American Journal of Occupational Therapy

The articles for the Special Section on Play highlight the complexity of play and the many ways occupational therapy practitioners study and promote play with children, families, and adults across individual, school, family, political, and cross-cultural settings. The authors of the articles in this issue view the importance of play across the lifespan and through multiple research lenses, including play preference, environmental supports for and barriers to play, the skills required to succeed in play, and the extent to which play is self-determined. The guest editors offer suggestions for how to enhance occupational therapy’s voice in the study and promotion of play as a primary lifelong occupation.

The guest editors for the Special Section on Play offer suggestions for how to enhance occupational therapy’s voice in the study and promotion of play as a primary lifelong occupation.

Importance: Assessment of praxis skills is an essential aspect of understanding autistic children’s development of play and playfulness.

Objective: To assess the relationship and influence of ideational praxis skills on play skills and playfulness among autistic children.

Design: A cross-sectional study.

Settings: Homes, schools, and early care centers across Spain.

Participants: Children ages 4 yr 6 mo to 6 yr 11 mo (45 typically developing [TP] and 45 with autism spectrum disorder [ASD]).

Outcomes and Measures: Student’s t tests were used to compare means between the two groups. Pearson’s correlation and multiple linear regression were used to determine possible effects of ideational skills on play and playfulness.

Results: Scores for the TP group were significantly higher than those of the ASD group on all play dimensions—space management, t(88) = 4.58; material management, t(88) = 5.86; pretense–symbolism, t(88) = 8.12; and participation, t(88) = 7.31—and on the Test of Playfulness (ToP), t(88) = 10.18, and Test of Ideational Praxis (TIP), t(88) = 4.38 (all ps < .001). Multiple linear regression revealed a statistically significant effect of TIP dimensions—space management, F(3, 41) = 4.83, p < .042; material management, F(3.41) = 8.49. p < .001; pretense–symbolism, F(3, 41) = 5.66. p < .002; and participation, F(3.41) = 7.81. p < .001—and on the ToP, F(3, 41) = 5.96. p < .002.

Conclusions and Relevance: Ideational praxis skills combined with diagnostic information significantly predicted play skills and playfulness, highlighting the influence of ideation on play.

Plain-Language Summary: This article provides data supporting the influence of ideational praxis skills on the play skills and playfulness of autistic children. Understanding how ideational praxis skills affect the ability to recognize and act on object affordances might promote greater possibilities for play interactions among autistic children.

The study findings provide data that support the influence of ideational praxis skills on the play skills and playfulness of autistic children.

Importance: Parent recall is the primary method for measuring positioning practices such as tummy time in infants. Concerns regarding the accuracy of parent recall have been raised in the literature. To date, no study has examined the agreement of tummy time recall measures with gold-standard methods.

Objective: To assess the agreement between parental recall versus direct observation of tummy time in infants, and to explore the impact of prematurity on this relationship.

Design: Cross-sectional observational study, spanning 1 yr.

Setting: Participants’ homes

Participants: Thirty-two infant–parent dyads (19 full-term, 13 preterm), with infants ages 3 to 6 mo and caregivers ages older than 18 yr.

Outcome and Measures: Home-recorded videos of infant play across 3 days were used as a proxy for direct observation of tummy time and compared with a 12-item parent recall survey.

Results: Parent recall had a significant moderate correlation (ρ = .54, p = .002) with direct observation in full-term infants but was not correlated (p = .23) with direct observation in preterm infants. On average, parents of preterm infants overestimated tummy time by 2.5 times per day compared with direct observation.

Conclusions and Relevance: For full-term infants, parent recall measures of tummy time exhibit an acceptable level of agreement with direct observation and can be reliably used over shorter periods. Parents of preterm infants may display a bias in recalling tummy time, leading to overestimations. To accurately assess tummy time in this population, a combination of subjective and objective measures should be explored.

