynamic therapy r rams y yres (3) 0 (29) Hunt (21) and DuJnoff (14), stress the mportance of st uctur n act v ties for movement. o d often ut·11ze enjoya le activities for the ch.ld during the therapy process, allowin the child to man pulate toys wh le 5 ma ntainin h s ody in eneficial postures. She analyzes play equipment such as a children's lide and dev ses dynam c activities or the st mulation of the labyrin thine an vestibular systems (29). ~ Iollin for vest· ular st mulation as well as n- cre2.e k nesthet c awareness is used y Ayr s, Rood, Hunt and Dubnoff n their pro rams for children with body ·ma~e and sensor·-mot r problem. Hunt observed that the children needed to exper ence the effects of ravity on the bod by movement throu h space such as sl n or roll·n· to deve op body schema and directional concepts (21). Ayres ut"lizes portable equipment with which the ch dries or swin s or rolls to radua ly increase the level of vest bular stimulation (31). The Dubnoff school program offers experienc ~ such as ,jumpin on the trampol ne ro lin with attention to body parts action songs, and locomotion through space or obstac e courses (14:7-9). Smith and Henry influenced sensori motor development in rain damaged . individuals by act ve, repet tive practice of static and dynamic rain ng pro cedures. It was necessary for the activities to e repeated a suffic ent numb r of times to be learned . ID addition f the act vity was sign r·cant to the 6 nd v dual, he was more likely to remember it and reproduce the movement pattern (32 :460-461) . Design In planning an env·ronment to ·nfluence sensori motor development, prov sions for repet ton of motor skills and developmental act ·vities is important . The area must have chan in contours for challen e as well a safe surfaces for pract ce of balance and developmental activities . When a child feels ready to test his ab"lity in a new skill there needs to be suff.cient variation from one level to the next . W th varyin heights of inclines and slopes, the child could experience increas·ng demands on his ab lity to motor plan and maneuver . Conce tion and Design of the Thera-play Un t These concept for this safe stimulatory, sensor - motor environment for handicapped ch ldren of the UCLA Pre-nursery School ori inated with Margaret H. Jones, M.D . the Director, and this nvest gator . P ann n and des .gn of th s unit were the joint effort of the invest·- at r, a physical therapist and Marv·n • aylor an ·ndustrial desi ner . Dr . Margaret H. Jones served as consultant urin the plann ng, construct n, and test of the un · t . The desi ners called the unique un t, "Thera play . 11 7 Limitat ans imitati ns of tl e Subjects The number f subjects n th·s pro ect ·s limited to th·rteen, as this s the total populat·on of the UCLA Han icap ed Ch ldren's re-nursery School. T a e ran e ·s from one an a half to three years of a e. ach child's neur lo ical dys unct on or psychomotor retardat on ·s uniq e there ore, each ch·1a is at ad f erent level of en ori-motor eve o ment. The h.ldren 1 s level o devel pment ra es from an am u~atory ch·l wt mo erate hear n loss to a n n-am ulatory ch:.ld w· th severe visual and hearin loss. One child has n apparent phys cal 1 m·ta t ons, but is unable to communicate. Snee the extent and area of the ra·n es on cannot b determ ned, it is not ossibl to match the children for a control roup. Tw chilaren ho appear equal n development may e only momen tarily e ual. Change may occur ecaus of enetic differ ence, oss ble extent of mental retardation, rate o maturation effect of home pro ram oc al and cultural ractices, severity of involvement, and personalty devel opment. Therefore each ch ld 1111 be s d as his own control. imitat ons of Time Durat on of th observat anal per d will be lim ted to the five weeks 1 wnrner sess·on of the nursery sch olj 8 the children will not be attendin school for approximately to months . Other planned pro rams w· 11 completely ut lize observational t.Lme durin the falls ssions . imitations Im osed by the s·tuation The time spent daily should b nter,oven w th the nursery school schedule . maximum of one hour aily is planned to com lne the activities ·n the play env ronment with social activit·es . ndurance and state of health of the child ·11 also have an effect on the amoW1t oft e th ch ld can pend in the unit. God weather is needea fr act·v·ties, since the nit s outdoors. Certa n ac tivit es may be curta led for ind v·dual chi dren on the adv·ce of h 0 therapist teacher, or physician. Limitations Imposed b the Loca on In the nursery school pay yard there are several lar e p·eces of play equ ment and a play house, trees, lants an walkways. A spr··nkler system to ater the ar en is placed every 12 feet . quipment ana materials must either e waterpr ofed or protected from the elements with a cover . The round surface 1~ uneven and the ase of the structure must be made level for the un·t . 9 Delim tation It is ac no ledged tat th project m· ht "nflu- ence the visual, ocial p rceptual and psycholog·cal developm nt f these ch"ldr n also. Ho1ev r, t ·s beyond th cope of th·s project to inc ude all the~e aspects. The c ·1aren ~ill, of course, experience some maturat on dur·n the er·oa o t·me, so ·mprovement mu t e beyond the predicted rate f d velo m nt for each chi d. Many varia es are pre ent in the deign fa play environment fo han icap ed children; therefore, an bservat· nal-type stu y is bein un·t. ade to determ·ne the f ectiveness ft e al and ibli- _ _.;__ ~--o~ces h sourc s of inf rmat· n or the literature s_arch an desi_n of th project will be ·m·te to the ent·re "brary systems oft e Univers ty of Southern Cal"f rnia (inclu in t e ducation an raduate librar- ieu), ad the Univers·ty o Calif rnia Los n eles ( nclud ng t e Biome ical and esearch 1· raries). Metho olo y The remainder of this stu y w·11 be r an~zea as f llow~: 0 T re wi 1 be five main sect · ons for thP. 1 ·ter ature rev · ew . he fist sect · n w· 1 cons st of two parts : firstly an ·nvesti at on of n rmal motor devel- ment of n ants and youn chil ren 1ith the ·nrlu nces of enetics an envir nment . econ ly a normal motor d elopment a ccurs in cere ra palsie ch·1 ren w 1 b ~ scus ed . The sec n sect·on il consi t of cus ion of b dy ima8e and distur ances of ody image . The effect o restricted environ ent also w· 1 be included nth secon secti n . The third sect on w 11 consist f wo part 0 : irstly explorat on and manipulatlon of the env ronment, and the second part will consist of a· tr anc sin sensory inte rat·o . The forth ection will scuss therapy etho of r influencin motor devel o ment and o y irna . Te f "fth section w 11 give methods s d by special e cat on, s ecial nvironments created for intervention and early trainin m thod, as well as metho measurem nt . Chapter III will descri e the setting or the st y--the esi n and plan of th Thera - play env ·ronmental u i an its ·nctiv dual features . Chapter IV includes the nformation on the sel c t · on and evaluation of the sub·ects, p ano for c nduct of the experimental sess ons observers and types of informati n to e rec rd , and orms to b u ed to rec rd the results and observati ons Chapter V 11 consist of a presentat on f the res lts and obs rvat·ons set forth ·n ta· les, raphs, and descriptive narrat·ves o individual and a re ate scores. Chapter VI will e discussion of the f llowing: results problems encountered dur n experimental testin, comments c ncerning recordin of data control roup pos i le future stud es factors affect ng pro ress of the children use of films for record n activi es r act· ns and behavi r o normal children, pro ress the subjects be avi al problems, and d scus on of evaluat on metho s . The summary o st dies. inal chap er 111 ·_ve c nclusions and a this study as well as su est·ons or future :VI CHA OF R II LITE T Introduction The revie1 of literature will discuss inf uences and modes of ~ntervent on for the ch ld who is atypical or has sensor·-motor handicaps. Normal develo ment of the child as ell as the unparallel development of the ch 1 ith neuro uscular problems such as the cerebral-palsiea ch·1, will be revie,e. In ad it on, the influence of genet c and env·ronment on motor development, types of environment ·1hich may · nfluence adequate or non-adequate en or -motor d velopment, therapy, and t hvrapy-in-play xperiences, w 11 be ·nvest ated. N rmal Development The nfant 1 s early development is usually measured n terms of neuromuscular d veJnpment. The nfant•s motor skills rather than mentality are r11easured. ~L.onates possess all the abilit es to sense but perceptual a ility is not innate. When they appear to perce ve, they are experienc n the var u~ stimuli d fferentially. The neo ate does not need to learn a re pone to stimul 12 13 as the reflexes control his response to stimul . The mu oles neces~ary for th responses have been stren thened y prenatal exercises (36:245-46). Development mpl es pr ressive chan e from one sta e to another. Onto enetic development follows def nite atterns, but each child s unique n his rate of development. Devel pment may be a smooth, con nuous process of or an zation o complex ehav·or or appear n sta es. While -here may et me~ f no apparent pro ress, behav oral sycholo ists el eve that the nd vidual is continuously evo1v·n throu h se quences ·nto increasingly complex sta es (2:7). Gsell behavioral psycholo ists bel e,e that the motor develop ment behaviors are uniquely indiv dual zed and pre-deter mined. Thus a person with great nnate capacity could pro ress to a hi her level o skill than one with less innate ability. Environment can greatly modify motor evelopment and behavior, but will not "generate progres s·on of development" (1:121-22) . Louise tes Ames of the Gesell Inst tute states: 11 ••• behavior has shape behavior is a function of structure an we behave as we do lar ely because of the way we are built" (1:121). Ames and the Gesell behavioral psychologists bel eve that "the nv·ronm nt can modulate and modify but it does not ener ate the progressions of development . " Inherent qual ties u e an rect the re ular pro ressi n of develo ment (1:121-22). 14 Mussen, Conger, and Ka en are less insistent that enetics are the major nfluences on the child's develop ment. The influence of the child's mmediate family, peers and teachers can make the difference between an individual who is function ng at the lower bordcrl ne of normalcy and one who ·s fulf 11 ng maximum potential for development. "The chil 1 s behavior and personalty are, at any one time, a product of the continuing interact on of nature and nurture." Although we speak of r-enetic and environmental determinants of behavior, we always acknowledge that they act in unison; that s, as true of the individual cell as it is of the whole person (27:33). Illingsworth states that it is necessary for change :n structure to occur before change in performance can occur. This means the necessary neuromuscular develop ment w 11 proceed the activit es of sitting, crawl ng, and walkin. Initially, the infants react to the envi ronmental stimuli w·th a mass pattern, which gradually is modified and inhibited as his nervous system matures (23:169). The primitive reflexes of the newborn are _radually inhibited as the righting and equilibrium reflexes beg ·n to ta e control. Head and trunk control precede control of lower extremit es because the infant needs to balance his head (which s qu te large n propor tion to h s b dy) in order to direct and see the rest of his body . The in ant mod fies the tonic la yr nthine reflexes when he is a le to develop extension in prone and flexion in supine position (18 :16-17) . 5 Observat on of then rmal ·nrant reveal that head control be ins in prone pos·tion . The infant pro resses from m mentary head control at four weeks to ood control at t~elve ,eeks, i th shoulders off t e supporti surface and le s fully extended . he n ant roceeds from prop ping ·mself on forearms 1th elbo s flexe t suppor n we ht on the hands with exten e e bo sat twenty-four eeks . He is also rollin onto his back at this a e . y twenty-ei ht weeks the nfant can t y propp n h mself ith his hands in the forward pos tion on the floor . hen the ri htin reactions are well establ shed, the infants ts ithout support ; usually th sis by thirty six weeks . Crawlin on the abdomen at f rty ~eeks re cedes creeping on hands and knees by about am nth . It s necessary for the tonic neck reflexes to be ·nhib ted before rec procal creeping or crawlin can occur (29) . lthou h the infant can pull himself up on furniture at thirty-six ~eeks, he is una le to stand nde endently and safely until he develops the backwards parachute reaction he parachute react ons help the ch~ld to recover balance and protect self when falling by extend n the arms . Upri ht walk · n requ rs many c mplex dev lopmental 6 functions fr which the maturation o the neuromuscular system is necessary. Usually by the a e of n 3 months, the ·nrant has developed the t lt n year or and ri ht n r actions as well as the arachute reactions n cessary for 1alkin in pen ently (43:2 7). The evel opm nt o upr ht locomotion is a complicat d process involvin many prev·ous ta es. The ·nrant's asic net·c endovnnent to ether ith the environmental st·mu · an op ortunities or exper mentation etermine h·s mental an physica as well as mot·onal development. h sun ol ment is influenced by depr·vat·on or enrich ment of re ources (2:6). Abnormal otor evelo ment he general term "cerebral alsy" descr·bes a variet of motor defects associated ith dama e to th rain ce ls. Ins me in~tances, it may be a result of ack of oxy n during the ·rth process. T ~tchell escr·bes specif·c problems ·n )osture n motor control amon cerebral palsied children. a tents who lack postural tone and stability may also have alternatin inv luntary mov ment call d athetos s. Atheto· children may also have resi ual tonic neck reflexes, nysta mus and poor eye focus·ng and low muscle tone. ec procal movement potential is pr sent, butte lack stability prox mally im a·r~ attempts at fixation 7 and p stural c ntrol . The spastic ty e f cereb al palsy result in hy erton a 1th hyperactive stretch reflexes and d· fficulty in isolated movements . Mass patterns of movem nt are seen h n the · nct · v ·dual att mpts a·scr te n vement (40 : he classical aescr ·ption of athetosis i written by T~·tc ell : The phenomenon of athetosis i an instability f postur resultin fro con 1 ct bet een anta onistic motor reactions that are essen tia lyre lex ·n nature . Thus the alternatin, perioaic flexion and extens on of in,ers and toes or ursin an partin of the lips result from a unstable equ librium bet een the rasp reflex and avoidin response •... The move ments ~ere slow and paroxysmal (39 :1 1) . 'vitchell d scribed pure athetos·s ot connected ·1th spastic or cerebellar s ndromes . True athetos sin th pure form is relatively rare as tis usually seen n combinat on with nfant le spast c hemiple ia, d plegia, or qua riple ia . T itchel s descriptions of the per sistent primative reflexes, the avoidance re ponse oro reflex, r hting reflexes a normal p sturing , associ ate movements, mass movements and rest ng state are detailed and precisely accurate . In makin the diagnos s of cerebral palsy, there is no clear-cut border betveen normal and abnormal development . Twitchell states that : ... those w th 'minimal de rees ' o· cere ral palsy represent the 1 nk between normal and a normal mo or funct on . Indeed th 4 hysi- logical basis for mil motor defect · n the clumsy ch"ld ·s dent cal to that fo d cerebral palsy althou h of lesser de re H s discourse ends on a hopeful note: in ( 40). ... con enital bilateral athetosis is not a static condit on •.. maturat on of motor function delayed and imperfect in form doeo ·naeed occur •.. eventually many patients learn to walk, fed and cl the themselves (39:130). 8 1 If ther s excessive muscle tone, as in cerebral layed. S me ch ldren w·th cere- bral pal y n er alk. • • • Intelli ence has a profound effect on motor ev lopment" (23:212). In a ct·tion to the neuromuscular status o the ind·v dual ch ld the familial rate for myelination of the spinal c rd may have a bear n on the a eat which the child is ready to walk. Another factor ·1h • ch may contri ute to delay in walkin is mental retar ation (23:212-13). There is no typ·cal picture of a cerebral alsied child's movement ehavior. One ch.ld may be hypotonic ·1ith increase tone only dur:in er ods of reflex behav - ior. Another child may have developed the right ng re flexes suffic ently to have control for sittin and locomot on by crawlin but not have developed the Dostural control for sta ility wh le stand n or walk n, even though he has passed the chronolo ical a e to do so. An athetoid ch"ld may be able to am ulate but be unable to stab l· ze the upper extrem t es suff c ently to manip ulate ob·ects . A spast c ch ld may e unable to flex 19 an extend his le s recipr cally for walkin or cl mb"n upstairs. How can these children velop a body ·ma e and learn about the relat onships and ·nteractions of the r bod es with the env ronment? Landreth descr ed the ch"ld's pl ht Per stence n assoc ated motor and emot onal characteristics s also apparent in children w th some known brain dama e . The r diff - culti s . n perceptual motor funct onin are associated rith low frustrat on tolerance and anx·ety. ome of thee ch ldren are described as 'driven by motor mpulses beyond the r control 'pulle y fluctuations in muscle tone handicapped by motor inadequacies, flooded by sensory stimuli, unable to screen out peripheral sensory stimul highly d stractible, and in a state of emotional turmo 1 (25:174). Development of Body Ima e An adult may de ne body ima e as the way he appears to h"mself, h s o y size, type, and d mensions as well a how he himself moves n space and relates to space n comparison w th h s deal body ima e. A child uilds h s body ima e by sensory explorati n, especially with the use of touch. A child may not understand the concept of boy ima e but may be able to descr be the way he feels as he performs an act v ty or what he feels about the ma e of his body reflected :n them rror. ody image is composed of feed ack from our exteroceptors in the body skin the proprioceptors in the ·01nts, 1 aments, bones, tendons as the body moves The interplay of thee 20 receptors in integrated manner gives an awareness of the body ( 2 : 71) . iaget describes the earl evelo ment of the ch 1 as comprised of developin 11 sensori-motor schemas." The ch·l y 18 months develops the ab·1 ty to imitate others an recognizes similarities between himself and others. Durin the pre-conceptual ta e (from one and a half to three years) the chil •s schemas are derived from his actions. He thinks that he ·s the center of the activ ty and causes ob·ects to appear an disappear. Memory and body scheme evelop as the child moves, explores tests situations by trial and error, and arrives at successful solutions. He uses "accommodation' to solve problems ·n the environment and remem ers some of his physical actions. ta later stage, between two and seven years o a e, he ill become capable of using sym ols and ma ery to de- v lop his memory and represent h s body ima e (6:12-13). The child learns to name his ody parts directions of verticality an laterality. Finally ~hen the child is between seven and 1 years of age, he arrives at the sta e of concrete operations when the permanence o objects is well established and the ch·1a can a·stin uish the internal sensations from external ob·ects. The ch ld : s aware o spatial dimens ons. evelo ment of ody mag pr resses as a con sequence of constitut. onal and acquir d equipment mat ration, and psychosoc·a1 exper ence . It is particularly acquired throu h act·ons o explor ation, imitat on, man pulat on and play (9 :3). Hunt describes body ima e as: ..• a model a~a nst ·hich perception~ are measured and an experience ith which other experj_ences are evaluated . Body ima ·e is the memory of experiences Nith the body recorded in the fo of images that can be centrally aroused with or without external st muli . 2 Hunt cons ders the self-ima e as a measurin un tin per cept on . 11 ◄very hwnan experience ·s connecte with the ex erience of one's wn body . Man perce·v sonly as le is aware of the attitude and orientation of the body . ': 0 's body ec mes st·mulated y contact with the surroun - ine sur aces . The alms and soles are the most sensitive to contact with surfaces. Boy we ght is felt more near the center of grav ty of the body . ~ nesthet·c sense is felt more at the roximal ends of the joints . The child must learn about his body in relat · on t gravity in order to tel the directions of up and don for1ard an back var, sideways . His ody feels lighter slidin throu h space as on a sli e, and heavier upon landing or sudden contact w th a are mass. Improvement in motor patterns may lead to improvement in ody image . It s most likely to occur in the early year of development while the body identity is stron est (21:84) . 