Plain-Language Summary: Tummy time is an essential movement experience for infants, especially for preterm infants, who are at a higher risk for motor delays. The most common way to track tummy time is through parent reports, or recall, versus a practitioner directly observing tummy time in the home. Despite the widespread use of parent recall to track tummy time, no study has examined the accuracy of parent recall versus direct observation in the home. Accurately assessing tummy time is crucial for improving and supporting health outcomes for infants. This study found that prematurity may affect the accuracy of parent recall for assessing tummy time in young infants. The authors discuss the implications of this finding and provide suggestions to guide the selection of appropriate methods to measure tummy time in clinical practice and research studies.

This study found that infant prematurity may affect the accuracy of parent reports, or recall, of tummy time in the home versus a practitioner directly observing infant tummy time.

Importance: Play is the primary occupation in childhood and fundamental to occupational therapy practice.

Objective: To evaluate a play intervention in special school settings.

Design: Pre- and postinvolvement of a 7-mo play program.

Setting: Four special schools in Victoria, Australia, for children with IQs < 70.

Participants: Thirty-eight children with diagnoses including intellectual disability, autism, and global developmental delay, 7 teachers, 2 speech pathologists, and 2 occupational therapists.

Intervention: Learn to Play Therapy for 1 hr per week over a 7-mo period.

Outcomes and Measures: Pre–post outcome measures included children’s pretend play skills, language, social skills, emotional regulation, and academic competence.

Results: Mean age of 38 children (15 girls and 23 boys) at baseline was 5 yr 7 mo (SD = 0.46 yr). Results showed significant changes in children’s pretend play (p = .03), ability to recall sentences (p = .02), social skills (p = .022), and academic competence (p = .012). Learn to Play had a large effect on children’s narrative skills (d = 2.72). At follow-up, object substitution at baseline influenced expressive language (p < .001), narrative mean language utterance (MLU; p = .015), social skills (p < .001), and academic competence (p < .001); elaborate play at baseline plus time influenced social skills (p < .001); and elaborate play at baseline influenced narrative MLU (p =. 016), sentence recall (p = .009), and academic competence (p = .001).

Conclusions and Relevance: Embedding pretend play within practice positively influenced children’s language, narrative, social, and academic skills.

Plain-Language Summary: This study adds to the limited research on play-based therapy programs in special school settings for children with an IQ of less than 70. Children participated in Learn to Play Therapy, during which an occupational therapist, who has observed and assessed the child’s play and understands the child’s play abilities, played beside the child. Learn to Play Therapy is a child-centered therapy that is used to increase a child’s ability to self-initiate and enjoy pretend play. The positive impacts of supporting the children’s pretend play ability were highlighted by increases in their pretend play, language, social skills, academic competence, and narrative language after participating in Learn to Play Therapy in their special schools.

This study adds to the limited research on play-based therapy programs in special school settings for children with an IQ of less than 70.

Importance: Play has been viewed as a critical occupation supporting health since the founding of occupational therapy, but the complexity of play presents challenges to scholars who study adults. Researchers in occupational science and occupational therapy often address experiential qualities of occupations, including those considered to be play. However, the literature lacks clear descriptions of what constitutes adult play as well as the experiences of adults during preferred activities.

Objective: To contribute to the body of knowledge on the wide range of preferred activities adults in the United States pursue and may perceive as play experiences. We refer to these activities as adult play because they contain experiential qualities of play described in key play literature.

Design: Cross-sectional survey study.

Setting: A 31-item survey, the Daily Occupational Experience Survey–revised (DOESr), was uploaded to Qualtrics for data collection using snowball sampling. The online survey link was distributed to participants aged 18–64 years.

Participants: The survey was completed by 491 participants. Exploratory factor analysis was used to extract the most prevalent patterns of play experiences reported. Internal consistency and content validity were also examined.

Results: The factor analysis yielded an optimal solution of five factors representing distinct patterns of adult play experiences: Creativity–Adventure, Restoration, Deep Engagement, Ludos, and Mastery.