22 Disturbance in Body ma e Skills and sports may enhance body image; however, some ch·lctren do not feel comfortable erformin athletic sk 11s and activ t es . There are some people who have poor o y ma e and negative feelin s about thrown an object, ump n and catchin . ositive-trainin experiences n early l fe may help to correct the attitude in these ch ldren efore they become fixed. Hunt expressed the idea that p sture is the key to the ty e of od ima e wh ch a p rson has about himself. If one has poor pos ture, he s kely to have an unsat· sfactory body image. On the other hand, the person w th a flex·ble body ma e is ikely to be able to en·oy a reater d vers ty of phys- cal activit·es . She posits that the child may not be able to fully appreciate and nterpret stimuli ue to a lack of organization and nte rat on (21:74) The infant w o has severely impaired body ima e due to developmental delay, and motor dysfunct on cannot ·r fer nt ate betw en his hand hol in an ob·ect, and the object tself. He may be a e to discriminate fore- round from back round or r ght from left . Interact·on between the nfant and objects may be limited due to poor control of movement and postural nstability (33 :74) . Restricted nvironment Motor development may be used as an ndex of physical and ntellectual maturation n youn children as it reveals possible neural or brain dama e .... Motor development also influences social ad ustment; for example, a ch ld who is crippled or restricted to wheel chair or braces will also be handicapped in the opportunity to play with others (2 :51). 23 Denn s conclude that ·nfants who do not have the oppor tun ty for experience in practice of gross motor sk lls may e retarded in development to some degree. "Experi ence affects not only the ages at wh ch motor items appear, but also their very form." Dennis and his wife ra sed infant twin irls for the first nine months in a very inhibited atmosphere with no social or phys cal stim ulation. The infants were not allowed to sit or climb as they were restricted by sheets. After nine months, the infants were iven the opportunity to sit, but they could not do so. After several weeks, sitting was accompl shed. At 52 weeks, the infants could not support their body weight while standing with help. The normal infant man ages this at eight or nine months. Standing was achieved after a few days' practice. Eventually, these twins caught up to the normal development. One twin d d not suffer retardation in crawl ng, walkin when led, stand ing or walking ndepen ently (12:33). Snee these stud es were done t analyze the effect of restrict on on motor 24 development and socialization, tis not known if percep- tion was delayed. Tact·1e stimulation and nformation s necessary for development of body ma e, form, and space concepts and motor plann n _ accordin to Ayres (3:121). Iranian and Lebanese nfants n inst·tut ons who were kept in sheet-lined er bs were more retarded than those who were allowed opportunities to sit and play. Hop and avajo Indians boun ch ldren on boards wh ch were carried on the mother' back. For three months the infants were carrie wh"le arm and le movement were pre vented. No sin ficant difference was found n their motor milestones when compared to Hopi infants reared n the cradle. In ian, Japanese, and 'orean babies who were ound to carrying boards for the first few months did not appear to suffer delayed motor development. There ~as no difference between the children so bound and their Amer ican counterparts raised n cradles (28:34). Of course, results epend on hen the practice ceases, at three months, n ne months or loner. Feral children ra se in iso ation without other hwnans have been studied by Zing, Itar an Sequin (2 :51). Zn found 40 cases, some of which were hidden away in attics and were found t be feebleminded. Itard's famous "w 1 Ch"ld" was able to learn fundamental learnin tasks and develop motor ab liti s but did n t 1 arn speech. He was a nocturnal child with a reat sen e of smel. S qu n used sensor - 25 motor trainin to hel Victor, as the oy was called. V ctor did earn t ident fy simple obtjects, run errands and play with others, but the enr ched environment could not make up for the many years of deprivation. This is also true of m ntally retarded who do not receive suffi c ent attention for the r sensori-motor development (2 :35-36). xplorat on and Manipulation of nvironment y Infants and Ch ldren Soln·t and Provence comment on the ch 1 's master of h·s ody dur n play an expl ration to achieve mental ima es or schemas . . . . thus, body mastery s linke to compre hension of space, size form, an texture. Additionally in play the ch ld w 11 manipulate fasteners, conta ners, mplements and mechan ical devices n his toys. Trial and error im tation of peers and elders ans control over h s body necessary to continue with his exploration into the env ronment and at the same t me these physical activit es facili tate the development of mental representat on of space, form, an texture and depth perception (34:580). Cratty as een concerned with programs for coord nat on and motor learning of ch ldren with m nimal deficits. He comments that play f\Jlfills a def nite need for activity, release of ten on, and for m tat on of p~er and adults. Play may be useful n preparin the ch ld for adult respons b 1 ties. "Play s the man festation 26 motivation to move, to explore and to manipulate the environment 11 ( 11: 146) . Bijou considered the infant's exploratory behavior to be a stimulus-response condition ng occurrence. As the infant touches objects and interacts with the environment, he is reinforced by pleasant, acceptable stimulation and negatively reinforced by unpleasant stimulation . For ex ample, sticking the fingers under a heavy toy leads to pain and is negatively reinforcing. Tasting food which he brings to h s mouth w th his fingers successfully is a pleasant, positively reinforcing stimulus . As the baby touches surfaces in his environment, pleasant contacts stimulate further exploration . Skillful behavior grows in strength, while clwnsy behavior grows weaker and is $elf-defeating (7:102-03) . Development of Integration of Sensory Information The child must learn to separate the activity from the sensation and perception of it . He gradually learns to discriminate and tell the attributes of things . A typical response of children is the attribution of live characteri stics to inanimate objects, "animism . " This gradually changes or becomes extinguished (33 :68) . Hunt reported on sensory and motor ntegration in young chil dren . The youn child apparently does not have a unity of incoming information from all the senses acting in a given .:.t tion . s the ch ld evelops h 27 radually is a le to assim late and int rate ·nr rmation received from one sens Jith that of anoth r . Aroun the age of three or four, a child develops an equivalence oetween ~hat he sees and f el whe handlin an ob·ect . This ability to ·nte rate th haptlc w·th he visual sense ec mes more ref·ned by adolescence . I a ch 1 cannot ee 1hat he i handl n, or experienc s a pas ve kins t etc m v ment aroun the bject, he is much less 1 ·kely to learn what it s . By the age of seven a ch ld eg ns to ea le to use pure k "nesthetic sense (21 :69) . The stuct·cs of ·rch and Leff rd tend to agree w th Hunt's in that they reco n ze the ch·l 1 s inability to equate hapt·c w·th v·sual sense .Lnformat on unt 1 about the a e of five . t that time, the child can also equate hapt c and {inesthet·c senses in rder to dentify and recognize o jects (8:5-10). lthough the my 1 nation of nerves has occurr , the perc ptual processes cont·nue to e inte rated at this age . Behav · oral organization is necessary for complex sk lls in sports and manipulat on . There s an nteract on of sensory and motor aspects ; one ass· sts in the development of the other at any a _e (21 : 7lt) . Solley and Murphy foun that ind victuals may rad ually chan e their response to tacti e sensations y 28 habituat on or sensitization. Habjtuation occurs when the individual acquires the ability to reduce sensitivity tor petitive stimul. The threshold is raised by feed- ack fibers which connect the receptor area with the c rtex and cause runping of the nerve fibers. The a ility o become increasingly discr minative or differ ent ate may ccur by process of sensit zation. This he· htened response occurs with repetitive experience; thus, individuals have the ability to learn by practice (33:204). Disturbances in Sensory Integration Tactile Dysfunction as it Contributes to Poor Motor Planning and Incoordi natio~ Murphy and Solley describe the necessity for bal ance between the exteroceptors and interoceptors. If this delicate balance is disturbed, or has never been acqu·red then the ch ld may ignore external stimuli and incomin informati n a out the world n favor of accept n h sown nternal cues and stimulation. Thus, he is satisf ed to learn relat vely little about the world and does not feel the need for exploration of the world or man pulation of his environment. He may become a pass ve dependent-type of person. Some children ho appear to have d fficulty n rela~in to their env·ronment have the desire and are 29 a are of external and internal stimul, but these stimuli are aware of external and nternal st mul but thee st mul are d storte or misperce·ved due to problems w th the inte rative processes n the central nervous system. There may be a combinat on of distorted percep tual input as well as disturbed motor output because of the diffuse bran dama e (33:204-06) . Bortner, B rch, and Walker distin u sh et 1een percept·on of a pattern, I PU, and perceptual motor a ·11ty OUTPUT. One must first perceive the pattern and then perform the perceptual motor funct on. If a person has perceptual organ zat on, ut is disorgan zed n cerebral funct·on, he has ne ic ent voluntary action. If one cannot discr m nate, then it is a recognition prob lem, and s diagnosed as a perceptual problem. In normal persons, inte rat on occurs between the percept on and motor response so that efficient voluntary mot on can occur (16:923-34). erceptual motor dysfunction. Ayres has identif ed several syndromes which are related to perceptual motor dysfunction; these are: (1) apraxia, a deficiency in the ability to motor plan; (2) perceptual dysfunction n form position in space; (3) deficiency n integrat on of the two sides of the ody; (4) v sual figure-ground roblems and tactile efens veness. ach syn rome consi ts o a 30 separate const llation of deficito in function . These syndromes may also e present n a child with cerebral palsy . Accor in to Ayres the ability to motor plan is ependent upon tactile nformation to a reater extent than proprioceptive or k nesthetic information . Thus, tact le ysfunct on contributes to a poor ody ima e- a raxia--and post on in form an space (3 :121-25) . frequent findin durin the testin of a ch ld fr poor coordination that he also has tact le dysfunc- t·on which contr butes to the prob em. If th oal is to mprove motor plannin methods to normal ze tactile func- tion should be used as we 1 as tra nin in motor sk lls (3:123) . Dysfunction of the tact le system--tactile defen siveness . Ayres d st nguishes two types of tact le sys tems--the phylogenet cally older protect ve system (spino thalamic), an the discrim native (lemniscal) system . In or er for incomin stimuli to be interpreted n a pos - tive manner, th scr m native system must inhibit the operat ons of the protect.ive system . The more pr mative protect ve system pre om ·nates uring t ·mes of stress when the nd victual feels threatened , wh le th discriminative system predom nates durin homeostatic per ods of 1 arnin . an nve t gat on . I there 1 an imbalance bet een the two systems ue to perceptual disorders the protectlve 31 system predominates . Tactile defensiveness s exhib te w·th arousal, increased somatic d · scomfort, hyp ractivity, decreased discr minat on . The child over-responds to certain types of stimuli, particularly to 1 ght touch . The hair cell receptors and others responsible for light touch appear to elicit a protective response when st mu lated . Th s may be evidenced n the manner in which the ch ld responds to a li ht touch ith the f n er . He may attempt to withdraw or leave the situation, show dislike in facial expression, or react with increased motor ac tivity. If the ch ld is the rec pient of tactile stimuli not init ated by himself, he may be anxious, even thou h it ·snot done in a threatenin manner. Even the child's own tactile activities can cause discomfort and arousal of the defensive system . When the child attempts to ex plore or manipulate an object, he may evoke the protective reaction and cease the exploration. Ayres observed that periods of deprivat on of cutaneous stimuli caused de creased tactile percept on, and intensified the protective react · ons . She postulated that the ch ld may not improve his condition by avoidance of cutaneous st muli . The ch ld may be able to cause inhibition of the protective reaction by radual cond tioning procedures . Ayres recom mended rubbing the face and palms and forearms with rou ;h towelin and the use of touch pressure rather than light touch to con tion the response . Attempts to ach eve 32 better balance between the two systems include the use of heavy muscular exert on to activate the deep pressure receptors, and Jo.nt pressure to increase the kinesthetic awarenes. Cerebral palsied children who walk may assist in the inhibition of the protective system by pressure stimuli to the soles of the feet durin standin and 1alking (3:122-25). Therapy ethoas for Influencin Motor De elopment and Body Ima~e o -Condition n Sensor Receptors b Contact\ ith Resilient Materials and the Use of a Special nvironment Rood ives the neurophys ological basis for treat ment of cerebral palsied children with much· nsight into the underlyin mechanisms wh ch can mediate positive changes. Rood comments OT.t the need for conditionin the receptors 1hich mediate mass patterns of response in cere bral (palsied) or neurolo ically handicapped children. In order to gain a better comprehension of the asic prin ciples un erlying their responses, Rood refers us to Hooker Davenport's treatise, Developmental Psychology Today wherein he describes the prenatal infants respon e to stimul as a sympathet c "away from" pattern. Thi protect·ve response s normally mod fed to the parasympathetic "toward re ponse" soon after irth. The ne,born ·nfant ill clin to anyt n placed in h s hands. 33 In the cerebral palsied infant or ch . ld this parasympa- thet c control is not adequa t ely developed · he remains w·th an "away from" response to stimuli . The mass "away from" response is re··nrorced by continued uncontrolled respcnses mediated by the Alpha cutaneous pathvay . This occurs at a high en y cost to the child (2 :55 58) . It is necessary to ach ·eve a low ener y means of ain ·n co trol of the mass "away from" response and to develop the 11 toward 11 response or mass contact pattern via the arasympathetic nerv us system . Contact receptors of the thighs ab omen and shoulders may respond with ad f ferent pattern (tonic flexor pattern) if there s oppor tunity to receive full body contact. Control of the sympathetic response might be accomplished by ying prone or stan ing on a flexible, pleasant, non-alarming surface. Furthermore if the child could roll on a pleasant , resil ient surface contact receptors of the thighs and abdomen cold be activated for a toward flexor pattern with less energy cost . This body contact act vity el cits a response to move toward the surface rather than arousing the alarm state of the sympathetic nervous system . (Hemiple ic chil dren with hypersens·tivity refer t 1 eon the involved s de when sleeping to aecrease the sensation . ) If the child is n need of extensor dom · nanc of the tonic labyrinthine refl x , a chan e n posit on of the ody w·th acceleration of movement may help m dify the influence 34 of the reflex . For example, 1 a ch ld oes down a slide or incline ·n the head-f rst positi n, there may e fac 1- ·tation t certa·n screte muscle rou~s such as the anti- rav·ty muscles . After this s din activ ty, the ch ld may exh· it tter control of osture . He may ut 1·ze this facilitat on of select muscles for ass stance in standing w·th better posit onin of his feet. Then, the bare foot in contact with a comfortable resilient surface may grad ually ecome desens·tized t the "away from' response . Gra ually the heels come down until the feet are earin weight more evenly . urther stu y could e done by bser- vat on of children with neurological dysfunction in an env·ronment which is totally safe and resilient (30). obath-T erapy to Influence Developmental Processes In treating the cerebra palsied ch.ld with residual prim·tive reflexes Bobath places emphas·s on postural changes wh ch prepare a person or vol ntary movement . For example, when a person readies himself for standin the feet are drawn under the body to bear wei ht and the body leans forward efore risin . Head control s main tained by postural reactions . These automatic static and k net cc ang s of posture comb "ne ~ith the r· ht·ng a equ "libr um reactions t ena le the person to walk . If th child w th upper motor neur n les·ons as stereotyp d 35 rs on es to change in position, postural controls are a·s t rte and voluntary or skille funct·onal activities can not be performed accurat ly. Bobath treatment princ· les ar ased on techn·ques which attempt to alter or counteract the abnormal patterns of tonic refl x act·v ty with dynamic patterns . Then the child is assi ted to use selective voluntary mov ment pat terns. ◄ventually the ch·1a can pre are fr funct·onal sills such as ~alking . nsory stimulat·on ·n the form f tapp·n, ressure, co press · n, placin_ and holdin echniques is comb ned with reflex ·nhibitory atterns for hypoton·c or weak m scles. One of the bas c princ ples ·n the Bobath metho of treatment ·s to increase decrease, or stabil·ze pos tural tone. silient equipment. Often dur ng treatment Bobath uses a large ·nrlated bal to el·cit equili r wn and pos tural ri hting responses. The surface of the ball is smooth an comfortable to lie upon. The yielding surface rov·des opportunity for the child to cl mb crawl, roll, sit and alance. While the c ild is n the head-down pos·tion over the ball, he balances ~is weight on his hands . Th s head down pos tion s helpful for eliciting r hting r flexes of the hea an trun. Wei ht bearin throu ht e jo nts of the upper extremities s thou ht to e fac l·tory to the 36 anti-grav ty muscles of the upper extremit es. If a ch ld benef·ts from head-down os·tions, one could prov de stable surfaces for sliding and cl mb n (head f rst), as well as ncl·nes n a planned environment ( 0:18-22). Hunt- ct vities for Development of Body Image and Motor Coord nat on Hunt is a physical therapist ~ho has concentrated on act vit·es wh·ch take place in ymnast·cs, dance, and sports fr the devel pment f motor coordination and body a e These activ t es · ve express on ·n movement thr uh sensor·-motor exper·ences and allow the nd·vi ual to evaluate his own movement. The follow·n act v·ties are desi ned y Hunt to be used for children with disturb ances n body image or coordinat on. The ent re body is moved se mentally upon a mat or ru to stimulate touch receptors an help define body boundar es. The sub·ect s hands or feet are rubbed ver his body as in ath n for touc sensation. V rious textures such as rass, sand and asphalt are touched y the body. The contrasts n the urfaces are note. The body is moved n a confined space for reco nition of size of the oody. The k . nes thetic receptors are stimulated by moving each joint through full ran e and experienc n pressure, tract·on d rectionality an extent of movement. Obstacle courses are et up to cha len e the problem-so1v·n ab lity of the 37 child . Vestibular sensations are noted as the ch . ld moves n many directions up and down sl des, leanin , turning and recovering balance . The sensation of body weight changes as t e child floats in water , or moves throu h the a·r on a trampol ne . It appears that Hunt's ·ntent·on is to brin an awareness of movement , and accentuat on o performance to help the child improve his body ma e and er rmance n motors 11 (21:87-90) . ethods for Int rvent·on pecial ducation Perceptual motor train · ng . The Dubnoff School for emoti nally disturbed ch ldren inte rates perceptua motor train n nto the classroom act v ties because many of the chil ren have perceptual motor problems in addition to spec r · c learning disab.lit es , hyperactiv·ty, min ·mal rain dysfunct · on or mot · onal problems . For ·nstance, dur ng segmental rollin , emphas s spaced on the tactile sensation as each part of the body contacts the loor . Tactile st mulation such as stroking, ru bin, tappin, is use to ncrease the ch ld's ab lity to reco nize the ody parts . Body movement s tau ht by act ve participat·on · n sons w th estures and rhythms ·mitat on of pu pets and jointed doll and movement throu h real and ima nary obstacles . Developmental 38 sequences as well as advanced skills ut·lizin the tram o line or swimm n pool are taught to assist in th develop ment of body ma e and motor plann ·n~ . From sensor. -motor exper ences, the child is ·radually led into t e classroom activ·ties wh"ch ncourage translat · on of act ons nto pictures on the blackboa d or paper (14 :7-9) . Intervent on for pilot infant pro ram is des ened to ·m rove nteract·on between m ther and ch"ld an prevent serous problem from developin in the emotional and physical development of the nfants . Infants in the program have exhibited sins of potential problems such as slo~ sensori-motor development, ·nab lity to respond to stimu1· apathy, lack of eye contact phys cal hyperactivity, an resistance to body contacts. The therapist uses a special play room wit a var·ety of textures in urnisnings and equipment for dem nstrations of developmental sensori-motor activ t es and peer interaction amon infants . A one-way m rror allows the mothers to observe the· r infants in s·· tuat · ons with therapists , other babies and adults . The mother may learn ways to intervene with the child's activities , and to assist in h s soc ·a1 emot~onal and phys · cal develop ment ( 1 : 1-9) . 