Conclusions and Relevance: The five factors identified by the DOESr represent distinct patterns of adult play experiences. The DOESr demonstrated acceptable internal consistency for three of the five factors as well as for the overall tool.

Plain-Language Summary: Previous research on adult occupations has not addressed the array of experiences that adults seek or enjoy while engaging in play. This study identified five patterns of adult play experiences. Understanding these patterns may assist occupational therapy practitioners when tailoring clients’ play experiences to promote optimal health and well-being.

This study contributes to the body of knowledge on what constitutes adult play as well as the experiences of adults during preferred play activities.

Importance: Although research has examined early identification of autism spectrum disorder (ASD), few studies have found behavioral markers during midinfancy associated with later ASD diagnosis.

Objective: To examine infants’ play behaviors and atypical positions at age 6 mo and later outcome classification among infants at elevated likelihood (EL) and typical likelihood (TL) for ASD. Atypical positions refer to movement patterns indicative of motor delays or deviations, including atypical extension and flexion, poor weight shift and rotation, hypertonicity or hypotonicity, and the presence of primitive reflex patterns.

Design: Observational cohort longitudinal design using blinded video analysis.

Participants: Fifty-eight infants (41 EL infants and 17 TL infants) 6 mo of age.

Results: Infants later diagnosed with ASD needed more support to engage in play at age 6 mo compared with infants who did not receive an ASD diagnosis (U = 130, z = −2.29, p < .05, r = .31). Atypical positions at 6 mo of age were not associated with a later diagnosis of ASD.

Conclusions and Relevance: Play behaviors may be early indicators of developmental differences for infants later diagnosed with ASD. The results of this pilot study suggest the need to observe the quality of interaction with a caregiver and objects during early play, which may serve as potential early indicators of ASD.

Plain-Language Summary: Few studies have found behavioral markers during midinfancy that are associated with a later diagnosis of autism spectrum disorder (ASD). The results of this study showed that infants who were later diagnosed with ASD were found to have differences in play behaviors compared to infants who were not later diagnosed with ASD. Thus, early play behaviors may be an early indicator of developmental differences for infants who are later diagnosed with ASD.

Infants who were later diagnosed with autism spectrum disorder (ASD) were found to have differences in early play behaviors compared to infants who were not later diagnosed with ASD.

Importance: Research is limited regarding parent–caregiver perspectives of occupational therapy (OT) intervention for children with challenges in sensory processing and integration and whether changes immediately following OT intervention are sustained over time.

Objective: To evaluate whether changes in identified goals are maintained following OT intervention and to determine what aspects of OT intervention parents–caregivers perceive to be most valuable.

Design: A mixed-methods research design.

Setting: A large midwestern pediatric hospital, with follow-up telephone interviews with parents–caregivers.

Participants: Sixteen children with sensory challenges and their parents–caregivers.

Intervention: Children participated in 1-hr OT intervention sessions, 3 days per wk, for 6 to 7 wk. Parents–caregivers of children who completed OT intervention were interviewed via the telephone 6 to 12 mo after the intervention.

Outcomes and Measures: The Canadian Occupational Performance Measure (COPM) and Goal Attainment Scaling (GAS) were used to determine whether changes were made and sustained over time. Qualitative data on caregiver perceptions of OT intervention were collected via open-ended questions during phone interviews. COPM and GAS scores before intervention were statistically significant compared with scores immediately following intervention and at 6- to 12-mo follow-up. Five themes emerged from the qualitative data.

Conclusions and Relevance: Children with sensory challenges made significant changes related to occupational performance following OT intervention, and goal achievement was sustained over time. Parents–caregivers valued many aspects of the OT program, including the increased frequency of therapy services, the occupational therapist’s advanced knowledge and skills, and the education and information provided during the program.