3 The sensor stor . J nes an rrett developed a sensory story to allow handicapped children to overcome tactile defensiveness increase hand usage , sensor -motor activ ty and ver al communication . The sensory story allowed the child to interact with familiar materials which varied n texture, s ze, temperature, color and f rm to receive tact le and kinesthetic input and perform functional movement . While seated at a special table, bilateral hand usage wa encoura ed , especially in hemi ple ic children . The ch ld was alone w th his teacher urin, the exper ence so as to minimize the distractions . Reinforcement was given by the feedback from the handling of the mater·a1s which \ere part of his da ly environment at the nursery school . The teacher used the ch . ld ' s name in the story and encouraged verbal communication (24 :448) . Importance of tact le stimulat on . Bi ·ou re ated the importance of tactile stimulat on as reinforcement for "secur ty . 11 He cited the common preference among ·nfants for soft, cuddly blankets and toys which they utilized to obtain maximum phys · cal contact (7 :102) . Sensor stimulation durin Stewart sug ested that if the nfant sallowed freedom of move ment to explore and rece~ve sensory stimulation , the child may show advanced sensori-motor evelopment . he cites 40 nvest· ations of the free om for explorat on allowed the child by permissive parents and restrictive parentu . Over restrict ve or overly anxious arents prevent the nfant from act·.vely explor n and rec ivin fee ack rm sens ry st ·mulat· n t provides (35:293-95) . Hansen's sensori-m usin Hansen rea i ed the ·mportance of the chil 1 s interaction w·th t e envir nment and ·t eff ct on h. sensori-motor experiencea Hansen ed her grou of four-year-o d chi dre t rou ha var ety o mov ment and tactile, k·nest etc and ro rio ceptive exper·enc s by chan ing the rnater·a sand the manner an methods f presentat·on. She utilized orct·nary eq ipment such as rows of cla'rs placed ·n unusual confi - uratio s for k·nesthet c awareness (as the children moved over or around the chairs). Some o the ·nnovations ~ere the r su t f the manner in h"ch conventional equipment was used. Vet· ular st·mulati n was ac ieved y swin in the ch"ld in a blanket, or ro line over a var ety of textured surfaces . pushing or pullin ropri ceptive input ~as achieve by a ch'ld s vehicle loaded w th locks or us ov wat r, by jumpin from ra ually increas n hei ts, body contact w th a variety of surfaces or cra1lin throu ha confined space . Ch dren exper·enced temperature chan e with bare eet or hands placed on a ternat n areas of wa and cool surfac s. Te chil ren were encourage to discuss an express the·r feelin s about tlese exper ences. Children learned to move w th awarenesc of the r own bod·es as well as the surround n areas ·ndoors and outdoor. Interact on amon chi dren ·ncrea ed as they ere encoura ed to use body movement as a f rm f se f- xpress·on. Many of he ch· ren were clumsy and inept, with poor body ima es and ·nabil"ty to expr ss feelings appropriately when t e program gan . These ch ldren ere a le to achie e ma tery of the"r wn move ents and mov w th ncreased a ·"lity and c nfidence after ten weeks' tra·n·n ·n the m vement-behav or program. 1a1sen n ted that both the iol gical development and the interaction of the child w·th the environment affect the sensori-m tor experiences ·n quality and quan t ty . New exper ences must e presented in careful manner so that the ch"ld t·1·ze feedback to stren then his body ima e and a·stin u·sh h"s ody as a separate entity from t e environment. I the ch"l develops a strong boy i e, he app ars to co e better, ke better a just ents n new ex eriences and move w·th more control an smoothness . Play can be a th rapeut·c d vice if attention ·s given t chanees in movement pattern durin a iven cour~e of t·me . The ch"l may use play t act out h s feel"n and problems (19) . "Pla is the chi d s 42 natural me ·um of expresu·on" (5:16). Montessori schools. The environment must be appro priate and su:table for development of skills. Maria Montessor· el eves that a child's curiosity and inqu si tiveness can brin sat sfyin answers as well as unl m·ted unf ldment and inpenuity in the use of materials and re sources, oth taneib e and intan ibl. The 1ontessori teacher sets the sta e for the child to have a meanin ul experience, then allo,s the child to invest~gate the s·tu ation. The teacher may ive direction to the ch.ld's movements to prepare for orderly development f sk"lls. Motor sk"lls may be developed by doing useful work in the arden or 'Ch ldren's House' (26:34-35). Althou Montessor schools in the United States are pr vate schools to which the middle and upper middle class send the·r children, ~aria Montessor 's worr had its impe tus in the slums of ome with the deprived ch ldren. Her central theme 1as to make "learning atisfy n to the youn child." She and her "non-teachers" led the children to ao thins for themselves, in a natural environment ,·th innovat ve equipment, such a sensory mater als and small scale-furniture (26:52-58). 3 s nvironments Wit n ier 1 s ada tive round . A pre-school ch . ld wit cerebral palsy usually has ad fficult time ettin n to c nventional play equ · pment such as a sw · ng jungle _ym or tricycle . Often ·tis a passive exper ·ence ecause he must e placed on t e equipment and u ded by someone . he ch .ld ·s n tin c ntrol o t1e s tuation and snot receiv·ng accurate feed ack from the environment necessary for the development of body mage and motor learning . Because of delayed motor development the ch ld mi ht ror · t more from act vitie based on early onto enetic pattern of development . These bas c postural sequences can be made more interesting to th cerebral alsied ch ·1a ·r the play area s situated to make -hese postures eas ·er to asswne . In play situations the children act·· vely seek new exper ·ences in movement when the environment is safe and attractive . W tengier 1 s play envir nment conta ns areas with carefully spaced o ·ects which form mazes, terraced areas like steps, ramps and inclines, tunnels and obstacle courses of foan shapes . This small child s environment is ri ht and colorful as well as challen ing and 'tolerant of h s 1 m tations . 11 The ch ld explores and touches, pushes and pulls climbs and balances · n a rela t vely safe area . " 1 'xercise and learn·n are naturally motivated by the ch ld's desire to move t explore, -o 44 play . " viten er sug ests that this unique play area provide opportun ty for develop.ng kinesthet c awareness , dynam c balance , spat·al relationships , body awareness, ·nte ration of the body sides and motor lanning (41 : 25) . Throu h play he learns more a out his body and its place in the env · ronment . Play prov · des repetition needed to ref ne and control motor sk lls . Th splay is crucia l to the development of motor percept · on ( 42: l~) . Opportun ·ty for mastery of skills in play : Bijou finds that children play in order to rece ve feedback and be able to feel some control of the situation . A new place is to be discovered and the child persists in trying all approaches to explore new areas . If the child has an opportunity to discover and investi ate a new area for pay he may learn a mores illful behavior through h·s interaction with the situation (7 :105) . Ayres M lieu- therapy in play exper ences . Before sett·n up a pro ram to assist a ch 1 in perceptual motor development for improved boy ima e motor plannin and motor skills Ayres carefully screens the ch.ld us ng a battery of special tests which she develope . The child's evel of function in several areas is determined by her screening tests , The Southern California erceptual-Motor Test and ot ers (4) . 45 Ayres' methods for the influence on th nte rat on of sensori-motor input in children with dysfunct·on 'nclude a unique env ronment. In a lar e ymnas urn-1 ke room, many tyoes f equipment or act·vities wh ch cause st·mula tion to the vesti ular and tact le systems are set up. This special milieu consists of ramps, slid s, nets, boxes, scooter boards overhead swin , mats and other improvise equ·pment. The ch~ld · led throu h act·v1t·es such as ridin a scooter board own a ramp and steerin ~t ·nto a desi nate area to ncr ase the level f vest· ular st·mu lat·on. H eful y th s br 'n s a ut increased inte ra- t on ft e senses and "mproved motor plann·n. The Ayres' ro ram is carefully controlled and directed so that the 'nd·v· ual ch ld is eva uated r the effect whic. the activities have on he performance of the ch"ld. Ayres cautions that massive multisensory input may cause reater disor anizat on of the ch"ld s erception and sensor - motor apparatus if the chi dis ver stimulated (3: 2 -22). Hatcher's obstacle course for training eye-hand-bod coordination. Hatcher deviNed an area for hana·capped children h ch offered much contrast in materials dimen sions of objects encountere, ana opportunity for exper· ence~ with sensati n v stibular st mulat on alance and movement throu h to cra,l throu h pace. The environm nt consists f arrels alkin beam~ and alance boards p t1ways 46 of many contrasting materials, walled areas with ma es cut out and ar as where the ch~ may stretc out on the groun to mak I an els in the snow . 11 rat onale for each item and nstructions for use are ·iven in Hatcher's book re Than Words (20). Motivation Constant desi nor pattern in movem nt . mith and Henry prop sed that activ t·es must have sustained inter est, si n·r·cance and c nsistency for the b ner·t o pa t·ents with brain drunage . If pattern and movement are of definite des n that can be re reduced over and over, memory and repro uction f the pattern are rein orcea . In the·r study the cybernet·cs of rehabilitation, Smith and Henry d scovered that children can perform and remember dynamic trackin ~ith more precision than static patterns an f rms . Movement patterns which can e reproduced, an which take place in a systematic act·vity of si n · r · cance to the ch 1 are most li<ely to be esta lished in the memory. Thus, a structured, confined play env ronment wh "ch allows the child to practice patterns of movement repetitively and dynamically until they are cons·stently reproduced should be benefic"al (32 :460-61) . Stimulu~ events the settin for Bi ·ou dis- covere that in cond ton n ch ldren for an event, it · s 47 useful to stabl sh a routine usin the same area and mater· ls consistently to establish a st mulus-response rout·ne . There are certain k nds o stimul which ma be presented to strengthen desired behavior . These are called "sett nJ-events . " Setting events are more complicated than the simple presence , absence or chan e of st mul .. Instead a settin event is a st ·mulus-response ·nteraction which simply because it 1.as occurred w· 11 affect other stimulus - response relat onsh ps which follow it •••. A child's h"stor of past n eractions w· th his nv ronment may be looked upon as a collect on of settinr events influencin current behav or ( 7: 22) • • • Interaction with the environment . The child s continuously interactin · with the environment . 1hether his development is progressive or not depends upon his ab 1 ty to use the opportunities available to h ·m at his level of development . We do know from many stud es that the child's responses can e controlled by both precedin stimulation and consequent stimulat on . To some extent his behavior can be controlled by shaping or operant cond- tionin (7 : 22) . If the goal for the child s learnin a sequence of actions which comb ne to form a motor pattern such as crawlin , we may ncrease motivat · on by makin the experience more pleasant for h · rn He may enefit rom play on pleasant, secure sur ac s which are tactually stimula- t ne; and ·ghtly resilient . A for iv n I surface yields 48 slig tly under pressure of the ch ld 1 s we ght and allows t me for the c ild to make postural adjustments for al- ance . y continued exposure to thi~ same phys cal play environment, the ch . ld may learn that he can ain tract on to move safely even thou h his movements may be hes tant while overcomin spast c ty or atax a . He may move be cause he hear a st ·mulating sound ahead of him, r ee a co orful fam liar object near y that he wants to reach . If he has had several pleasant exper ences in mov n over an obstacle course tat fun for h m, he a learn to ant c · pate the exper ence and attempt to go further w·th his exploration each time (7 :22- 3) . Positive reinforcement . The ch ld s voluntary behav·or can e shaped by operant conditioning . If e wish to cause the child to traverse a certain section of the play path, we may want to use positive reinforcement . This could occur y allowin the c ·1 to find a rewardin situation after movin a certain a · stance . For example the child may f nd a slide w th a soft land ng a furry ru to roll onto a toy that makes a sound when squeezed or touch images of animals on the wall mural . In th s manner ar ient behavior (directed toward certain conse quences) can be reinforced ·n a pos tive way (7 :33) . CHAT III D CRIPTIO OF THE ◄XP ◄RIM<NTAL ◄NVIRONMENT ettin for the Study Th ex erimental Thera-play unit ~as rect d n the lawn of the arden lay yard for the UC Hand capped Chil- ren's re-nursery School in Westwood . The la1n f the arden sl pes sl tly and is landsca e ~in at ractive shrubbery and flowers . A small playhouse sandbox swin s, and parallel ars are nary . Desig Feat res Th first rerequ site in the design of the unit was safety . This was achieved y utilizin r s·11ent materials throu out the ·nside oft e structure to promote an ele ment of c nfi ence in the ch ld . Changing cont urs were anned t invite explorat on and pp rtun ty to test motor skills . This art cular model was designed for the ne and one-half tot ree-year-o d children . The var ous colors, te tures of fabric, and des gns of the pathway and alls w rec osen to ·nterest th·s a e group . ( ee lats I an II . ) 49 p AT I ,_ ---- 1 ~ I -~ ___,- I ~' I ti I ,, ,, - ,,, -- I -- ' J\c:-:_ - - - - - - '-'." __ - --- -- --~ - -- 50 C. I ct1 L (I) _c +-' Ct: 0 Ct: w t z PLATE II THERA-PLAY UNIT CENT BO \J7 52 Exterior of the Structure The exterior is hexagonal ; one side is o en with a door which prov·aes in ress and egress, the other five walls are solid three-quarter inch plywood, four feet high and six feet lon . The hexa on-shaped structure is covered with a fa ric roof support d by alwninwn rod r·bs . The d ameter of the nt·re unit ·s 12 feet, and th o ter c rcwnference io 34-1/2 feet . Ins de Path ay Inside the structure is an enclosed circular pathway with ramps , inclines, and bstacles of vary ng degree which s rround a central owl-shaped area . The levels of the res·lient cushions are graduated from low slopes to higher, more complex slopes and contoured shapes . If the ch ld progresses alon the pathway to the right of the entrance, hew 11 come to the stairs . The stairs lead elther to the slide or the central bowl area . The sides of the bowl lope downward toward the center wh ch is almost level . At any point on therm of the bowl, a child may climb or j ump into the owl, or off onto the foam pathway wh·ch surrounds the bowl . The circular construct on of the path way allows the child to move f rward and experience move ment w thout feeling conf ned . It s intended to eem like a never -ending pathway to the explorin child . As the 53 child crawls or walks al ng the path, he may touch the fabric wall murals which are familiar an·mal scenes . The fa rics vary ·n texture from soft fur to coarse, rough textures which encourage the child to explore and differ ent ate forms (see Plate III). The Slide A solid urethane foam trian ular structure which is covered with naugahyde form the slide . Its dimensions are 36 nches by 46 nches by 24 inches . Approach to the slide is made ether from the stairs or from the bottom of the slide. The outer wall on one side and the vertical si e of the bowl on the other si e form the "si es" for the slide . Kinesthetic stimulation occurs with the var ous changes in position and body contact with the changing surfaces. The rapid acceleration down the slide causes a feelin of lightness of the dy weight, which s followed by the sensation of increased weight upon landing on the pellet-filled platform . With rapid movement thr ugh space, the boy experiences vestibular stimulation which can facil tate an increase n the tone of the trunk, ne ck , and extrem ties (38 :9) . The slide is an mportant part of the unit because a child may improve his balance and ga n confidence us ng it . In add tion, the ve ti ular and kin sthet c stimulation ass st n the development of dy mage (see Plate IV) . 54 PLAT III TH -P Y NTRY V W 55 PLAT TH - P Y UNIT-SLID 56 Landing Platform, Pellet J3ag The fa ric-covered form ellet ba is approximately four feet long and thre feet wide . It is loosely stuffed 1th f am pellets and is about one foot thick . The pellets shift whenever pressure is apol ed so that a chil must make postural adjustments in order to balance in quadriped or upright postur s . Since the pellet bag molds to the contours of the body hen a child lies the child a feeling of security (see Stairs nit, it can give late IV). Four ste s lead to a small level platform which ives access tote large central bowl, or t e slide . The stairs have four inch high risers with a six inch tread . Chi dr n may find them a familiar sight nd quite naturally attempt to crawl or climb up the stairs . Since the stairs are also made of urethane foam, the children can use them without fer of injury . The stairs are designed for chil dren who are naturally cautious because of instability, incoordination or muscle veakness . They may ecome more secur in th ir actions after some practice . The Rolling Bowl he central feature of this structure is the large, s · x-foot, iameter II owl . 11 Since it is formed of flexible urethane foa covere with vinyl, it i resilient yet firm when walked on . It slopes down from therm to the center 57 with a depth of 20 inches where it ·s almo t level . The children can cl mb over the 30-inch hi hr m anywhere alon its c·rcurnference, or approach it from the platform at the top oft e stairs. Therm is four to five inch s thick at the top circumference, so a child can sit on it eas ly. Th nau ahyde coverin _ of the solid foam bowl allow a child to gets ff cient tract on to clim ·nto the bowl. The sl p ng sid s f the owl ·nvite ch.ldren to invest - ate ays to traverse ·t. Most c ildren sl de down the slops first, then isc ver t ey can crawl, r 11 or cli over the surfac. Theo lder children ·wnp r a·ve fr m the r·m to th ath, lan in on the soft surfaces ( la e V). Small Inclined Ramps Thees 11 trian ular-shap d cushions when place adjacent to one another, form sli ht so es. The trian les ft into the hexa onal sha e of the basic structure since t e plan ·s ased on the triangular module. It ·s possible to walk u an do1n the inclines y makin s i ht postural ad·ustments. hen chil ren c ail ov r them, they are al- ways wit nan up or down slope. The tr·an les can be arran d alternating colors so that children without ood de th p rce tion can n tice the chan 7e of the inclin s. Double I a1nps Th·s lon cushion ha an inverte V-~haped top surfac or ri e . It s des n d to cause the ch 1 •s 58 P T V G CENTRAL BO:J L 59 wei ht to be lac don the outer orders of the feet . Th c 1 on all ours can crawl ave t y balancing is wei ht overt e c ter . The dou 1 slope is anoth~r unique f rm i hich the child may learn to a·frerentiate from the tr· an ul r forms . The curving f rm wa ut·1·zed in a cushio which was sc pd out on th to ~urface n r er to cause th pos tural refl xes t b ut·1 z d as the child moved over th surface. C ildren w· t oor coordinati n traverse this ec tion sloil nd caref 1 yin ord r to maint in the r al anc ( ee Plate VI) . Sensory Murals h walls of Th ra-play are art of the design to ena e the ch ldren to use the·r ha tic, tact·1e, and visual senses toga n infor ation. he anels are cover d with resilient actct·ng to protect the ch.ldren from injury . T xtured fa ric wall angings ith familia cenes of er the children visual as well as tact·1e exper ences . The sensory murals ·nvit cur ous children to touch and nves ti ate the materials . On one wall a farm scene with a arn aystacks, an familiar farm animals is made w th a variety of fa rics and f rs to emphasize not only color and fo outl ne, ut also textur differences . The pond scene with aquatic irds an ·mals and r · sh may stimulate conv rsati n amon the children . Ch · 1 ren ~1ho are reluctant 60 P T VI INCLI O C NTRAL BOv 61 to speak may d scribe tings which are v·sually or tactu ally st mulating to them . Sharin an initiat on of per nteract·on can occur w th the use of the felt wall and felt cut-out forms . These forms can be removed from the wa 1 and then replaced . The felt wall offers the insecure child a famil ar scene or activity in which to articipate (see ate II and III). CH TR IV RIM NTAL P FO T STING TH UNIT The 'u jects Sample population tested. The thirteen ch"ldren with delaye motor d velopment psychomotor problems, or cerebral palsy attend·n the UCLA Pre-nursery School for Handicapped Children n Westwoo ere chosen as the sub jects for this study . There were several reasons or the selection of this unique roup of ch ldren. Th sage group o one and a half to three-year-old ch ldren is often more amena le to su~ estions for chan e and the influence of d fferent env·ronments than 9lder children . The pre-nursery a e children have more flex·ble .atterns of development and responses than older ch ldren. The close medical supervi ion of Margaret H. Jones, M.D., and orientat on of the therap sts and teachers toward teaching and research is advanta eous for the testin of an exper· mental model env ronment for youn children. This popula tion enables the researcher to ob erve ch ldren 11th phys- cal limitations and/or behavior affect problems as well as psychomotor retardation. In motor development there is aw de ran e from a two-year-old ch ld who is at the 62 63 r·ve-month level to a three-year-old ch ld at the three year-old level. Evaluation of the su jects. Init al and final evaluations of the handicapped children were done by two physical therap sts and one occupat onal therapist us n the Los An eles County Crippled Ch ldren•s Services Growth * and Development Scales (see Append x). The child's level of ross motor skill ·n months was determined y compar·son w th the c.c.s. Scales for normal r ss motor function. If the child had motor retardat on, his gross motor function mi ht be assessed at a much lower level than his chronological a e. he in tial testin sessions were done over a two-week period by the therapists. ach ch ld ~as tested by two therap sts working together. The tests 1ere co pleted st prior to beginning the exper - mental use of the unit. Final evaluations were done by the thera sts urin the ast two day of the s ssion. Observation of Normal Chil ren Five normal c ildren were iven the opportunity to exp ore and play n the un t while the student observers were bein tra ned. Sine the normal ch ldren ~ere the same a e as the experim ntal roup, they tested the * lote: Hereafter the scales will be referred to as c.c.s. Scales . 