Plain-Language Summary: This study supports the results of previous studies on OT intervention for children with challenges in sensory processing and integration. The study also adds to the body of knowledge that shows that changes and progress toward goals that result from skilled OT intervention can be sustained over time. The study showed that children participating in OT intervention made statistically significant changes while receiving OT services and maintained progress after intervention ended; however, the children did not continue to make significant progress toward goals once skilled OT services ended. Parents and caregivers of children with sensory challenges reported that they found OT intervention to be beneficial. Other important factors influencing the effectiveness of OT intervention that were identified by parents–caregivers included the education provided by the occupational therapist, the increased frequency of therapy services, and the increased knowledge and skills of the occupational therapists who provided the intervention.

Children with challenges in sensory processing and integration made significant changes related to occupational performance following OT intervention, and goal achievement was sustained over time.

Importance: Children with hemiplegic cerebral palsy (HCP) require intensive task-oriented training to make meaningful gains in affected upper extremity (UE) motor function.

Objective: To evaluate the acceptability and utility of single joystick-operated ride-on toy (ROT) navigation training incorporated into a modified constraint-induced movement therapy (CIMT) camp for children with HCP.

Design: Single group pretest–posttest design.

Setting: Three-wk structured CIMT camp.

Participants: Eleven children with HCP between ages 3 and 14 yr.

Intervention: Children received group-based CIMT for 6 hr/day, 5 days/wk, for 3 wk. As part of camp activities, children also received ROT navigation training for 20 to 30 min/day, 5 days/wk, for 3 wk.

Outcomes and Measures: We assessed children’s acceptance of ROT training by monitoring adherence and evaluating child engagement (affect and attention) during training sessions. The effects of ROT training combined with other camp activities on children’s affected UE motor function were also assessed with the standardized Quality of Upper Extremity Skills Test (QUEST) and training-specific measures of ROT maneuvering accuracy.

Results: Children demonstrated high levels of training adherence, positive affect, and task-appropriate attention across weeks. Positive engagement during ROT sessions was correlated with independent navigation. We also found medium- to large-sized improvements in QUEST scores and toy-maneuvering capabilities after the combined program.

Conclusions and Relevance: Our pilot data support the use of joystick-operated ROTs as child-friendly therapy adjuncts that can be incorporated into intensive UE training programs to improve adherence and motivation in therapy programs, boost treatment dosing, and promote affected UE motor function in children with HCP.

Plain-Language Summary: This pilot study offers promising evidence that supports the use of modified single joystick–operated ride-on toys (ROTs) for children with hemiplegic cerebral palsy (HCP). The study used ROTs as one of several interventions that were part of a constraint-induced movement therapy (CIMT) camp program for children with HCP. The ROTs boosted children’s motivation, their engagement with and adherence to training, and their practice in using their affected upper extremity (UE) for goal-directed activities in their natural settings. ROTs are accessible, age-appropriate, and easy-to-use devices for both occupational therapy clinicians and families to encourage children to use their affected UEs by challenging their perceptual, motor-planning, problem-solving, and movement-control skills in an enjoyable and engaging way. ROTs can be used within and outside conventional rehabilitation settings.

This pilot study offers promising evidence that supports the use of modified single joystick–operated ride-on toys for children with hemiplegic cerebral palsy.

Importance: Although play and positive caregiving strategies have been associated with child well-being, little is known about the relationship between play type and strategies used by caregivers in early childhood.

Objective: To investigate whether a relationship exists between play type and positive caregiving strategies.

Design: Exploratory correlational nonexperimental design.

Setting: Early childhood center.

Participants: A convenience sample that included 60 observations of 14 caregivers during a therapeutic playgroup with 14 children with and without disabilities ages 15 mo to 3 yr (4 fathers, 3 mothers, 1 nanny, and 6 female early childhood teachers; age range = 30–39 yr). The caregivers were Black (n = 1; 7.1%), Hispanic (n = 5; 35.7%), and White (n = 8; 57.1%).

Outcomes and Measures: Positive caregiving strategies were scored using the Parenting Interactions with Children: Checklist of Observations Linked to Outcomes.

Results: Results revealed no significant correlations between play type and positive caregiving strategy. There was a positive, significant correlation between caregiving strategies (affection, responsiveness, encouragement, teaching, and total; r _pbs = .767–.970, n = 58, p = .001). The play type and caregiver type variables did not predict total positive caregiving strategies, F(2, 57) = 2.147, p = .126. One variable, caregiver type, added statistical significance to the prediction (p = .045).

Conclusions and Relevance: The findings show no relationship between play type and positive caregiving strategy. Consideration of the types of caregivers participating in a therapeutic playgroup and their roles and use of positive strategies during play is worthy of further investigation.

Plain-Language Summary: This study explored how parent and teacher caregivers supported children (both with and without disabilities) during a therapeutic playgroup at an early childhood center. Therapeutic playgroups are a special type of group play in which a trained professional helps guide play activities to support participation. The researchers wanted to see whether there was a connection between the type of play the children engaged in and how the adult caregivers interacted with them. The surprising finding was that there was no link between play type and how caregivers interacted. However, the caregivers often used positive strategies with the children, regardless of the play activity. Interestingly, type of caregiver (parent, teacher) seemed to make a slight difference in how they interacted with the children during playtime. Overall, this study suggests that more research is needed to understand how the types of play activities and objects might influence caregiver interactions during group play.

This study explored how parent and teacher caregivers supported children (both with and without disabilities) during a therapeutic playgroup at an early childhood center.

Importance: Benefits of children’s participation in risky play are broadly recognized. However, most related research originates in Western countries; none focuses on outdoor play in Eastern countries, including Saudi Arabia. Furthermore, although the literature identifies varying perspectives on risky play among parents, there is no objective measure to assess personal, situational, and cultural factors shaping their risk tolerance.

Objective: To establish the construct validity and internal reliability of data gathered with the newly developed Factors Affecting Tolerance for Risk in Play Scale (FAC–TRiPS).

Design: Instrument development.

Setting: Online survey.

Participants: Ninety Saudi parents with children ages 7 to 10 yr.

Outcomes and Measures: The FAC–TRiPS, a 17-item, self-report measure. We used Rasch analysis (Winsteps 4.4.4) to establish evidence for construct validity (item fit, match of item difficulty and parent tolerance, principal-components results) and internal reliability (person reliability index).

Results: Item fit analysis revealed that data from 15 of 17 items (88%) conformed to Rasch model expectations. Item difficulty closely matched parents’ risk tolerance level. The principal-components analysis of residuals demonstrated that observed variance (49.6%) closely matched expected variance (49.7%). The first contrast’s unexplained variance had an eigenvalue slightly greater than 2.5, suggesting possible multidimensionality. The person reliability index was .90.

Conclusions and Relevance: Preliminary analysis suggests that the FAC–TRiPS yields valid, reliable data measuring factors that influence parents’ risk tolerance. Further research is needed.

Plain-Language Summary: This study contributes to the knowledge of how parents in Eastern countries perceive risky play. The Factors Affecting Tolerance for Risk in Play Scale (FAC–TRiPS) is a newly developed tool that occupational therapy practitioners can use to understand parents’ beliefs about and tolerance for their children’s participation in risky play. The findings facilitate an understanding of the complex nature of parenting when determining whether to allow children to participate in risky play activities.

The findings of this study show that the Factors Affecting Tolerance for Risk in Play Scale (FAC–TRiPS) has utility for practitioners who want to explore parents’ beliefs about and tolerance for their children’s participation in risky play.

Importance: Contextual elements at school playgrounds compromise the right to play. An occupation-based social transformation project to foster occupational justice in play at a school playground was conducted.

Objective: To better understand barriers to and facilitators of children’s participation in occupations at the school playground to co-create actions that enable play.