64 appro iateness of the equ·pment for balance and gross mot r developm nt. Grouping of the children and frequency of sess ons. Because the observer th groups were l"mite needed to vjew each ch"ld clearly, to a max·mum of three ch ldren fo each rou. It was cons dered that 10-m nute sess·ons, three t mes weekly durln the warm swnrner eather, were sufficient to fati ue the chil ren an th ·r interest. In the case o the abnormal ch ldren, the teachers se ect ed three ch"ldren they thou ht to be most compatible for each group . A ress ve ch"ldren were placed w th those who could defen themselves or neutral ze the ntended a ress on. Because of absences, roups were sh fte in composit on, but attempts to keep nitial roups to evher cont·nued. It appene that one chil was alone most of the time becau 0 e the other roup members could not attend. of entry into th Before goin ·nto the unit, the children received no information or explana ti ns as to what they woul see or do. The t acher said "1 o 1 we' re ·oin to the 'Fun House, 11 ( as t was called by the chil ren). The children were placed n a wa on an taken to the site. The teacher did not influence the child' behav o in any ay. The ch ldren's hoes were remove as ell as braces unlesa the chi d requ red the h p o 65 races to ma ·nta · n a c rrect po ition ~ le m oving. The t acher sat outsi et unit near the ntrance , w·thin reach and si ht f the ch ldren but ntered only fa chil r quired special help . Th s occurred only once uring the study . Observations of Activ"ties n the Thera -play Un t It was realized that many t es of observation cou d be ma e in such an experimenta unit . ince t e main p rp se, s to nhance ross motor activity b dy mag ad balance three classif cat ons of observers w re utilized . he first roup of f·ve student observers was trained to observe occurrence and frequency of gross m tor sk ·11, b y c ntact , an speech . hey were n t ex erienced in ~u, in th quality of move ent . Th second grou con sist d of three exper ence tneraJists who recorded the type an uality of ross motor activities and the balance coor ination motor planning, s e d , ·ntegration , reflex mination , hand use and speech . The third roup con sisted f two teachers who N re exper · need bser ve r s ·n the use of special forms for recordin the ch ld s mood , social ·nteract on communication (verba and non - v rbal) , an overall state of emotions . Tl e teachers recorded ata on the three ch ldren simultaneou l y s tlat roup inter action ·m1tative play and conversation ere a so re- c rded (s e Appe ix for forms) . The teach r and student observers ere pr sent for each session, three t· nes weekly or fur weeks and the eek of tra·nin. Two f the therapists o erved sessi ns tw·ce weekly. The inv sti ator was pr sent at all sessions. 66 F" ming of th sess ons. n additi n to the wr tten records films were made one or two •imes ach week when a trained photo rapher wa~ ava lab e. Plans had een made to docwnent the ess· ns with a ref se ment for each child t sho· poss le r ress each week. h"s was not fas· le cause o the expense involved. PR~S NT TIO OF DATA Orranizat·on of Data Data collected w .11 be resented in narrative and rap ic form on an individual case bass xcept for that relatin to ross motor sk lls as rated by the CC Scales. eport ach child s report consists of an over-all narra tive report a Jraphic presentat on of gross motor skills and teacher's observations, plus a descriptive chart def nin funct onal object ves, sensor -motor exper·ences bserved, and resultin ehav or. In ividua * Narratives Ind·vi ual narrat·ves of the children ,ere ase on records of the teach r's ob ervat·ons, the motor activ·ty recorde by observers, and the therap·sts' observat ons. They descr bed the ch ld rior to the study and h "s pro ress durin the study, includ·n: (1) phys cal dysfunct on and * ote: The ch"ldren's real name were not s d . 67 68 1·mitat ons, (2) funct:onal objectives, (3) level of ross motor funct·on (4) attitude and mood, (5) persona -social a justment, (6) c mmunication. i ht of the children had phy~ cal problems with m·nor behavioral roblems . The other five ch ldren had behav oral problems with minor physical r perceptual problems. Ind_vidual Gra hs Graph·c presentation of each ch ld's ross motor skil sad t acher's o servat·on is presented n the same chart for comparison f amount of physical act v·ty an socia ization. Observat··on of i-er interaction and commu n·cat· n ecame s· nif cant eca se of the f·ve atypical chil ren who ha problem such as manner sms f se st·mulatory activities, ina il ty t relate to others or phys·ca a ressiveness. ( ee Table 1.) In victual Descript·ve Charts of Progress ach chart ncludes a description of the child's be avioral pro lems or phys cal ysfunction, functional obj ctives, sensori-motor xperience w·th equipment util ize and ost-experience ehavior. It is ased on the therapists• notes a out the child's ability to mot r lan h_s balance and coor inati n inte ration of prim t·v reflexes speed of movem nt hand use as oc·ated react·on and speech . These differences amon children were not 69 ev dent on the CCS Scales, because of the uniqueness of each chil 's problems. Compar son of the chil ren for parallel d v lopment w thin the roup was not practical. Therefore, descript ve charts of pro ress were made to illustrate types of pro ress fr ch"ldren with e"ther hys cal or behavioral problems. (See Charts 1 throu 4.) Grou Chan es in Gross Motor kills The results of each child's pre- and post-experiment measurement on the CCS Scales are resented ·n chart rm in Table 14. ach child was compared a a·nst h"mself for chan e durin the month of the study. The f" ures for the roup s avera es are a so presented. The children's major roblems were represented as either phys~cal or behavioral h chever dia nos s was most pertinent. Of the th"rteen ch ldren, nine showed no change while four gained between one and s·x months in motor skills. Of the ei ht children with physical 1 mitations, four had a total of four months' gain ·n motor skills. One child in the roup with behav ·oral problems (Tanya) made a an of six months ·n motor skills. The other four ch ldren d d not make sufficient motor ains that could be measured by the CCS Scales. Motor a es of the children varied from seven months to 40 months. Three of the four ch ldren who had been at the ten to 11 months' level of motor development made ans. 70 Louse and Mary ained one month each and ay ained two months n motor skills . Dennis Geor e , and ari who att nded only four to six sessions , made nos ni · cant motor ains . sis of Gross he G r oup These raphs shown on Tables 15 to 1 illustrated the i ferences · n pe formance amon the ch"ldren for the motor sk · 11 of s~tting idin climbin , and valk ·n . Th chil ren 1iho were most act ·ve ·n sliding w re al o act vein ci·mbin . There was no ·ncticat on that children ho ~ere active · n sl din ere als act ·ve · n al ·ng . ar as belo the ei hth month f development · n ross motor skills in much act vity . as W1able to crawl and did not en~age 71 valuation and regress Record--Mary Mary was a two and one -half-year old , dim·nutive irl who was orn prematurely with the syndrome of Rub lla em ryopathy with v sual an hearing mpairment . Since she had con nital c taracts removed, s e was able to detect only stron 1 ht intensit es and objects wh ch are blue colored . Althou h she wore a hear n s n s was observed dur n this study . ai, no response to She 1 as add ton- a ly hand·cap wt a varus d formity of her eet, w th a mil -to-moderate 0 pastic ty of u per an lower extremi tle. Goals had been set for Mary in the classro m. Since she . Peared to lie on the floor on her back unless d - rected int some activity, efforts were made to hep her explore the sch olroom an ain satisfaction from it . The therap st's oals were for Mary to earn to stand an walk Nith a oo ait ain constructive u e of toys, expl re and learn about her immed ate env ronment, and ncrease her attention span . Mary made little pro ·ress duri n her r·rst two brief excursions into the new environment . starin at the sun1 · ht neck archin observed . By the third day she had Mannerisms of nodd n, and body ·erkin , were e unto inte rate the rev ous experiences . She sensed the cont r . st etween her 72 usual env ronment and the res 1 ent materials when she be an to touch, press and handl e the rs l~en mater als, an move over the pathway. She ound the central bowl J th her feet, then pulled up to stand bes de it, and sm~led . She was n ted to use her tongue to detect the t mperature of new areas durin exploration . If the ar a was quite warm from the un she acked up and chose another route . Day y ay er explorat · on became more or ani ed and active . Mary cru se around the 0 1 , then tr ed pull herself up onto the rim with her arms while she pushed her knees nto the s de of the bowl . She d d succeed in cl · mb n up into the bowl durin her first attempts . Wh n she cru sed around to the sta ·rs, she was unable to d "scover that they led up to the owl . to not By er sixth session, Mary was more bold in explor ation an crawled over the lar e pellet a to the slide . She carefully touche the incline surface of the s de then l ic ~ed · t . She he d onto the side and rim of the bowl and walked up the sli e hen all e herself to s1 ·ae down the lide and land on the landin platf rm (pellet-f lle ba ) . It seemed that Mary remembere her experiences in the "Fun House" ecause she cont nued the previous day's act vit es where she left off that day . nee sessions were scheduled tlree t ·me each week, there wa a ays at 73 least a ne- ay ·nterval between sess·ons . On the seventh ay of explorat·on her attempts to cl mb lnto the 'owl" became otron er and more persistent. ~he pulled her ody up onto the rim of the 11 bowl" an rested her arms and chest on the nner lope of t e " wl . " 'he became too cautious to try sl d ng doqnward into the center and acked off the rim . Althou h she sensed the ·nc ·ne of the 'owl," she mi ht not have seen the bottom or known what lay ah ad . She cont·nued to wal on the sl de, and ab le and laugh. Mary's ei hth exper ence was fiv days later. She cont·nued with her conquest of the slide and "bowl, ,ut Houl not allow hersel to sl de into the 'b wl. 11 Her balance as od, her co r inat·on appeared sl·ghtly ·mproved ur·n feet correctly. walkin and crawlin o head nodd ng r . She made express ons of happiness . and she place her ody shak ng as noted. God motor plann n was evidence during the ninth sess·on as Mary systematically toured the unit, moved to ward objects, and used mouth and tact le exploration . Her movements aroun and on the slide, bowl and ath ay appeare well controlled and conf dent . She explored the felt-covered wall and handled a felt cut-out car . She walked up the sl·de an slid down it head first, landed on the pellet ba . A ain , she cr ·ed when taken out of the un t . 74 The very last ay for this sess on was very hot , but Mary increase her pe d of movement ! 0he continued to walk up the slide to therm of the "bowl" and 1 ·fte herself up onto the rim . She strained to keep from sl d n into the bottom and a pared fear ul . She backed out of it and onto the slide . Again she climbed nto the rim of the "bowl,' but this t me allowe herself to s1 · e down ward to the ott m ·t a reat deal of control . She er wled aroun the i nside and then returned to the or na pint of entry . Se alked around the 1 bowl 11 and up the stairs, lower · n herself into the "bo tl 11 again apparently enjoy n the o portunit to explore . Dur ng these ten sessions, Mary used her sense of direction inesthet c awareness, taste, actile sensat · on, temperature sens t supplement her oor v sion dur n explorat on fa novel resilient environment . She received mostly positive f eed back rom th s new structure, because she was able to ex- lore hei hts inclines ifferent shapes a~d s zes of objects and textures without harm to herself . If she fell or sl · pped, she did not ex erience pain , and even tually became confident enou h tor sk sl d n don the incl ne "bowl . " pparently, this ch ld was able to inte- rate sens ry nfor mation fairly well for ~he could differ entiate the ex er ences in the "Fun House" from the outs de . Shem ved caut ously over cement walks and hard surfaces and teste obje cts before cl·mbin , or han in onto them 75 for support. The "Fun House" type of exper ence may have helped her to sense new capab lities · n bod ly movements and coord nate these movements better. Her speed of move ment was good as well as her ability to motor plan. She did not exhib·t the "mannerisms" of body and head ·erk n an star n at bri g-ht l ht after the first week of the study. She used her hands well to touch and identify surfaces, lift her body 1ei ht, and help 11th locomot on over the unusual soft pathway. TABLE 1 Individual Report of MA.RY Teacher Observation Gross Motor Activity Date 1971 ENTRY STATE happy 4 interested 3 cries 2 non-aware 1 C~UNICATION gestures 4 uses expression 3 some eye contact 2 no eye contact 1 VERBALIZATION frequent vocal 4 imitates 3 infrequent vocal 2 cries 1 SdCIAL INTERACTION initiates 4 moderate 3 minimal 2 isolate 1 VERALL STATE layful, cooperative 4 nterest, participation 3 nhappy, aggressive 2 n on-aware 1 July Aug . N ..::t \0 °' r-1 rn \0 ro o C\J ..::t \0 r--i ,...; r-f r--i C\J C\J C\J C\J (Y) ...... ..... ...... ..... ..... .... ...... ...... .,,. .,, .,,. ...... ✓ ..,... ✓ ,,, ., ,,,. .,, .,, ✓ V .,, .,,. ,,, ...... ., .,,. .,,,,. ✓ . ff"" .,, ,,,, .,,,, ff"" .,,,, ,,,. ✓ ..... .,,,, ., ..-- ,,,, .,,,- .,, ..... ...- ..,. ..,. ..... - ______ n_a_t_e J uly A C\J ..::t \0 °' r-t ug • A CT IVITY lo H -t rl rl C1J ~~ ~ ~ C1J ~ '° Climb Slide W alk Crawl Sit Lie Fall 5 0 I I I ·· I I I I II 5 O 1 1 1 • • 1 r 1 1 1 1 .. , 1 1 11 5 Q I I I 11 1 J I I I I I I I II 5 0 5 0 5 0 5 0 ... rt__Jt ··· ... -l O'\ CHA RT 1 escriptive Chart of Progress ame: Marx Age: 30 mo. Diagnosis: Post Rubella Syndrome, deafness, visual loss. Dysfunction or Devel- Functional Ob.iective opmental Problem Delayed motor devel opment;severe hear ing and visual loss; ambulation poor, spastic toe walking Fear of injury from exploration;with draws from activi ties after contact with hard surface (falls or bumps) Self-stimulatory man nerisms;body jerking, head nodding, back arching, staring at light or sun. Improve locomotion Increase self-con fidence and ability to maneuver. Distin guish between safe, soft areas and dan gerous hard areas. Decrease or elimin ate self-stimulatory mannerisms. Sensori-motor Expe rience and Equip ment Utilized Pathway with poten tial for stimula tion of postural change ambulation on inclined planes, ramps. Crawl, climb, walk over uneven surfaces climbing on sides and slopes of bowl and high places and descend. Post Experience Behavior alks with one nand support heels down, less scissoring Climbing into and out of bowl. Exploring large areas of unit and school room. Provide challenge Integration of in- and interest to stim-formation for ulate gross motor more complex ac- -.J skills and integra- tivities and -.J tion of sensory motor planning information. goal oriented. 78 •valuat· n and Pro ress Report--Kay Kay was one of the oldest ch ldren n the study, be n three years and e ght months at t et me. She was mature in social development and speech, at a e for langu age, almost at a e for social devel pment (three years). She was not an independent walker ecause of her spast c lower limbs. She required sh rt le braces and a hand hold or support to am ulate. Kay also had a residual tonic neck reflex. It was noted that she res·sted chan e and 1 ked consistency in her aily routines. Goa s were to develop good reciprocal walkin patterns and improve alance. Her first experience in the "Fun House" was a pleasant one, as she entered happily and immed ately beca every act ve ·n exploration. lthough she did ask which irection she should go, she soon found her way nto the "rol ·n bowl." She and another ch 1, van, crawled around in the bowl for some t me. When she could not seem to get suffic ent traction with her feet to climb out of the bowl, she called for assistance. Th swasher usual way of askin adults for help w th phys cal activit es. When ignored by observers, she found her own way out of the owl at the stairs. 79 In succeed n experiences in the Thera- lay un t, ay commun cated well with the other ch ldren often d - rectin their pro ress t ward herself and ur n them on. She somet mes sat at the top of the stairs and acted as r,m stress of ceremonies'' for her roup. She continually urged one ch ld in lon -le races to crawl and to move. The two irls talked about the cenes on the walls and san sons to ether. She descr"bed her act~v ty to the teacher and ob servers w th ood evidence of motor planning. She followed a definite route along the pathway and ·nto the bowl each t·me. She experimented and succeeded with sli n, clim - in and div ng off the edge of the bowl. Each time she passed another ch ld she made comments or touched him. hen she was about to do somethin part c larly daring, she announce t sayin "Here I go again," or "Do you want to see me do it again?' "I'm oing to go n there. r, She pretended that the bowl was a pool, and dove into it. She was unhappy about having to leave the "Fun House." he cl mbed onto the ramp outside and stood up, then walked down the ramp sideways while holdin onto the outside wall of the unit. Initially she crawled around and explored more than she walked and often asked her teacher for ass stance, but none was iven She frequently described her act v - ties and followed defin te patterns in her use of the 80 e uipment. he was able to pull up on furn ture and qu p- ment and walk with support, but was not secure in doin so. The pathway and stairs provided much opportun ty for rac tice :n balance and ambulation. She became more conf· ent and spent more t me walk n and cru sin around the path way toward the end of the study. Sl d··ng d wn the slide head first required a good deal of courage for ay, but she tried it and succeedea. Her reflex dom nat on was evi ent here as her arms co lapsed when her hea was down n the land n pad. The CCS Scales evaluat on revealed she had a ne the a 1 ty to walk with one hand held, could neel without support, get to standin from a chair and from standi to chair wh le holdin. She was able to ba ance for a fev seconds on her crutches, but was not yet roficient in us ng them. It seemed that ay was pleased with the amount of phys cal activity she could mana e in the unit, because she moved more than she normally would n the school situ at ons. She became more independent because adults did not come to her rescue in the Thera-play unit. These chan es were later notice in the classroom also. Social Contacts She was noted to be able to tolerate close contact with her peers share w th them, and help them after th s ex erience . She appeare more elf-assured. TABLE 2 Individual Report of KAY Teacher Observation Gross Motor Activity Date 1971 July Aug. Date J uly Aug. C\J .:::t \.0 CJ\ r-f (Y) \.0 CO O C\J .:::t \0 C\J .:::t \0 CJ\ r-f (Y) \0 CO O C\J .:::t \0 ENTRY STATE ,-f ,-f r-f r-f (\J (\J (\J (\J (Y) ACTIVITY 10 lr-f -f r-f r-f (\J (\J (\J (\J (Y) I I I I I I I I I I I happy 4 V" ,r ...... ~ .,- .,... ,,,.. ...... interested 3 y" ~b - ~--······J cries 2 Climb non-aware 1 I I I t· '". I I CCMMUNICATION 5 _r--J ..... gestures 4 .,- Slide :. ... -· uses expression 3 ..... ...... .,.-, ...-- .,,,,. .,, ~ ..,,,.. 0 some eye contact 2 .. Jl, ........ ~ no eye contact 1 5 ---- VERBALIZATION !I W alk 0 I I I I I I I I I I I I frequent vocal 4 .,,- .,- .,_-, ~ ............ imitates 3 ~ ..... ~ 5 - - infrequent vocal 2 Crawl .... ri. .... .... cries 1 0 SOCIAL INTERACTION 5 rL initiates 4 ,r Sit moderate 3 ..... .,. y' 0 ... . ..... minimal 2 ....-- ..... ..... ...... V" isolate 1 11 I I I I I I I I I I I II 5 OVERALL STATE Lie playful, cooperative 4 ...... .,,. .,,,,. ..... ti" ,,,,. ,,, v" .,.... 0 II co interest, participation 3 t-J unhappy, aggressive 2 Fall 5 - non-aware 1 0 ~ ... ,-, Name: ay Dysfunction or Developmental Problem Limited concept of own physical ability. Too soon discour aged. t disadvantage in group situ ation, too slow, inability to maneuver quickly. Socially alert sought peer in teraction, but could not follow peers quickly (could not keep up with peers) . CHART 2 Descriptive Chart of ogress ge: 44 mo. Diagnosis: Spastic Diplegia, Cerebral Palsy J:i'unctional Ob.iective Gain positive con cept of self through physical achievements, new motor skills. Increase in speed of movement and alance. coordina tion. Socialization op portunity in con fined area with sufficient stimu lation and chal lenge for motor skills. Sensori-motor Experi ence and Equipment Utilized Practice balance and locomotion. Total unit utilized. Walk rapidly on path without fear of fall ing. Up and down stairs, dive off bowl, slide and balance. ntire unit-enclose path, central bowl slide. Use imaginary situations, invent ames to interact with others. Post Experience Behavior Bolder, new motor skills successful. Jump , walk climb quickly. Walk with crutches in therapy. Move rapidly on path and bowl . Retrace path each time. Mistress of ceremonies for group. Encourage peers to follow self singJ and talk to them. (X) f\) 83 ,valuation and Progress Report--Louise ou se made very slow pro ress n the Thera-play settin because of hr severe physical involvement. Sh was cerebral palsied c ·1ct w th spat c quadr pleg a who wore full on -le braces .. th a pelv c band. She wore the races all ay at scho 1 and ·nto the "Fun H use 11 because the therap·sts wanted her to learn to crawl n t em n t e correct manner. The braces helped to prevent contractures and ma ntain the correct posit on for locomo tion. ou·se id not seem to care whether she learned t use her new braces or not. She did not try to crawl in the classroom. Her usual technique was to dramatize her need to the adults and children around her in order to gain the·r assistance. She made little hys·cal effort toga n hero ·ect ves, but frequently verbal·zed her needs. Her functional o iective was to be n reciproca era, lin n the unit. Louise was first placed ·n the Thera-play unit w·th two rather quiet boys (Jerry and Gary) who c uld walk with fair balance. She had anticipated the experience and entered with a happy smile. Dur n the first half of her visit ouise made good progres draggin her body with her arms, and ettin up on her knees at t mes to balance. She then tired of try ng to follow the more act ve boys 84 and be an to examine the scen·c walls. Apparently dis couraged, she crie and wh mpered, then ucked her thumb. One of the oys who could not a just to new exper ences without anx ety cried most of the time durin the f~rst session. Durin successive experimental per·ods n the unit, ou se was reatly affected by the personalty of the children n her group. If she was placed in the unit iith a very anx·ous tearful child who was passive, s e d d little except look at the adult observers and her teacher, sometimes verbalized to them and kept eye contact. If she had the company of a spir ted, happy child who talked or sang to her, Louise managed to cover the distance y crawl- ng r dragging her body. She enjoyed the soc al exc an e and concentrated her efforts on reaching the other ch ld at the top of the stairs. Sometimes she noticed the ob servers and sm led at them. As she progressed throu h the un t, she observed the animals on the ~alls and touch d them. Sometimes she called out II o, go!n Her motivation to move appeared to be furnished y her need for adult an peer approval and contact and her natural curiosity . She apparent y received reinforcement from the eedback ohe rece ve from the tact le exper ences, and positions she assumed on the soft pathway. When asked to leave the un t she was able to turn and crawl out to the teacher . 85 On the days she was in the unit with her fr end, Kay, she was reluctant to leave the un.it . She rolled away from the teacher and tried to rema n there . When she left she sad, 11 G odbye house" as if the unit were anent ty. An asses ment of the ross motor skills efore and after the exper ence revealed that ouise had developed the ability to do rec pr cal crawlin dur n the experi ment in the Thera-play unit. This ability had een main tained three months after the exper·ment. Louise cont n ued to have post ve ee ins about her abil ty to move in races, and more enthusiasm or new activit es such as push·n a dol carr age 1hile alkin. --- TABLE 3 Individual Report of ours Teacher Observation Date 1971 July Aug. C\I .::t \0 0\ r-1 rn \0 CO O C\J .::t \0 ENTRY STATE r-1 r-1 r-1 r-1 (\J (\J (\J (\J (Y) I ACTIVITY I happy 4 ~ .,,,. ...... interested 3 ,,,,,- ,,,,,- .,... .,... .,... .,... cries 2 .,... Climb non-aware 1 COOMUNICATION gestures 4 Slide uses expression 3 ,,,,, .,... ,,,,, ., ...... ., ...... some eye contact 2 ,,,,, ., no eye contact 1 .,... , I I I I I II VERBALIZATION I H W alk frequent vocal 4 I II .,,,. .,,,. ._.- imitates 3 .,,,. infrequent vocal 2 ., ,,,,,- ...... ., Crawl cries 1 ,,,,,- ...... SOCIAL INTERACTION initiates 4 Sit moderate 3 minimal 2 .,,,. ...... .,... ..... ..... ...... ..... isolate 1 ....- ~ ..... OVERALL STATE Lie playful, cooperative 4 .,,,. ..... ..,. ...... interest, participation 3 .,... .,,,. .,,,. .,,,. ...... .,... unhappy, aggressive 2 Fall non-aware 1 Gross Motor Activity Date J uly Aug. C\J .::t \0 0\ r-1 rn \D CO O C\J .::t \D 10 I r-1 --i r-1 r-1 (\J (\J (\J (\J (Y) I I I I I I I I I I I 5 -'- - 0 t·I rfl I I I I I I I .... 5 0 I"" I , 1 I I I I I I ,,~ 5 - 0 I I •• I I I I I I I t t 1· •• 5 - 0 1 ... [kJ d I I I I , .. ._ 5 - 0 1-··-~ I r. , ... 5 - L 0 11 8; 5 0 I, .. ·• I I • I t I I ~~_ .,.._ CHART 3 Descriptive Chart of Progress Name : Louise Age : 34 mo . Diagnosis: Cerebral Palsy, spastic quadriplegia Dysfunction of Devel opmental Problem Unable to crawl in full long leg braces with pelvic band kneeling balance poor . Slow movin Unable to pull up to stand . Functional Objective Initiate reciprocal crawling. practice. Practice kneeling . Increase speed of movement. Pull up to cruise in walking. Sensori-motor Expe rience and Equipment Utilized Pathway of unit with ower inclines at eginning of patu. Stairs Contact witn peers Challenge to imi tate and follow along path visual stimulation of murals on walls . Touching walls gives contrast in textures . Sides of central bowl and pathway . Post Experience ehavior First dragging body 11 combat crawl . " Progres sed to reciprocal crawl . W ith practice, in creased speed of movement continued reciprocal crawling in classroom, gain in confidence . Stands in braces pushes doll carriage neels with minimal support . co -:J 88 valuation and rogress eport--Evan Initial evaluation of van at 25 mont s revealed a d a nosis of upper motor neuron lesion with m ld spastic quadriplegia ross motor a e of 21 months. His main prob em was forefoot adduction and val us deformity of the knees. He was able to walk with short le braces and one hand on support. van was a bright, playful child who sed syllables ands me words, but ha delay in speech development and difficulty relatin to his peers and adults. Goals were improvement in mob·11ty, balance, social contacts, and speech dur n the exper ence in the 11 un House." •van entere the "Fun House" happily the very irst time with a very sociable 1 ttle three-year-al rl, ay, and a rather shy insecure three-year old boy, David. Durin th s first exploration of the un t, van d splayed great ·nterest in utilizing all the equipment while he laug ed and babbled in exc·tement. He noticed the other children wh le he crawle in and out of the "bowl" and the pathway and made overtures to them. He did not hesi tate to explore every part of the unit and had no iffi- c ulty walkin while holdin e ther the rim of the "bowl" or the wall. He seemed not to not ce the walls or the sensory murals on them but en a ed n some interact on with his peers. 9 •van's conduct cont nued to become bol er each time he entered the "Fun House . " He and the irl sat on the rim of the 11 bowl 11 and then dove off onto the pathway elow. They enjoyed nteractin w th each other and the r exc tement appeared to be commun cated . The th rd child in their group watched from a distance, but d d not join in the action. During the th rd session n the unit with Jerry, an ataxic ch ld, van demonstrated ood motor plann ng and asp· rit of helpfulness toward h s compan on. Jerry tried repeatedly to find an easy access to climb nto the bowl with van. Jhen van noticed this, he quickly craw ed across the bowl and stretched his hands out to Jerry. The air exchang d glances as Jerry cl·m ed ver therm of the bowl while holding onto van. They then began to climb around ·n the bowl while squealing jub lantly. While laughing, Evan climbed out of the "bowl," down the stairs and then returned to invest gate his com panion's activity. The two had a wrestling match as van attempted to remove Jerry's helmet wh le they were both in the "bowl." •van went quickly down the slide, head first, u led a felt cut-out car off the felt wall and threw it to Jerry in the "bowl . " There was much verbal zat on be teen the two as they described the r act v ty . van used s n le words with an occas ·onal par n of iords, such as "o up . 11 This conversat on was noted by the teacher who 90 had not observed th·s amount of verba ization from Evan in the classroom, previously. On his fourth visit to the "Fun House," Evan con t:nued to walk around the un t, but as he did so, he noticed the walls. For the f rst time, he touched the soft fur of a lamb on the ~all. He cont nued to be very active n crawl ng, slid"n, and walk ng over the pathways, down the slide and sta·rs and ·ns de and around the "bowl." He held the hand of h s friend affectionately, pulled h·s helmet of, and tried to put it on h sown head. Many words of speech were noted y the teacher. He used words appropr ately to describe h s act ons and repeated numbers which he ha heard called by the timer. As the visits continued, Evan and erry sometimes wrestled with each other as f for possession of the bowl. Then Evan would go down the sli e and rin the felt cut out cars from the wall to Jerry. van's progress continued as he mastered his balance and m vements in the 'bowl." He concentrated on the slide and the stairs until he was proficient in the use of each different type of equipment. He became bolder in h s physical activ ty as well as his approach to other chil dren. He made overtures to a child who did not move or nteract durin her nfrequent visits to the "Fun House . ' At times his h h spirit and activ ty carried over to the play yard after the "Fun House" sessions 91 Evan's progress from simple activities to more com plex act vities nvolvin other children and motor plannin was very evident. He sustained h s nterest in the "Fun Housen to the last sess on, and even built his own "Fun House" at home usin p 1 ows and cushions. His speech pro ressed to the use of two-word comb nations, such as "too hi h," "big day," and "my turn." Socially, he became more alert and nterested in nteract n w· th other ch·l- ren and often initiated play. His parents reported he used furniture and toys with more ease and conf ence than prev ously. The amount of body awareness and self-concept improvement is difficult to measure n a two-year-old boy, but he di seem to exhibit more confidence in handling himself on equipment, climbing, tumbling, and n general, physical act v·ty. Gross motor development dur n ·nitial test n showed a lack of backward parachute. At final assessment, van had eveloped a backward parachute re sponse on the r ght side. Since his left side was more involved with spasticity than the right, it was expected that the reactions on the ri ht s de would develop first. Durin the stu y, he d not gain on the CCS Scales of motor development but a proximately six ve ks after the exper mental sessions, Evan was walkin unassisted. TABLE 4 Individual Report of EVAN Teacher Observation Gross Motor Activity Date 1971 ENTRY STATE happy 4 interested 3 cries 2 non-aware 1 CavtMUNICATION gestures 4 uses expression 3 some eye contact 2 no eye contact 1 VERBALIZATION frequent vocal 4 imitates 3 infrequent vocal 2 cries 1 SOCIAL INTERACTION initiates 4 moderate 3 minimal 2 isolate 1 OVERALL STATE playful, cooperative 4 interest, participation 3 unhappy, aggressive 2 '.'lon-aware 1 July Aug. C\J ..:::t \.0 0\ rl ('() \.0 CX) 0 C\J .:::t \0 rl rl rl rl (\J (\J (\J (\J ('() V"" ..., ..... ~ v- ...... ...... V" ..... ..... ...... .,,,,, V"' ...... ti' V"" ..... ...... ...... ..... ...... ~ .,,.. ~ ..... ..... ..... ...... ...... y'" ....... ~ ~ ..... y"' ..,,.. ~ ....- .,..... ....... ,,, ..... V" ...... y ...... .,.., ...... ...... .,.,.. ..... ..... ,,,.- ,,,,_ ,,,,,.. ..... ..... ...... .,_.. ...... Date J uly Aug. _________ C\J.:::t\.00\rl('()\.OCX)OC\J.:::t\.O l O I rl . --1 r-t rl C\J C\J C\J C\J ('() ACTIVITY Climb Slide W alk Crawl Sit Lie Fall 5 0 I I I I I I I I I I I I II 5 0 I I I I I I I I I I I I II 5 0 5 0 5 0 5 0 5 0 \.0 f\) 93 valuation and rogress Report--Jerry Jerry's problems were severe distal and proximal ataxia, intent on tremor, dysmetria w th moderate hyper reflexia, an spastic lower extremLties. His balance an equilibr um reactions were present but slow to react. At the time of the study, his a e was three years and four months. He had a rather calm and pers stent attitude about h s hysical ct vities. Once he started an activit~ he ou d pers st even thou h he mi ht be left beh nd by the others in his peer group who were more agile and mobile. Goals were to mprove balance, increase speed, and mprove ody ·mage. In the unit, is slow aced" not prevent his match ing physical skills an remain n n close ran e with the children in h s rou. He could focus his attention on the other children at play. In the Thera-play un the was on more of an equal footing with h speer group. The circular design of the unit and the central bowl structure seemed to draw the children to ether for roup nteraction. Jerry seemed happy to try out new cl robing and tumbling skills not possible on hard surfaces of the ordinary play round. He had frequent eye contact and commun cat on with Evan at times verbaliz n w th h m and int atin pos tive play. The two ch ldren touched each other an wre tled n 94 the rollin bowl area . His usual d sadvantages of slow ness of movement and tremors were minimized in the con fined area with the resilient surfaces . He could see the other children from any point n the unit and mingle with them in the central rolling bowl area or on the pathways . His attent on seemed to focus on go np up and down the stairs and tumbling in the rolling bowl. He also practiced balancing in the kneeling position on the rim of the bowl and standing at the top of the stairs. Good motor plannin was exhibited as he at first fell on the stairs, then in success ve times, tested his hand-holds for firmness and placed his body in more stable positions to prevent fall ing. He announced his plans at times, saying, "I'm sitting on the edge now, 11 or "I'm going 0ut now." He pract ced falling inside the bowl, letting himself fall backward purposefully. At times, he started to fall, caught himself and recovered his balance by leaning forward and catching hold of the rim of the rolling bowl. He practiced balance many times while walk ng over the varying levels and inclines of the pathways. After the 11 Fun House 11 experience, Jerry sometimes exhibited his typical unsteady gait, and at other times stood up unassisted and walked a few steps independently . His confidence and body image may have improved so that he sometimes became more daring after the experience in the Thera-play unit . Stimulation of the Structures in the Thera-play Unit 95 As he became familiar w th the var ous ieces of equ pment and structures in the unit, Jerry was able to ncrease the peed of m vement. He was constant y stimu late by the chan ing leve sand incl·nes of the structures and seemed to want to move more qu· ckly and conf. dently. H·s peers also increased h s motivati n to move and explore the areas at times. The sl·de was one structure which he esitated to use with confi ence. H"s compan ons dis covered and d monstrated many different V,ays to use the s1· e but Jerry stopped at that po nt. Goo concentrat on for ptimum f ot placement was necessary or balance. If his foot was on the edge he wobbled. He always held onto the wall or the rim of the bowl when alking up and down th stairs. Interest He maintained his sustained interest ·n the un t after the practice period was over. He moved away from the teacher, laughed, and said "no" when she called him to c~me out. He made a game f avoidin her as she attempted to take h m out of the unit. The ornamentat on and textures on the walls did not seem to interest Jerry, as he used the walls for support and seemed en rossed in th ross motor sk 11 tasks. 96 Comparison wt is revious CCS Scales evaluat on revea d few chan es ·n gr ss motor development. Jerry was able to walk unsteadily and slo ly w th quad canes prior to this stu y. After the study, he could walk a out 12 steps w·thout the qua canes or assistance. Also, e was able to walk backwards a few steps. His a ility to stand on one foot for one second remained the same. 'qu librium responses were sl htly ·mproved, w th a more rapid consistent and skilled backward extension of his arms. The most noticeable re ponse since the experience in the Thera- lay unit a pears to be ·ncreased self concept because of his ab.lity t keep pace w·th the more a ile ch.ldren. TABLE 5 Individual Report of JERRY Teacher Observation Gross Motor Activity Date 1971 ENTRY STATE happy 4 interested 3 cries 2 non-aware 1 C~UNICATION gestures 4 uses expression 3 some eye contact 2 no eye contact 1 VERBALIZATION frequent vocal 4 imitates 3 infrequent vocal 2 cries 1 OCIAL INTERACTION nitiates 4 m oderate 3 inimal 2 solate 1 :>VERALL STATE playful, cooperative 4 interest, participation 3 IDhappy, aggressive 2 ~on-aware 1 July Aug. C\J ..:::t \.0 CJ'\ r-i (Y) \.0 CO O C\J ..:::t \.0 ,-; ,-; ,-t ,-t (\J (\J (\J (\J (Y) ti' ,,,,. ,,,,,. ..... ,,,,. ,,,,. ,,,,,. .... ,,,,,. ,,,,. .,,,. ,,,,. y"' y"' ,,,,. ., ..... .,,,. y"' ,,,,. ..... ,,,,. ..... ...... ..... ...... ..... ...... ,,,,. .,... ,,,,. ,,,,. " ..... ..... ...... ,,,,,. ,,,,. .,.. y" ,,,,,. .,, ti' .,,,,. V"' .,,,,,, ...... .,.. ,,,,,. ...... ,,,,,. ..... ,,,,. .,,,,,, ...... - _____ n_a_t_e July A C\J ..:::t \.0 °' ug • A CT IVITY lO I ri ----1 M rl ~ ~ '£ ~ ~ C1J .::t \0 Climb Slide Walk Crawl Sit Lie Fall 5 0 I I I I I I I I l···I I f 11 5 0 W 11 I ti 11111 II 5 0 5 0 5 0 5 0 5 0 \.0 ~ 98 valuation and Progress Report--Kari This cerebral alsied child had severe dy function of her total body with spastic·ty an menta retardation. She was at the seven months' level of ross motor develop ment. She c uld use her arms to dra her body combat style, ut needed t be hi hly motivated or assisted in order to o so. She had 1 er siblings and par nts who could anticipate her nee s. Therefore, she was very sl w t react to new situations, or try to move. ne motor sk lls were slightly better, for she could feed hersel and reach, rasp, and release purposefully. Goals were reciprocal crawl ng, improved ody ma e, and balance. ar was severely limited hys cally and also had early behavior or affect pr blems. She used speech spar- ngly and only spoke wen she felt secure with the teacher in her classr om. In the "Fun House," Kari d d not feel secure. She attended ·nrreq ently for a total of only five periods of 10 minutes each. During her short inter vals in the "Fun House," she to erated other ch ldren mov ing arourd and over her w thout crying exce t for one t me. Her efense against threaten ng or news tuations ,as t remain st 11 and quiet. lthough she could ver alize, she id not take the opportunity to do so with the other chil dren or her teacher in the "Fun House . " ~he watched the children and rema ned ·n her ori ·nal pos·t on, ether n 99 all fours or prone durin her v sits to the "Fun House . " At times she smiled at th children . The observers who look dover the walls were stran ers to her . Perhaps th · s made her feel insecure so that she immobil · zed herself to avoid any and all contacts . She did not attempt to touch or speak to any of her peer roup . Gross Motor Development At the end f the experimental testin sessi ns, she had egun to creep reciprocally and to learn sides tting . This might be attr·bute to her physical therapy treatments since she d not try t creep in the 11 un House . " It appeared that Kari neede a seres of sustained and frequent visits to the "Fun House' to utilize it for socialization with peer group or ross motor development. ~ Teacher Observation TABLE 6 Individual Report of KARI Date 1971 July Aug. Gross Motor Activity Date July Aug. ---------------C\J~~mr-f~~OOON~~ _________ C\J~~mr-f~~OOON~~ I ,-; -i r-f r-f N C\J C\J N ~ ENTRY STATE happy interested cries non-aware C<Jv1MUNICATION gestures uses expression some eye contact no eye contact VERBALIZATION frequent vocal imitates infrequent vocal cries SOCIAL INTERACTION initiates moderate minimal isolate OVERALL STATE playful, cooperative interest, participation unhappy, aggressive non-aware ,-; ,-; ,-; r-f C\J .C\J (\J (\J ~ i I I I I I I 1 .-1 1~1 1--Lr 1 4 H I I I I I I I I I I I II 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 ,,,, ..... ,,,, ..... .,..-1 I it""I 1 .,......1 ~ .,......, lv"I 1...-1--' ...... .,.... .,,,, .,.. ACTIVITY Climb Slide Walk Crawl Sit Lie Fall 10 1 1 1 1 1 , t I 1 1 I 5 -+ Q 1·~·1···1···1· .. l·"I·· I 5 + 0 j·· ·t···t .. ·1···1···1,,,1 1'"'1 I 5 + Q I'· ·1· · ., .. ,1 ... , ... , ••• I 5 - 0 I· .. 1 •• • 1 .. • I .. ·1 ... I • ., I 5 -+ -- 0 • • •J • • • l • - ~--~_a-~~~-!.-~ J • --• • 1-1 • • • I I ,,_ 5 -+ ............ 0 5 - 0 ~._.1 •• u......__tlPtt&t••S••·· I I I ·~- - -1~'!L~•I ... • 1. • • .Lu.-----i......_~~ I 1 , ---...--- ~----. ---1. ••• . . • . !-J 0 ... o valuation and Pro ress Report--Geor e Geor e was one of the atyp cal ch ldren who had ·mpa·red a areness because of Mobius Syndrome . He w a s 01 su ·ect to involuntary patterns of movement and visual problems . He was often unable to coord nate fine move ment in his hands wit his eyes . He was unable to comrnun - cate except to show displeasure by making utteral sounds . It as ·s ha it to 11 fall asleep" ,;hen he a·a not wish to part·c pate in an activity at sc ool . His attent on span was very short . George was at the 11-month gross motor s i 1 a e . At times, he preferred self-st·mulatory manner- sms such as wav·ng his hands in front of his face . Be cause he could crawl wit slight assistance in head con trol, it was hope that the un t would stimulate him to greater mob lity, such as rec procal creepin _ and rolling. During hio infrequent visits to the un·t, Geor e was usually propped up against the side of the bowl so that he mi ht observe better . Since he was unable to crawl unle s someone ui ed his head and encouraged him, he i not attempt to crawl n the unit . He had a tendency to hyper extend his le sand back in a standin position . Occasion ally, he stared at the observers or walls . He was able to tw st h s ody around to look at the wall beh nd him . He wa observed to move h s hands over the surface of the bowl directly · n front of him . 102 At the beg nn n of the last session, Geor e was placed in a sittin position. He attempted to move nto a crawl n position but could not flex his legs suff c - ently. He did move sli htly as f to peer at the walls which were bri htly colored. When the other children touched h m he di not seem to notice, unless it was deep pressure. He expressed little emotion, except to rowl or whine occas anally. When instructed to move out of the unit at the end f the session, he attempted to move but could n t coordinate his efforts. Observations of Ge rge in the unit were not very conclusive. Snee he remained very passive the major_ty of the t·me, twas diff cult to assess what he could ass mil te of the environment. His infrequent visits, because of a1 s nces from school, contr buted to the lack of continuity in his experience. erhaps he attempted to look at the observers and walls with fair concentration at times . He was able to express d spleasure if someone bumped him accidentally. After the exper·ence, he had ma e little change. When tested, he was able to creep three to four feet without ass stance. H s severe defi cits in integrat on of sensory st mulation appeared to contribute to h slack of interest and uccess n the u t. --- Teacher Observation Date 1971 TABLE 7 I ndividual Report of GEORGE J uly Aug4 Gross Motor Activity Date J uly Aug. ----------------N~~ffir-f~~OOON~~ _________ N~~ffir-f~~OOON~~ l r-f -i r-f r-f N N N N ~ ENTRY STATE happy interested cries non-aware Ccr.1MUNICATION gestures uses expression some eye contact no eye contact VERBALIZATION frequent vocal imitates infrequent vocal cries SOCIAL INTERACTION initiates moderate minimal isolate OVERALL STATE playful, cooperative interest, participation unhappy, aggressive non-aware r-fr-fr-f r-fNNNN~ ~ I I I I I I I I I 11 1 ., 1' ✓ 1 I I I 1✓ 1.,,1 I I I 1✓ 1.,1 I 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 vlv' ✓ .,, ✓ I✓ .,,. .,,, .,,, ..,,, I✓ .,,,,, v ...,...l✓ I✓ .,, .,...,.,,.,, V I..., v-,.., ACTIVITY Climb Slide W alk Crawl Sit Lie Fall 10 1 t 1 1 1 , 1 I 1 1 I 5 - . 0 , .. ··1, ... , .. · ........... •-1~--~ l l 5 -+- 0 , ... i .... , ... ~-~1 •• ··1 , .... , ... ·1 I I 5 -+ 0 _i._._._,hu _ _...__._.. ;,., •I I'•·~•~· -r 1 5 - . •• ·..l..!.•. 0 1• •••t••••k• • I I - 5 -+ ,- I a • ·• ■■ I■■ ■ ---~ I • I I ••• I• I I I I I I , • l ,_._,__L_.__, #..!__t: .......... ~~-•_.1___!._~~t l I ~ ---. 0 5 - 0 5 - 0 _t_~.1~.• ••••• D I ••• ........._ _ •• _•l~--~ " . 1-l 0 w 104 1 valuation and Pro ress eport-- enn u ennis was a three -year-old, oy w th spastic d - ple ia secondary t cerebral alsy . Denn · s had made eood pro r ss w th his motor development for he wa sl htly advanced at the three and a hal year level of perform ance . His greatest phys cal problems were clums ·ness and exaggerated flex on of his lower extrem es while alk n . He often reacted to playroom situations in an ·mmature manner . ew situat·on seemed to upset h m, and he balked ~hen asked to partic·pate in act·v·ties. Someti es he wa happy and playful an at ther time he a phys·cally ag ressive and moody . H s lan ua e and mental development were at age evel . During hi v sits to the unit Dennis was accom panie by t~o boys ho had behavioral problems--Shawn and Joseph . The fir t time Denn s came to the un·t, he was reluctant to initiate any activ ty wit them . He remai ed at the same area by the felt board during the entire time, playin by himself, sin ·ng and talking . He seemed not to not· ce the others except when another ch ld wanted to play w th the felt cut-out cars, then he hit the child . Joseph let the area to sit by his teacher . Shawn reaa ·1y ex- plored the ent re un · t at times not cin Denn but not interact n w th him . 105 On the next v · s · t to the "Fun House, 11 Denn· s was in a playfu mood. He moved rapidly through the entire un·t and entered the bowl area w·th great speed. He described his actions: "It's on to be my turn; I'm on to et ·n here. 11 Th n, about to d ve of the ed e of the bowl he announced, "Wow, look at me; I ly 1·ke a b 0 rd.n ach time he maneuvered himself on the equ pment, he seemed to gain better control. Shawn followed him nto the bowl. Son Joseph also entered and all three boys rolled around in the bowl together. This was the first time ·n the bo 1 for all oft e boys. At the close of the sess·on, Dennis did not want to leave the unit, so he teased the teacher. Denn s attended the sessions :nfrequently and thus did not have the same opportunity as the others to practice in the unit. On his th rd visit to the unit, Dennis was in an aggressive mood. He called out to the o servers, "stop looking at me." He was sl ghtly upset during the fir t minute or so. (The previous day he had received medical treatment which may have affected his balance s1· htly.) Shawn pushe him out of the bowl and then watched h m for reactions. Dennis jected but discovered he could eas ly climb ack nto the bowl. He centered his attention on the other child Joseph and talked to him. The next visits were posit ve ones for Dennis assumed the role of eader with Joseph and teven happily 106 him tr uh the unit. As Dennis went don the oli e, others followed. He described what he saw on the walls and h w he fe t to the other ch"ldren. Sha~n repeated some f h"s phrases. At time, Denn s ordered the other boys to be quiet, but he was not phys·cally a resu ve. When hawn tried to push h"m, Denn s kept his balance an told Shain to stop. AlthouJh Shawn attempted t provoke hims veral t mes enn s was able to i nore him or tell him to cea e. The teacher su e ted that Dennis had a·ned n e f-contro and ability to initiate posit ve play from his xperiences in the unit. He ut lized his very ima i native vocabulary to describe h"s reactions to the unit ad to nteract with the other children. Prior to the study, Dennis was advanced in motor development. On the CCS Scales he d d ot show any change. He attended only five sessions during the four eeks. The therapists rated his balance and coordinat·on in the unit as sli htly improved, with a good body irna e. TABLE 8 Individual Report of DENNIS Teacher Observation Date ENTRY STATE happy interested cries non-aware CCXvlMUNICATION gestures uses expression some eye contact no eye contact V m m 0 p ERBALIZATION requent vocal mitates nfrequent vocal ries OCIAL INTERACTION nitiates oderate inimal solate ERALL STATE ayful, cooperative 1971 terest, participation un n happy, aggressive n-aware 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 J uly Aug. C\J ..:::t \.0 0\ r-f (Y) \.0 CO O C\J ..:::t \.0 rl rl r-f rl (\J (\J (\J (\J (Y) ACTIVITY ...... ___.. ...... .,,,,. .,,,,. Climb ..... .,,,,. ..... .,,,,. Slide ..... Walk ,,,,,, ..... .,,,,. .,,,,. .,, Crawl .,,,,.. .,,,,.. Sit ...... .,,,,.. ,,, Lie ..... .,,,,.. .,,,,.. ..... .,,, Fall Gross Motor Activity Date J uly Aug. C\J ..:::t \.0 0\ rl (Y) \.0 CO O C\J ..:::t \.0 10 I rl. -, rl rl (\J (\J (\J (\J (Y) I 5 r ... n ... ...... ... n···-··· 0 5 t .--, ... r···1 ···-· .. 0 5 T r,. r-··· ... .-. ... r·· 0 I r-···-, . . . ···- ... . 5 0 I 5 t I r···1 __,... ···-··· 0 I 5 i ---··· r···n···-···· 0 I-' 0 5 1 r···ri .... - .. ·-····~ ---:J 0 108 1 valuation an ro r ess Report - -Shawn This nterest ng little boy wa placed n the sp - c · a1 nursery school because of emotional problem an de icits in recept ve and expressive speech as well as tendency toward physical ag ression or mal · ciousness with peers. At t·mes he preferred solitary play and repeti t · on of same activity rather than mix w th his peers in school . He seldom played with others and used a ressive phys cal action~ when he wanted others to pay attent·on him. He usually pushed or struck other ch ldren to et a reaction from he ch ld or adult. e~ s·tuations were upsettin to him and he neede to be told in advance about any change ·n activity . He enjoyed order and sameness in his activity . One possi le contribut n actor n his ehavior was early emotional depr·vation . It was expected that the enclosed un t NOUl offer Shawn an opportunity to observe and interact with his peers in a positive way . Shawn's first experience in the unit was fairly positive . He was with two boys who were also ambulatory; one child with cerebral palsy affectin his le s was also phys·cally ag ressive . The other child was shy and imma ture socially with an atax · c ait . The sen ory murals appeared tog ve him the reate t sat · sraction, for he 109 alke throu h the un · t lowly, xamin ng and touchin the walls many t mes . He njoyed slidin down th slide , then removed the felt cut-out cars from the felt wall . Soc ·a1 interaction was limited to an accidental t uchin of an other child and infrequent eye contact . Shawn appeared to enj y the next sess · on since he smiled and hummed as he walked or moved in the unit . There as occasional gestur ng or pantomime with his peer and mo erate interaction ,h e using the felt board . Several words were heard as he observed the walls or not·ced the other children and the observers . Each time the "Fun House 11 ex erience Nas offere, Sha,n entere happily an retained his nterest in ex loration as well as observa tion of the other childr n. urin his fourth visit to the unit, Shawn dis covered the c ntral bowl ar a. Every possiole physical activity he tried, as he rolled, c imbed, jumped, and mingled ith the oth r childre in the bo,l . He was extremely active in exploring ways to use the central bowl an slide area . He touc ed the other ch lciren many t mes as well as pushed one ch "ld over the rim of the bowl . lthou h he pushe his playmate over the edge of the bowl, he did not succeed ·n elicit n a react on from any adults, and the other child was surprised to feel the res lient sur ace upon landin . Then xt attempt to push a ch ld w a s w·th an a ressive ch "ld who was s ·ttin n the rim 110 of the owl . He pushed rather 1 htly, the child held fast, and the teacher 1ho sat in the background rema ned calm. When he received no reaction from the other ch·1a or teacher, and heard no cries, he ceased the attempts to be a ressive. Several times he made loud noises. He seemed happy to have other children notice him in the central bowl. They rolle over one another and touched ach other several time. As their visits continued, Shawn ecame ncreasin ly aware of the other children ·n his roup. H frequently repeated descriptive ords which were used by the other children to describe the all murals He mimicke one active child and follo·•1ed h m around the unit, an down the sll e. On one occasion, he and the rather shy ataxic oy were alone in the unit. contact 11th this child Sha1n was v ry interested in and attempted to push h m. The other boy cried and told him to sto. Shawn smiled at this, but di not bother the child after that. He became very active in jumpin, mov·n quickly over the edge of the bowl and somersaulting. Previously, Shawn had a tendency to remove h mself from situat ons in which he was not the a ressor . He sel o spoke unless in a one-to-one situation w th his therap·st . During the experiences n the Thera-play un t 1 Shawn •1as not under pressure fr m adults as he was not corrected for his physical a gressiveness when it occurred. H appeared to f nd great stimulat on from the hysical activities in the un t and the contact vith the other children. The freedom to control his actions without adult intervention may have given him a sense of omni potence. His actions with the other children became more positive as he exchanJe lances, jo·ned them in play an imitat d their talk. s the amount of ver al·zat·on in- creased, so did th interaction and socialization. ·1 th time Shawn a·a not feel the need to attract other ch·l ren by bein physically ag ressive. His communication b gestures, eye contact, an s eech appeared to increase. After th wnmer se s·on at the cerebral palsy pre-nursery school Shawn was laced ·n a regular school or normal children. TABLE 9 Individual Report of SHAWN Teacher Observation Gross Motor Activity Date ENTRY STATE happy interested cries non-aware Caw1MUNICATION gestures uses expression some eye contact no eye contact VERBALIZATION frequent vocal imitates infrequent vocal cries m m p OCIAL INTERACTION nitiates oderate inimal solate ERALL STATE ayful, cooperative 1971 terest, participation un n happy, n-aware aggressive 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 J uly Aug . C\I ~ \.0 0\ r--i (Y) \.0 a) 0 C\l ..::j- \0 rl rl rl rl C\I (\J (\J C\I (Y) ,,,,, .,,, .., ✓ .,,, ✓ ✓ .,,, .,,, ,,,, ..... ,,,,,. ..,.. .,, v" .,,, .,,, ✓ .,, ti" .,, v' ,,,, ..... .,, ,,,,, ....... ..... ✓ ,,,, ...... ..... .,,,,- ..... .... ,,,, ,,,, ,,,, ,,,, ,,,, ~ .... ..,,,. ,,,, ...... ,,,,,. ,,,,,. ,,,,,. ,,,,,. ,,,, Date July Aug. _________ C\l~\.00\rl(Y)\.OCDOC\l..:::t\.O 1 O . rl. -; rl rl N N N N (Y) ACTIVITY Climb Slide Walk Crawl Sit Lie Fall 5 0 I I I I I I I I I I I I II 5 Q I I I I I J J I I I I I II 5 Q I I I I I I I I I I I I 11 5 0 5 0 5 0 5 0 f-J f-J I\) 13 ◄valuation and rogress leport--Joseph Joseph was one of twins, oth of whom were delaye in development, secondary to prematurity . Althou h Joseph appeared to be funct·oning fairly well at the three-year ol level n motor activities he did not relate well to others and was considered to have moderate to sev re psy chomotor retar ation. t three years of a,e, he could perform most gross motor ski ls forth.sage, but he had po r balance, walked with a slightly atax·c ait, fe 1 frequ ntly. Socially he was quite immature . If e made ov rtures to the other chil ren, ·twas usually in a nega tive manner . He usually preferred t play with the same toy ay after day was fasc·nated w th flowers, bus, and vehicles . Joseph was a , 1 to use language to ex ress his needs but not to ·nteract with other children . The functional bjectives were ·ncreased balance an bo awareness, improvement n social nteraction, and langua e use . Joseph was rather impatient durin his first visit to the unit . He explored the pathway rather quickly, d d not enter the bowl . He imitated the two other boys , Shawn and Dennis, by throwin cut-out cars into the bowl . His companions were both rather a ressive and a ile in mov ng aroun the pathway and into the owl . Jo eph did not 114 appear overly ·nterested in h s new surround n, an u ht cm art from hi teach r wh sat ·n the fore~roun near the entrance to the unit. He )Ushed the curta·ns es de the unit as settle down ession. f to leave, and cr·ed t o out. Then, he es· eh teacher t wa·t fr the end of the Durin the cceedin vis t Jo~e he ther follo ed the other boys ar und the unit and mitated them, or looke at ·s teacher and the flowers near the entrance. Whether he en·oyed h s v sit r was rea y to nteract th h s c mpani ns depended upon h·s mod prior to on in o the un t. At times he was not ready to make the tran tion from the classroom to the" un Hou e "and merely toler ated vhe ex er·· ence. The first four v s · ts oseph d · not try to cl"mb nto the cent al bowl, al hou h he could have one so easily. He walke around and somet mes looke at the observers or thew the cut-out car to them. Flowers an him. Josep insects near the entrance seemed to fascinate abbled r talke frequently at times w·th goo imaginat· n. Dur·n h s fifth visit to the unit Dennis, Joseph a·scovered he coul :ump central b w and turn somersaults ·nit. ith Shawn and n ad ut of the He seemed to b n a more relaxed and happy m • Dennis and Shawn were oth p ysically a resslve chil ren, and when al thr e 11? boy wer in the bo 1 to ether, they rolle on top o each other an Sawn pu 0 he Joseph over th rim of the bow. Althou h Jooeph cried r·efly and went to h·s t acher, he returned to the bowl to cont nue play ne. He a lowed h m self to be touched and d.d not object to the ody contacts w·th the other children. He seemed to be te t n the unit to f'nd d fferent ways to balance, turn jump , and c imb. From this point on he seemed to accept contacts from he other ch ldren w·thout becoming upset. By the eighth V Sit o ep was slid n don the sl"de head first and umpin off the boil wit good balance upon lanaing. He found elight in usin his b dy in a urposeful manner. Josep I last f ~ v·sits to the 'Fun House" ere positive. Joseph was able to express displeasure when he was pu he by hawn an coul al o move more quickly and defend himself. Shan ceased pushin him or pursuing him. He ecame ecure in the environment and wa aware of the safeness of the equi ment. Durin therapy, Joseph ex presse more eagerness to try new sk 11, such as climbin · to the top of the stall bars jump·ng an balanc ·ng. His ba ance self-c nfidence, boy ma ·e and motor lannin appeared improved. He had a more normal ga·t with etter oot p acement less fallin and better equili rium The teachers note that Joseph wao a le to ·nteract with h,... la ate ·n a pos t·v manner a 11 a verbal- ze more cl arly and more oft n ~ th ~ood ma ·nat on. TABLE 10 Individual Report of JOSEPH Teacher Observation Gross Motor Activity Date 1971 ENTRY STATE happy 4 interested 3 cries 2 non-aware 1 CCMMUNICATION gestures 4 uses expression 3 some eye contact 2 no eye contact 1 VERBALIZATION frequent vocal 4 imitates 3 infrequent vocal 2 cries 1 SOCIAL INTERACTION initiates 4 moderate 3 minimal 2 isolate 1 VERALL STATE layful, cooperative 4 nterest, participation 3 nhappy, aggressive 2 n on-aware 1 July Aug . C\1 ..::t \.0 0\,...... (Y) \.0 CO O C\J ..::t \.0 r-i r--1 r--1 r--1 C\1 C\1 (\j (\j (Y) ✓ .,,,, ...... ...... .... ...... ..... ✓ ✓ ...... ,,, ,,,,, ...... ✓ ,,,,. .,,,. .,,,. .,,,. ,,,,, ,,,,,,. r' .,,,. ...... ,,,,, ,,,,,,. ,,,,,,. ,,,,, ,,,,, ,,, .,,,. .., ,,,,. ✓ ,,,, .,,,,. ,,, V" ,,,,. ...... ,,,,. .,,,. ...... .,,,, .,,,,, ..... ...... .... .,, ,,,. ,,,,. .... ...... V' y" ,,,,. Date July Au -------- C\1..::t \.0 0\ r--1 g. ACTIVITY lO lri---; rl rl C\J g:;/~ ~ g C\J.c:t \0 Climb Slide Walk Crawl Sit Lie Fall 5 ... 0 I I I I r I I I I 1 F I II 5 O I n I r n r~ 1 1 1 1 11 5 0 I I I I I I l I I I I I 11 5 0 5 0 5 0 5 0 •.!. •• f--' 0\ 117 Evaluation and Pro ress Report--Dav d David ,as a very anxious three-year-old boy who was born prematurely with multiple developmental anomalies. Althou h his hearin was thought to be normal, he d d not speak except rarely, then only a few sin le words. His muscle tone ~as generally decreased w th subtle athetot c movements of the fingers and toes. There were numerous other m·nor abnormalities of the head an facial area. He was able to accompl sh all the ross otor skills for a three-year-old child and moved about qu ckly. Occasion ally, he flapped his arms, ~hen excited. His most notice able defic twas i h s personal-social elations with the other chil ren. He remaine aloof and tense much of the time that his peers were out-of- oors ·n the play areas. If he could not see his teacher, or ·nteract with her, he became very anxious, an cr·ed easily. At times durin his contact with other children he was physically a gres- s ve . In attemptin to ain their attent on, he somet mes hit them. This appeared to be some kind of a si,nal, since he seldom hit a child more than once. He occasionally stumbled over the ch ldren crawl ns about the play area, or pushed them out of his ~ay, as if they 1ere ob~ects . Goals were increased awareness of environment and peer interact on, improved body ma e. .11 Durin David's first few v sits to the 11 un Huse , " he ct · hit other children lightly , and seemed to settle . down on the lan n platform near h s teacher . He toler- ated the s·tuat on well compared to other novel experi- ence in Nh. ch he had een observed. There a only a fleetinp; interest in h s surround in s. Durin his th·rct visit Davi notice a 1 ttle ·r1 near im an playfully hit her ith a foam pillo • He touched her severa times and she returne th contact . He frequently chan e hi facial expressions an k t ey contact ith his teacher. hen the other children left he unit, he cri d an ran after his teacher. 'ventual y Davi venture a short ways into the "Fun Ho e" an looke into the central bov . He examined t e felt boar and car cut-outs on the all and rief y played witl th m. Noticing one of his classmates, he reached out and touched her then held h·s hand out to her. He did not seem to need to be n ar is teacher, and moved aroun the first part of the pathway. As the ss -· ons cont·nued avid be an to verbal·z vowel soun s rhile ookin at ther children or hi teacher. The forms on the wal began to int rest irn m re . He ma e ov rtur s to the other children usually in a hysical manner such as brushin again t them or play ng w th their races . H s manner wao m re relaxe y t end o the s ss ns . It was obs rved that David had made a os · t ve adjustm nt 9 t a new s·tuation n b inn ne to enjoy the visits to the 1 Fun House . 11 If the ~es ions had continued longer than four week , erhap would have increased h s social ·nteraction and v r~alization, as well as investigation of the entire unit . TABLE 11 Individual Report of DAVID Teacher Observation Gross Motor Activity Date 1971 ENTRY STATE happy 4 interested 3 cries 2 non-aware 1 CCWv!UNICATION gestures 4 uses expression 3 some eye contact 2 no eye contact 1 VERBALIZATION frequent vocal 4 imitates 3 infrequent vocal 2 cries 1 SOCIAL INTERACTION initiates 4 noderate 3 ITTinimal 2 isolate 1 :)VERALL STATE playful, cooperative 4 interest, participation 3 mhappy, aggressive 2 1on-aware 1 J uly Aug. (\J ..::t \,() 0\ ,-; (Y) \,() a) 0 (\j ..:::t \,() rl rl ,-; ,-; (\j (\j (\j (\j (Y) ,,,,,,- t,11' ✓ ,,,,, .,,,. .,,,. .,,,. ✓ t,11' ...... .,, ...... V .,,,- .,,,. ,,,,.. ,,,,. .,, ..... ..... ,,,,.. ,,,,, .,, .,, .,,,.. .,,,. .,,,. ,,,,, V" ,,,,.. t,11' ..... .,,,. ...... .,,,.. .,... .,,,.. ..... ,,,,.. .,,,. ,,,,,.. ..... ...... ,,,,, ..... .,..... ,,,,.. ti"" ,,,,, ....... ..... ,,,,,,- ..- .,, ,,,,.. Date J uly Aug. _________ (\J..::j-\,()O\,-;(Y)\,00)0(\J..::j-\O l O I ,-; . ---1 ,-; ,-; C\J C\J C\J C\J . (Y) ACTIVITY Climb Slide Walk Crawl Sit Lie Fall 5 O I 1 1 1 1 1 t ···II 5 0 ;- I I I I I I I I I I lrc•II 5 0 I I I J I I I I I I I I II 5 0 5 0 5 0 5 0 ~~ I-' I\) 0 Name : avid . Dysfunction or Developmental roblem High anxiety level Inability to nteract with his oeers ck of verbal communication CHART 4 Descriptive Chart of Progress Age: 34 mos . Functional Ob.iective Composed relaxed presence Social inter ·a-i, S .: c-- • -' u. "- ... ~pi cal child· Sensori-Motor Experience and Equipment Utilized ~nclosed play unit with ~extured walls con toured pathways bowl; gatherin~ action positive I area play; initiate r several children play Verbalization with peers and adults ntire unit or behavioral adiustment Post Experience havior ccepts unit sessions and classroom group activities ithout crying. Relaxe nter fun house and ob serve peers in bowl area slide and pathway Occasional single wor vocalization to peer adult t--1 f\) 122 Evaluat· n and roeress Report--Tanya Tanya was one of the ch ldren who did not have pro - lems with coordinat·on or balance, and was advanced in ross motor skills by three months. Her reate t deficits were in a moderate hearin loss and cardiac defects. In ddition, she was socially immature, lacked a 11·ty to communicate except by gestures and s·~ns and had frequent t mper tantrums. Her attention span was short, an he was easily rustrated because of the inab 1 ty to commun cate. Her first vis t to the "Fun House' was only briefly stimulat n to her. She very qu ckly and nim ly toured the pathways and settled down besi e her teacher at the entrance. She did not seem to real ze the purpose o the equipment, or ant to follow her peers example . On each succee ing visit to the "Fun House," Tanya became bolder tested her ability to alance on the rim of the roll n bowl, ran across the roll"n bowl and fol lowed her peer around the unit. She watched her playmate, smiled at him frequently, and imitated him. She made vertureo to one of her peers who seemed to be unaware of the situation . The textures on the wall murals seeme to attract Tanya as she touched them and examined them many times. The felt wall w·th cut-out cars was one of her favorite 123 places for play with her peer . As the visits to the "Fun House' cont nued , Tanya became more darin n her physical act·vities, moved quickly from one area to another, slid or ran down the s1·ae and the bowl, and climbed on the equ pment. Her interest was sustained because she watched her playmate and then e an to discover new approaches by herself. The area apparently allowed her to focus on the activity w th out distraction or pressure from adults or peers . V cal·zation was occasionally heard as babbl n or humming. As she increased her soclal interaction with her playmate, she used her smile and eye contact frequently. As a result of the stud, Tanya Nas observed ·n the school room for vocalization attempts. he appeared to be makin more attempts to vocalize, was able to say 11 mama . Socially, Tanya was observed to be relating to the older children in the classroom. In addition her temper tantrwns were less frequent . She continued to have fre quent eye contact with the children and teachers . In the enclosed safe, interestin area for play she became more aware of the activities of the other ch ldren, and exhib ited potential for spontaneous play, interaction competi tion without pressure, and physical contact. TABLE 12 Individual Report of ~ANYA Teacher Observation Gross Motor Activity Date 1971 ENTRY STATE happy 4 interested 3 cr ies 2 non-aware 1 C~UNICATION gestures 4 uses expression 3 some eye contact 2 no eye contact l VERBALIZATION frequent vocal 4 i mitates 3 infrequent vocal 2 crie s 1 SOCIAL INTERACTION initiates 4 moderate 3 minimal 2 i solate 1 OVERALL STATE playful, cooperative 4 interest, participation 3 llI1ha ppy, aggressive 2 non-aware 1 July Aug. C\J ..:::t \0 m r-1 rn \0 co o C\J ..:::t \0 ,-f ,-f ,-f ,-f (\J t (\J I (\J (\J (Y") .,,, I '✓ ✓ .,,, .,,, ✓ .,, t/ .,, ✓ .,, ✓ t/ ti' .,,, t/ t/ ✓ ..,,, ✓ .,,, ✓ ✓ ..,,, ✓ ..,,, .,,, ✓ .,,, .,,, ti' .,,, ..,,, ,t/ ✓ ✓ ., v' .,,, .,,, .,,, .,,, ✓ ✓ .,,, Date J uly Aug. _________ C\J..:::t\Offir-l(Y")\OCQOC\J..:::t\O l O I r-1. ~ r-1 r-1 C\J C\J C\J C\J rn ACTIVITY Climb Slide W alk Crawl Sit Lie Fall 5 0 I I I 111 r I I I I I I I I II 5 5 LJ rs; I r mf I I I I,•• I 0 I I r--· . .. 0 I I I I I I I I I I I I II 5 0 5 0 5 0 5 0 ... n r, ri-, .... _. L. .. ....J u . ... Jl ... -----···· ~ [\) +=" 25 valuation and ro ress eport--Gary Gary was socially immature with a delay n psycho motor development secondary to prematurity. Gary's twin brother, Joseph, is also in the populat·on which tested the Thera-play unit. Although clumsy he was slightly advance in his gross motor sk·11s for his age of three years. He was able to a ance on one foot an walk inde pendently wit a sli htly ataxic ait; alt ou he was able to run, he could not jum, r de a tricycle or alter nate h s feet when c im in stars. Lan ua e evelo men was fairly ood with a colorful descr·pt·ve vocabulary which he preferre to use to descri e fasc nation with inan mate o. ects. Functional objectives were ·ncreased control of bodi y movement, an balance improvement in socia nteraction an increase self-confi ence. Gary was unpredicta e as far as hi attitude to ard laying in the unit. He vacillate from be ng u shy retirin c ild ho sat y his teacher to be n physi ca ly a gressive tooth rs. Snee he had depended upon nan mate objects for secur ty, he d not ·mmediate y seek the company o the children int e un t. He was not instructed to enter the unit and chose to st outsi e w th h"s teacher, an watch flowers part o the t·me. Dur n h s r·rst d y n the un·t, Gary nspected the walls and walked around br·efly. He descr be some o 126 the objects he saw, then sat down outs de the unit w th his teacher. Gary's second visit to the un·t was d ffer ent. He was unhappy, cried then watched the teacher for react ons be an to yawn. Two days later, Gary happily entered the unit, watched the ther children, and talked requently about h s expe ences. During th next visit, Gary showed immediate inter- st in exploration of the central bowl area and watched an ·mitate Tanya. He used sentences to descr be what he did, such as climbing to the top of the tairs and say n, 11 I 1 m way up here.' However, he lost interest qu ckly and ret·red to his usual post bes·ae his teacher. His compan·ons were unable to join h m ·n conversat on, since Tanya was deaf and George could not spea. urin the next few weeks of v sits to the "Fun House," Gary seemed to have adjusted to the exper·ence and gained in soc al nteract on self-control, an posi tive use oft e unit. At times he asked where his other classmates were, and as ed for his brother, Joseph. He was capable of util zin the unit to its full potent al, such as sli ing, climbinr and jumpin . At times he appeared st mulated to use the equipment, and at other times he sat y his teacher. Gary had a great attachment for his teacher who was always access"ble to him at the entrance of the un t. 127 Init ally he o ten interacted w th her rather than the other ch ldren. Near t e end of the study, a neutral observer took h s teacher's place one day. Gary entered the unit and followed the other children happ·ly. He seemed content to utilize the equipment for cl"mb n, sl din jwnpin, and walk ng wit o d concentration. If the lowers near the entrance were covered, or he was told not to touch them, he entere the un·t and playe . The therap ts noted that Gary seemed to have tter knowled e of spat al relat onships for he exh ited better motor plannin and motor control. He eveloped the abil ty to jump from a w lat rm or tep. H· s balance an equili r·wn rin h s use of the rampsJ inclines and pel et-filled ba wer note to be sli htly teadier toward the en of the study. Socially, he was able to make over tures to Tanya an others n the unit and talked about goin to the II un House" be ore the sessions. Somet mes he called out from a high perch in the un t to Jerry or oseph out e. He seemed less moody and irr·ta le, more nc ned to nteract w th h s eer roup than previou ly. At the close of sumrner schoo and the sess·ons in the unit, h was placed in a sch o for better-adjusted chil ren. TABLE 13 Individual Report of GARY Teacher Observation Gross Motor Activity Date ENTRY STATE happy interested cries non-aware COMMUNICATION gestures uses expression some eye contact no eye contact VERBALIZATION frequent vocal imitates infrequent vocal cries m m OCIAL INTERACTION nitiates oderate inimal solate ERALL STATE ayful, cooperative 1971 terest, participation un n happy, n-aware aggressive 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 July Aug. C\J ..:::t \0 0\ r-i (Y') \0 CO O C\J ..:::t \0 r-f r-f r-f r-f (\J (\j (\j (\j (Y') ..... ..... v ..... t/' v"' ..... ..... ..... ✓ ..... ..... ..... .,; ..... ., .,, .,,, .,,, .,, ..... ,,,, ti" ..... ..... .,, v" ,,, ✓ ,,,, ti" ,,,. .,... .,,, .., .,,,.. ✓ ,,,,,. ..... ,,,. .,_..... .,,,. ..... ...... ..... ..... ..... ..... ,,,, ,,,, II""' ,,,, ,,,, ., ~ ...... ...... ,,,, ,,,, ,,,, Date July Au -------- (\J ..:::t \0 CJ'. r-; g • A CT IVITY 10 H ----t .---1 .---1 N g] '£ ~ $i N _c:t I.D Climb Slide Walk Crawl Sit Lie Fall 5 0 I I I I 1 I I I I I I I II 5 011 1 r ff 111111 II 5 0 5 0 5 0 5 0 5 0 ~ I\) (X) Child's Name Kari Louise George Mary Kay Evan Jerry (1 ivlonth) Pre-Experiment TABLE 14 Measurement of Gross Motor Crippled Childrens 3ervices ills Using valuation ?last) Gain; I-'laj or Post-Experiment day) Loss Problem Chron. Motor Are Chron. Motor Age Times Phys./* Age Mo.(CCS Age Mo. Mo. ( CCS) in Behav. UL_!'. 36 7 37 7 4 Same Phys. 34 10 35 11 ... 0 +i .t?hys. 41 11 42 11. 6 Same .2hys. 30 11 31 le 10 +l rhys. 44 11 45 13 9 ;-2 Phys. 25 21 c.u 21 12 Same Phys. 40 24 41 24 .l. l Same Phys. Change in Gross Motor Skills Beginning reciproca 1 0reeping, sitting neciprocal crawl/ l-Jith braces Improved creepin~ Walks with one hand 1--ield; parachute goo d ~neels indep . Walks few steps with crutches Gain backwd . para- chute; walks few steps Jalked 12 steps no i1elp; walks backwd . sideways; bkwd. ~ parachute I\) \.0 Child ' s Name Tanya David Joseph Shawn Gary Dennis Total Average for Total Group TABLE 14 (continued) ( 1 Month) ~last) Pre-Experiment Post-Experiment day) Gain/ Chron . Motor Af!e Chron. Motor Age Times Loss Age Mo . (CCS) .. ~ge Mo . Mo . (CCS) . in Unit 33 36 34 42 9 +6 34 36 '35 3r1 11 ,..3ame 36 36 37 3u 11 Same 40 36 41 36 10 Same 36 40 37 40 12 Same 37 40 38 -.C 5 Same 466 319 '-t 79 329 120 +10 35 . A 24 . c; ~6 .8 ?t; . ~ f""\ 0 .76 • Note: Phys . =physical problem predominates Behav . =behavioral problem predominates Ma,jor Problem Phys.;* Behav . Deaf Beha11. Fiehav . .ue11av. Behav . Behav. Phys . I Change in Gross Motor Skills Balance one foot . hn cnange 0umps with both feet off step ho change Jumps from stair ( 4 II ) Balance improved Children as a group gained 10 mo . in normal motor skills plus small ~ains t,--J w 0 131 TABLE 15 Quantitative Analysis of Motor Activity CLIMBING 1971 Date NAME C\J ~ \.0 CJ\ rl (Y) \.0 CD O C\J ~ \.0 rl rl rl rl (\J (\J (\J (\J (Y) July Aug. 10~-'--+-__.,_-"--+-~---+---+-~ 5 Evan 5 Terry 5 ari 5 Kay 5 Louise 5 ~avid Scale Oto 10 represents Date NAME 5 Dennis 5 *Shaun 5 *Joe 5 Mary 5 ~ary 5 George July Au • C\J ~ \.0 CJ\ ri (Y) \.0 CD O C\J 0 ,... rl rl rl (\J (\J (\J (\J (Y) · · ·-···n··· number(s) of minutes or 5 partial min. during period n n that child engaged in this -M-Tanya .... ....J U ~ .... a c t iv it y . Dot t e d l in e ( ·· · · · · · · · ·) o ~~~---'--"--'--1~---+--+-4--1 represents time absent, carried over y average . * Indicates behav or problem TABLb 16 132 Quantitative Analysis of Motor Activity SLIDI G 1971 Date NAME C\J ..::t \.0 0\ rl (Y) \.0 CX) 0 C\J ..::::t \.0 rl rl rl rl (\j (\j (\j C\J (Y) July Aug. Date July Aug. NAME N ..::::t \.0 0\ rl (Y) \.0 00 0 C\J ..::t \.0 r-4 rl rl rl C\J C\J C\J C\J (Y) 10----------- 10--------- 5 5 r····7 .... J .... -···· Evan Dennis 0 ....... --+----+----1--+--+--+----+--+--+--+---4 5 Jerry *Shaun 5 5 Kari *Joe 5 5 Kay ___r-t ... .. . .... r - Mary 5 5 Louise ~ary 5 5 George 0 ..................................... --..._:.:.~ Scale Oto 10 represents nwnber(s) of minutes or 5 partial min. during period that child engaged in this -wranya activity. Dotted line (···········) o ..... ~w.a,----.u~~ .... ...,_4- ·~ -· represents time absent, carried over by average. *Indicates behavior problem 133 TABLE l'"( Quantitative Analysis of Motor Activity UALh.ING 1971 Date July Aug. Date July Au • NAME N ..::::t \.0 O'\ rl (Y) \.0 a) 0 C\J ..::::t \.0 NA ME C\J ..::::t \.0 O'\ rl (Y) \.0 CX) 0 C\J ..::::t \.0 rl rl rl rl (\J (\J (\J (\J (Y) 10----------- 5 Evan 0 5 Jerry .... 0 5 Kari 5 ... fl-........ Kay 0 5 Louise Q+u-a-f._.. .............. ~~ ..... -..-.u.-4 5 *David Scale Oto 10 represents number(s) of minutes or partial min. during period Dennis *Shaun *Joe Mary *Gary George that child engaged in this *Tanya activity. Dotted line (··········) represents time absent, r--4 rl rl rl (\J (\J (\J (\J (Y) 10~1-t---+---+--+--+--+-~..-+-+-~ 5 r···- ··· r····-··· ~ ········· ... 0 ... . 5 . .. .. 0 5 0 5 0 ... 5 Q+-....-i---+---+----+---+-4--+-+--+--+---I 5 ___,.., ,··· ···- I....J 5 o ~+---t_....,__.,......_-+--+-+--...-..--+---t carried over by average. *Indicates ehavior problem 134 TABLE 18 Quantitative Analysis of Motor Activity 1 ITTI G 1971 Date NA ME C\J ..::t \.0 m rl (Y) \.0 ro o C\J ..::t \.0 rl rl rl rl (\J (\J (\J (\J (Y) July Aug. 10~-+--+--+--+--+-~~--+--+-~ 5 Evan Jerry 5 ari 5 Kay . i. ... •: :-·· ...... 0 5 Louise 0 ... 5 *David 0 Scale Oto 10 represents Date NAME Dennis *Joe Mary *Gary George 5 5 July N ..::t \.0 CT\ rl (Y) \.0 CX) 0 C\J - ,-4 rl rl rl (\J (\J (\J (\J (Y) • :. ............ . r-''''·'7 : ... , : ...... • • u 7 .... 0+--~:.......+---◄--+--+--+-4--.,__.--.,&..Lt.1 5 . ··1 , .. 7J 0 5 . • .. . ... . . ... 0 number(s) of minutes or 5 partial min. during period . LI' ~- ... : ~ .... . : • that child engaged in this -MTanya act iv it y . Dot t e d 11 n e ( ·· · · · · • • •·) o _,,,,_t--4---'-"-+--+-~1----4---+--.--'--I represents time absent , carried over by average . *Indicates behavior problem CHAPI'ER VI INTERPRETATION AND DISCUSSION OF RESULTS Original Objectives Thera-play unit was built and tested with the prem ise that it is possible to improve balance, and gross motor skills by means of a specially planned environment. Devel opment of body ima e might be enhanced if the env ronment contained a sufficient quantity of stimulatin forms with which the child could test his body control. Provis on was made for vest bular, proprioceptive, tactile and visual stimulation within the unit. Additional Objectives Opportunity for social interaction was evident in this type of structure using the central bowl for a focus point as well as circular pathway with wall murals . The teachers hoped to see an increase in speech and nonverbal communication as well as personal social adjustment . Progress With Motor Skills Problems with Evaluation of Subjects The CCS Growth and Development Scales gave an over al l assessment of the subject ' s gross mot r skills . Be cause the scales give only major motor a chievements they 135 36 list the skills for a child at uneven intervals of 2, 3, or 6 months. Since this study was completed in four weeks' time, insuff cient changes were seen to evaluate o jective ly and accurately with this scale. Children w th cerebral palsy and other neuromuscular problems ~sually show a delay in motor skill development. Therefore, any child who ained one month n motor skills durin the study could be consi ered to have made a "normal" gain. This would exceed the expected goal set for a child w·th a motor dysfunction. rogress of Subjects: Gross Motor Skills No ch.ld regressed or made ·mprovements greater than that expected for his chronological a e. The child's pro ress would approach normal f he were able to ach·eve act vit es at h·s chronolo ical age level. Considering that these children have problems such as ataxia, tremors, spasticity, athetosis, perceptual def cits, visual an hearin loss and sensory disturbances, normal progress is not expected. If a child was able to overcome his deficits and was able to function at his chronolorical age level, he achieved oals beyond the expectations of this study. Not all children benefited equally. Children with persistent primit·ve reflexes and a mental retardation who tested lower than six or seven for months ·n gross motor development, were una le to use the unit. Influence of Other rograms 137 It was impossible to separate and control the many factors which influence the child ' s development . In order to prevent contamination of the study by outside factors, many other current programs need to be suspended. Children in the cerebral paloy re-nursery school receive occupa tional and physical therapy, special training programs such as train·n for the deaf, educat onal enrichment and therapy programs which are sometimes performed by the parents. These programs cont nued dur·ng the test·ng of the un t. Normal Group The type of gross motor activit es, tactile explor ation and peer interact·on engaged in by normal chil ren, was noted dur ng the observer's train'n period. This "normal behavior' could e used as a standard to which the children with deficits are compared ford ff rences. In this stu y th s could not be done because no standar - ·zation of normal behavior in tle Thera-play unit had been made previously. Progress of Sub'ects--Body Ima e Body image has been defined as the schema or ·mage the individual has of h mself. Movement in space is neces sary for the development of the postura model one calls boy ma"e . A search of the 1 terature did not reveal any 138 test for body image which could be applied to children one and a half to three years of age. Older children are some times asked to draw a figure of the human body. This is evaluated for his concept of self in addition to observa tions of his style, speed, and rhythm of movement. If a child gains knowledge of how to move his body forward, sideways, backward, up and down, he has gained orientation of his body in space. One child, Evan, who utilized the central bowl area and stairs extensively, made the above mentioned gains. Several other children--Jerry, oseph, Tanya, and Gary--were bolder in performing activities such as balancing without canes or crutches, and jumping off a stair or platform. The therapists observed that the chil dren gained a knowledge of utilization of their bodies n a safe environment and distinguished the differences of safe and non-safe areas. Children who formerly fell frequently--Joseph, Gary, Jerry, Kay--appeared to fall less after the study. Perhaps the unit made the children more aware of balance and safety. Children With Behavioral Problems All five of the children with behavioral dysfunction were more advanced in motor skills than the children with physical problems, except for Dennis. On the CCS Scales, these five were scored from 36 to 40 months in motor skills. 139 esults showed only one ch ld (Tanya) advanced in motor skills, by six months . Init ally not all chj_ldren were suscept ble to the nfluence of the colorful walls, or the contoured cushions an athway. Two boys (Shawn and Dennis) ho had revious ly en~aged in h stile or aggress ve act:ons with their peer~ 1ere surprised y the unusual non-threatenin set- t n. T ere was none d for a r ssive physi c~l contact ecause there were many areas to expl re vith a reat var ety of n ss·ble act·vities. Thee chi dren 1 ere at first suspici u r rather dubi us about the s·tuation int ~hich they had been laced. They had received no warnings nstructions or limitations n hoi they were expected to behave. They d d not know whether they would e discip ine for hosti e activit es for they seeme to have complete fr edom of choice. Sharin oft ys, which is so often a problem with young ch.ldren did not bee me a problem because the design of the un t fostered gross motor activit·es. There was amp es ace fr movement around the pathway and into and out of the II owl . " The central bowl area did present an opportunity for the more physically a ressive ch . ldren to ush or pull each other. Ho ever , this type of behavior occurred very nfrequently and dropped off toward the end of the study. After one experience, the less a gress ve ch.ldren learned to hold the r position or move out of the path f the aggres or . 140 No react·ons or reprimands were necessary from the teacher; thus the aggressive child did not succeed in upsetting anyone, or eliciting a negative reaction. If a child fell off the edge of the "bowl, 11 he landed unhurt on the foam cushions. oon the a gressive ones learned there were more interesting challenges than combat. They practiced on the "bowl" or sl·de t·1 they had mastered many types of ac tiv·ties on t em. Sensory Murals Observers recorde the num er of time each child touched the all with his han open. On the ·rst day, tho e who touched the wal sand looked at them the most were ch ldren w th c mmunicat ve problems, except for one ch ld who id not mov_ alone the pat way. The children with motor deficits moved a on the pathway and explored the contours, but d not touch the walls except for support. Ci ren who had roblems relatin tot eir peers seemed to ook at and touch the walls and play with the felt car cut-outs from t·me to time durin most of their vis·ts to the "Fun House." The felt wall was sometimes a gatherin place for two r three ch ldren at one t·me. The irl who had severe hearing defic.ts appeared to touch the walls more than the other ch ldren. The walls did not sustain the interest of Mary, who had 141 oth visua and hearing def cits. She pursued the central bowl and gross motor activities . One child, Shawn, used physical ag ression or contact to attract attent on because he appeared to be unable to communicate. He looked at the walls and touched the animals many t mes. While he played with the felt cut-outs, he sometimes handed them to other chil ren. He mimicked the one or two-word descriptions of the scenes ven by another--Denni. Ap arently, the vi ual and tacti e stimulat on prov ded some fac 1·tat on or ver alization. Personal-Soc·a1 Development and Speech Amon the f ve children with behavioral problems, there ppeared to be an incr ase in pos t·ve play, a de- crease in physical ag ression an isolate play. peech di seem to increase in several children (Evan, Steven Joseph, Gary) during the study. The results are descr bed int e escr ptive tables, grap s, and in the children s ndividual narrat ve accounts. Observers Problems ncountered n Exper·menta Test n of the Unit Since no prov sion was ma e to compensate observers, student volunteers from the UCLA Rehab 1 tat on Serv ces Guild who had been prev o sly screened to work with the nursery school were chosen . one of the observer ha ever wor ed on a research project or observed cerebr al palsied children before, although they had worked with chil ren . The untrained observers had problems a ree n on the type of behav·or they were observin even though they ha be n instructed on the criteria and method of recording motor activ·ty . Trainin sessions were ven 42 the week prior to beginnin the ex erimental study . Durin the training perio, everal normal ch ldren and one hand - capped child ere observed in the un t. The ctual Recording of ctivit es t least our and no more than f ve student ob servers watc e the act"vit es and recored the type of gross motor activity for each minute dur n the 10-min te sessions . ach observer watched on y one child at at me· for relia lit, to observers watch d the same ch ld. Jhen there w s lac of agreement, i was somet mes because ne recorded an then looke up to note the ch la's next move whi e the other r corder was don the oppos·te . Children w o move quickly are ifficult to assess fr the various activities . One volunteer was recru·ted to conduct the timing of each session . tach m·nute he called out the number for the observers . At times , there were inaccuracies aue to hwnan error and many distractions . Because there were sever al other observer (the therap sts and photo- rapher) , it was not alway poss ble to keep the child ·n 143 the most optimwn view . No bservers except a teacher were allowed inside the un · t durin t e sessions . In order to note how far a child pro ressed into the unit, areas were esignated y nwnerals on each wall . If the child was half way n between t ese numerals, the observer had to ar itrarily choose one nwneral to record . Thus t~o ob e vers might each choose ad ffer nt numeral . Tactile Discrimination an ine Mot r Skil s o attempts to measure tacti e a·scrimination ere planne. It was hop d that increases in hand use an iscriminat on would follow from a pro ram rich in sensory exper·ences . Many of these planne experiences were omit te from the first n t because oft me and finances . The nsory murals were intende to st mu ate tact le sense. In future un ts, cons deration of the age and level of chil 's comprehens on is necessary. eather The unit was compl te by uly f·rst, dur n the summer weather . The sett·n for the un twas out of do rs in the ar en play area of the nursery school . The enclosure for the un twas a temporary structure\ th a li htwei ht dome cover wh ch was rolled up to allow ventilat on . At times dur n the hot 1eather the ch . ldren complaine of the heat . .f the pathway and bowl were 144 shaded a r circulation was ecreased. If the un t were placed indoors, these problems could be eliminated. The un t also could be enclosed insi ea eo esic dome, wh ch has aperture for c rculati n of a r. CHAT• VII CO CLUSIO ram th s study, we now it is possible to create a complete sen ori-motor environment wh ch is safe and stim ulatin for youn children . There are many ossib liti s wh·ch cou d not be ·ncluded n th·s first Thera-play unit because of the co~t an time ne ed to constr ct such structures . Auditory lfactor, and vi ual ex eriences could be include. The visual stimulat·on was done ·n a limite Jay with the murals and chan n contour and shapes. Among the benef c·a1 fea ure ere the poss b 1 t es for free e ploration w thou ad t ntervention opportun ity for repetit·on of ills stimulat on f movement through space an over equipment a de ree f succe sf r each chi , space for ross motor activ ties without crowd in, non-threatenin stimulat·on for movement , p sitive feedback from safe resilient mater al, peer nteraction and increase in self - confidence . Recommendations for Future Studies 1 . Conduct a study for loner per · oa , such ass x months to one year , usin each ch ld as his own control . 145 46 Have interval fro servat·on of sub ·ects without use of the un·t . 2. Use normal ch ldren to assess and standardize expected be avi r in unit. 3. At th st me group are ntereste in the vale of the unit to assist in amel'orat·n children's emot onal or ehav·oral di ficu1t·es as well as reach·ng autist·c c ·1 ren. 4. Deve op aunt for infants vhich are atypical. 5. and the sensori-motor ex er·ence and the ze of the unit for different a e roups. 6. Determ ne the timum amount of t·me ac ch d should spend n the unit. 7. Util ze the t to evaluate ne~ children for hys·cal probl ms such as alance and coor ination as ell speer nteraction and behav or. A P 1 DI ~RO'iS MOTOR ' l 1, 0. >AO l 3 r:ios. J.AO .. , • 1 mos. MOS e 6 I !OS. MOS 1 ... 40tr, I I cs . ~ e . IP.; S. MO~ 10 10 mos. MO~ '1 l J 1 :'0S. HO 1 1 \' f. rll 1 e MO~ l:i lil QS. 11 18 mos. MO~ 21 21 mos. MOS 2 2 yrs. rRs z I 1: 2 yrs. rH~ 3 3 rRs rs. 3 J 3:; yrs. YRS • '(I) ~ 4 ~rs. • I ·"• ,1 1 , yrs. e <RS 5 yrs. 0 YR~ vrs. p T VII County of Los Angeles Cf<:PPU:O CHILDREN SERVICES GROWTH AND DEVELOPMENT ',loro reflr.)( Tl.R a) S11p1ne NAME TL R b1 Prone Pos1 t1 •c surport1ng ref lex ccs fl rr R Jl Sym rnR b)As m BIRTH DAT ~Jc>rk r1r,hl1ng L dts he,id fro:• prune Supports self on forc;irrn H n1j b, lance• Holds I e:id stc,1oi1; erect Hcnd co 1trL,1 wh1.:11 pulled to s1tt1ng Supports sr.lf on ex r-nded elbows f;clls from s11 1 11,e o prcnc (segawn al) Pro c!I ·c Jrn extension appears E u1l1br1urn rec1ct1on 111 a) Prone Eouil1hriurn reaction 1n b) Supine B nJ, r r: ,t,rg react,cr acting on body Lil c:: t n 1J fr n sup1 1 c L. .1111 ,, re ir t f'1 r, 1 n r.11<1.' 11nn \!I r.osit1ons np;-c;ir As ~u· ~s crc~p 111g pos111011 Stands at r;-1•1 1! placed /holds on with both hands) Sits lnne >'.it iout us1n~ h111ds for support (back erect) Equ ll1Lr1urn rcsrons :; rn s1tt1ng Creeps reciprocally Kneeling balance Pulls sci o feet Cruises s1drwa sill rail ,', J t~ s · 1.ilh t::o hJnds held ,·;,, 1~'j ,•,1111 nne h111d lield Flo r to standing lndr,.cndcn st;inding balance \','alk f;N SIC;JS (5 to 10) f.quil1br1um reactions 1n kneeling Chair to Slilnd1ng Standing to chalf l'/,1lks 111d'pendcntly • seldom falls ','Jl~s bilck·:,ards '/J1ks s,dewJys Eat i11b,1u·" rc:1ct1ons 1n stand1n1? Squats in play Up and cown sta1rs holding rail Runs well I' al sup stairs alone (2 feet per step) Kicks large ball Walks up and down 1ncl1ne l'/nlks uo and down curb Jt:"1r,5 w1 h bo h feel ' ,',;-d,s up st· 11rs • alternatC's feet Rides Irie cle Ju1~ps from bollo111 stair Swings arm rcc1procaily 1-1hen walking Stop and go ( •1al~1ng) Turri<; sh:-ir:1 corr,ers / N:11kinp) St.inns on on.:? foot · twJ seconds - l',:111-.s down sr.11r • t •,o per step Ho ~'i on one loct four times S,,; s i11l rn~tcly 1 ,Jl11S L1u:.r1 <: 1rS · It rnt1les feet 01 0 fn ,1 st:"l·1rl1npJ}:iln11ce • 10 ceconds S;,;1ps, hops, 1u111p with ou t dill 1culty 48 Department of Hospitals - OBS Chil 1 s Name Movement lie roll si crawl scoot knee stand wa k sl"de climb jwnp fall Touch Touch Palm Touch Fist Touch Other Child COMM.ENTS : 1 S FORM -------- Minutes 1 2 "') 4 ? 6 7 8 9 10 ) 49 R ◄CORDING GROSS MffiOR ACTIVITIES Date M vement Comments 1 e roll sj -f- craw scoot knee stand alk s1·ae c.Limb jump fall Touch Palm Touch Fist Touch Other Child Observer Reliability Form Child's Nam.~ Date Jbser ver .JJ. .L 2 j 4 1 2 3 " 1 ') 3 4 1 2 3 4 l 2 3 I, 1 2 3 <-i l 2 ..... ll Movemen~ .. - Minute 1 Minute 2 Minute 3 Minute 4 M;n,1te i::.. Minu~e 6 1vr1 i-:ute 7 lie roll s ~t crawl scoot kneel stand , .. ,al.re slide climb :wnp fall touch palm toucn fist touc,.'1 child talk ~ \Jl 0 Child's ame Date -------- lance eaction: s t roll craw kneel stand walk s1·ae clim s t roll crawl kneel stan alk slide cl mb jump outh upper extremity lower extremity other Coordination Speed sit roll crawl kneel tand 1alk slide clirnb jump fall roll Nal"' crawl jump clim Ste eotyp d Behavior Comments 51 152 P Tb; VIII DATE 7 //t,/ 71 TEACHER #s IV,°Ar, _)t,<'j r/1 OBSERVER CHILD MINL TE 1 2 3 1 2 3 1 2 3 1 2 3 CODE ¼ l Non-aware STATE 2 Cries, unhappy, uncooperative, tense OF or aggressive CHILD 3 oderate participation, watch fu 1, in- UPON ENTRY terested ✓ ✓ ✓ ✓ t/ v 4 llappy , playful, cooperative l Does not look at adults. peers, obiects COMMUNICATION 2 fnte rmittent eve contact 'on-verba 1 ✓ 3 Changes in facial and/or eve expression ,/ ✓ ✓ t/ ✓ 4 Pantomine, gestures with eye contact v lA No vocalization 1B Crying ,/ ✓ ✓ 2 Occasional vocalization Verbal ✓ ✓ 3 - !odera te vocalization with some imitation of language patterns 4 Frequent vocalization .,i i th aopropriate use of language patterns 1 Isolate or oassive observer SOCIAL 2 1inimal interaction with one peer or INTERACTION adult 3 Moderate interaction with peer or adult ✓ ✓ v ✓ ✓ v 4 Initiates olay with one or more peers l Non-aware OVERALL 2 Cries, unhappy, uncooperative, tense STATE or aggressive OF 3 Mod erat e participation, watchful, in- CHILD terested ,/ ,/ ,/ ✓ ✓ ✓ 4 Happy, playful, cooperative COMMENTS and/or OBSERVATIONS T 1 ACH 1 RS 1 SlJlVlM RY OF OS VATIO S 153 Name Birthdate --------------- ------- D a~nosis -------------------------- No. of T mes ntered Date Observer ----------- TAT O CHILD UPON ENTRY: COMMUNICATIO --Non- erbal Verbal SOCIAL I C IO: Date of ep rt ------- ov LL STAT OF CHILD (Comments, General Observat ons, valuat ons): 154 T INO OGY U I TH~SI ·nitions f Terms Used ccommodation. Modification of sequences of mental or physical actions to solve pro lems as a result f new exp rience . Atypical ch"ld. child whose velopment ·s a - n rma eith r physically o emotionally or a com ination of both. wh ch is mage or schema. A ental represe tat o velo ed throu h nformat on received from sens ry receptors an rein orced b feed ack fro purpose ful movement. It requ res neurol ical or anizat on of tactile inest1et·c an vest· ular stimu1· in associ ation ith p ann mov ment. Gross otor activ·ties. Movements ·n h ch the arge muscle grou s artici at as oppo ed to the fine el cate movements such a rehensi e activities . Ha tuation . "Decrease sensory reactivity of a fairly p rmanent nature." The phenomenon may e duet a chan in the threshold of sen ory receptors (33:204). Ontogenetic development. The ndivi ual 1 s develop mental progress throu h the normal motor ilestones such as craw1·n walkin and reach"n. eadiness . That period of t·me when a child appears to exhibit an inter st in an activ·ty and is eveloJmentally ready to investigate an learn the activity. 55 ensitization. 11 He ghtened response for the pur- po of different ation wh ch occurs with repetitive expe rience." Percept·on may become more discrim nat·ve or if er ntiated with experience. Sensori-motor earning. Integration of sensory ·nrormation w th move ent to util"ze in learning new motor skil s. astic S asticity of lower extrem1t·es wh ch may occ r in the spastic type of cerebral palsy. S astic ia. Spast·city of both upper and lower extremities n any de ree which may be the result of c rebral palsy. Tactile defensiveness. Hyperact ve or emot onal b havior ue primarily to fight or flight mechan·sm. The child's nervous system is erating at the primat ve defensive stage rather than the integrated discriminative stage . Tactile Sensory integration and organization of sensations received from touching , manipu latin objects . Ability to discrim nate variety of infor mation received from the touch and pressure receptors. BIBLIOGRA HY 156 ◄L'CT D BIBLIOGRAPHY 1. Ames , ouise B. "Individuality of Motor Development," Phys . Ther . 46 (February 1966) . 2 . Anonym us . Developmental Psychology Today, Del Mar, Calif . CRM B oks, 1971 . 3 . Ayres, A . Jean Ph . D. "The Development of Perceptual- 1otor Ab lit e " Arn . J . Occupa . Ther , II , 6 1963 pp . 121-22 . ( "A Theoretical sis for Treat ment of Dy function~) 4. 6. • • o. yres Te t 196. . Jean . uthern Ca f . erceptual otor os An ele estern Psycholo ical Serv·ces (Copyr ht . ) xline, Vir C "ldhoo College Beard uth L ndon nia . Play Therapy, Inner Dynam cs of e ite by Leonard Carm chael, Tufts Cambridge Mass . , Hou hton-Miffl n 1947. • iaget•s Developmental Psychology outed e and e an Paul 196 . Bi·ou S dney. C il Development of the Universal Sta e Vol. 2 Century Crofts 1967. arly Re nforcers e1 Y rk, Appleton- Birch Herbert and Arthur ef or . Inters n ory Devel opment in Chil ren, Mono raphs of the Soc ety for esearch n C il Development Serial . 89 Vol . 2 o . 5, 1963 . Blom Gaston M . D. , Gordon arley , M . D. and Car Guthals , M . d . "The Concept of Boy Ima e and the emediat · on of Body Ima e Disor ers , ,. • a r nin Disabilities, Sept . 1970. Bobath , Berta . 11 The Treatment of Neuromuscular n · s orders by Improvin Patterns of Co -ordinat ·on,' u . Ph si ther January 1969 . 11 . Cratty r yant J . Movement Behavior and Motor Learn ng Phila e l ph a, Lea and Feb er 1967. 157 12. 3. 14. 5. 16. 18. 15 Dennis, ayne and Marjorian. 11 Infant Development Under nvirorunental Hand cap, '' in sych. Monorraph, 1957, #71, No. 7. Dubnoff Belle. "•arly Detection and emed at·on of Learn in D sab lit es 11 unpublished art cle, Dubnoff School for ducat·onal Therapy, orth Hollywo d, Calif., March, 1970. Dubnoff, lle. "=>erceptual Training as a Bridge to Conceptual Ability" (a Multifacted Approach), in 1 ducationa Ther., Special Child Pu 1 cations of Seq · Scho 1, Inc., eattle April, 966. Fi ts Paul and Michael Posner . Human Performance, elmont, Calif. Brooks/Cole, 1967. uller, Friedrich n Ha kin. ichigan U. J. lls Vol. 29 1969 ( ortner • Gesell Arnold and Amatru a, C.S. Dia~no is, e; York Harper and ed. • Developmenta 1947 (2nd Goff. Barbara. Phys·other "Appropriate Afferent Stimu ation 11 January and February, 969. 19. Hansen, Deanna. 'The ffec of a Cone ntrated Program in Movement Behavior on the Affective Behavior of Four-Year-Old ch·l ren 'unpublished Ph.D. Dissertat on, Uni. o California, Los Angeles, 1970. 20. Hatcher Caro, d. D. and H 0 lda Mullin. More Than Words. Movement Activities for Chi dren . Pasadena Parents for Movement, 1967. 21. Hunt Valerie V. 'Movement Behavior a Model for Act on," Quest 1lono;:raph No . 2, pril, 1964. (Pu 1 cat on o~ N~tl. Assn. Coll. omen). 22. Hurlock, 1·zabeth B. Child Growth and Development, New York, McGraw H 11, 1956 (2nd edition) . 23. R •• Illingsworth . and Yo · J lliam The evelopment of the Infant Normal and Abnormal , Baltimore ins 1970. - 159 2L~ . Jones Mar aret H., M . D., a nd Mary L. Barr tt . 11 ensory Story with Thr ee Dimensional Model Turntables , " Jev . Med . Child Neur o, 19 , 1969 . 25 . 26 . Landreth Knopf Catherine . 1967. Montessori Maria . Schocken Book _arly Childhood , ew York Dr . ontessor 's Own Handbook , e, York 1965 . 27 . Mu sen , aul H., John J . Con er , and Jerome a an . Child Develo ment and Per onality Ne~ York Harper and 19 9. 2 • Murray, John B. Develo mental Psyc o o Y, e•; York St . John ' s Uni . 1965 11 sychologica tudies of aturat·o and Learni . 29 . 30 . ood argaret . Lectures, pr n Univ. o 1 69 . oo 1argaret S un·v . o Communication an Int rv outhern Calif. Class Southern Cal·f . >ersonal e • 31 . Silberzahn, ary L. Univer ity of Southern Califor n a Cl ss Lectures Child Development e . 1971 . 32 . S 1th 1 arl and John P. Henr . tions for eha ·1·tation 11 Vol . 46 eb . 196 No . 1 . C ber etic Faun a r . J • "'hys . M d • , 33 . Solley, Charles M . and Gardner Murphy . Development of the erce t al World e York, Bas · c Books 19 7. 34 . S lnit , b rt J . an Prov nc . Modern 1ros- ectives in Chi d D ment e · York Interna- tional Pre~ _I_n_c __ ___ ._c_ __ 35 . Stewart , Mary Lou. Sp culations," 1971 . "A Child ' s First Steps : Some ·1a cat · on Vol . 47, N . 6, 36 . Stott , Leland H. Ch 1 Devel)~ e1 u~l ongitudinal - r- ~ - a- c~ h -,_;...,,. N ~ e-~----'-------- d- \J . nston_ Inc. , 1J6 { . 37 . uutton - mith , Br ian . 'C dren at Pay at ---- ________ M _ a ___ g_ a_ z_ i_ n_ e c • 1971 ew York . Nat 1 . H·· st . (pub . ) • L •

Asset Metadata

Creator Taylor, Janet Louise (author)

Core Title An innovative play environment for handicapped children

Contributor Digitized in 2022 (provenance)

School Department of Physical Therapy

Degree Master of Arts

Degree Program Physical Therapy

Degree Conferral Date 1972-06

Publication Date 06/01/1972

Defense Date 06/01/1972

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Children with disabilities,OAI-PMH Harvest,Play therapy

Format theses (aat)

Language English

Advisor Rood, Margaret S. (committee chair)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC112723836

Unique identifier UC112723836

Identifier P.Th. '72 T243 (call number),etd-TaylorJanet-1972.pdf (filename)

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Rights Taylor, Janet Louise

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