Design: A participatory methodology—Photovoice—was used. The research consisted of four phases: involving the community in the research design, community-led data generation and analysis, discussion of findings to increase the community’s awareness, and a community agenda for changing the playground.

Setting: Public primary school playground in northwest Spain.

Participants: All children (n = 450, ages 3–12 yr), families (n = 12), and teachers (n = 15) participated. A thematic analysis of visual, textual, and oral material was conducted, including member checking.

Results: The study revealed several barriers to play, including the short recess duration, poor floor (surface) conditions, jail-like atmosphere, and violence. However, participants identified an ad hoc lending games system and playground murals advocating for children’s rights as facilitators. These findings have direct implications for improving the play environment.

Conclusions and Relevance: Conflicting priorities between children’s and adults’ desires and needs for the playground were unveiled, displaying the relevance of invisible contexts (i.e., social or institutional contexts) in shaping play opportunities. A critical occupational stance combined with a participatory and playful methodology generated space to unveil these conflicting priorities, reconcile agendas, raise awareness, and propose collective actions to transform the playground.

Plain-Language Summary: Playing is fundamental to children’s development and inclusion. This study focused on making school playgrounds better places for kids to play. Researchers found that things such as short playtimes, bad playground conditions, and violence made it tough for kids to enjoy playing, but they also discovered some good things, such as a system for borrowing games and colorful murals promoting children’ rights. These findings show that changing the playground’s physical and social environment can make a big difference for kids. By listening to kids and working together, adults and children can create playgrounds where all kids can play meaningfully and safely. Occupational therapists can promote such processes.

Changing a playground’s physical and social environment can create better places for kids to play.

Core concepts in occupational therapy have often developed over time with contributions from multiple clinicians and scholars. This makes it difficult to determine exactly from where, or from whom, ideas originated. Without original sources, we cannot chart the historical development of ideas and honor those whose scholarship made it possible. This article documents the process undertaken to properly cite one such common concept in occupational therapy, the just-right challenge; illustrates the value of doing so; and advocates for the importance of thorough historical scholarship.

The authors discuss the process of properly citing the just-right challenge, a core concept in occupational therapy, and highlight the importance of thorough historical scholarship.

Importance: The transactions between the physical environment and children’s play have not been well studied. The theory of affordances provides a way to better understand how environmental characteristics offer opportunities for play occupation.

Objective: To investigate the relationship between environmental characteristics of outdoor play spaces and children’s outdoor play and to develop an environmental taxonomy to support the analysis of play affordances in community play spaces.

Data Sources: Peer-reviewed literature (1974–2023) was sourced from a previously published scoping review (Morgenthaler, Schulze, et al., 2023). The Academic Search Complete, Avery Index to Architectural Periodicals, CINAHL, MEDLINE, PsycINFO, Scopus, and Web of Science databases were searched using the keywords and synonyms of playground, environmental qualities, and children with and without disabilities.

Study Selection and Data Collection: A secondary analysis of the previously published scoping review was conducted. Included studies were those that provided descriptions of physical environment–play activity transactions.

Findings: A qualitative content analysis of 45 articles was conducted and used to form an environmental taxonomy. This taxonomy consisted of 14 space and object categories defined by their functional qualities and linked to play affordances. An array of 284 play occupations were identified in different forms. Play affordances of spaces and object categories and their functional environmental qualities were subsequently identified.

Conclusions and Relevance: This study provides evidence to support the understanding of how the physical environment shapes children’s outdoor play occupations.

Plain-Language Summary: The study authors developed the Environmental Taxonomy of Outdoor Play Space Features as a tool that occupational therapists can use to better understand and describe how the physical environment shapes opportunities for play. The tool could also be useful to justify environmental intervention in schools and public playgrounds to create spaces that support more play for a diversity of children.

This study supports the understanding of how the physical environment shapes children’s outdoor play.

Importance: Outdoor play in homes, schools, and communities provides children with unique opportunities to explore their worlds, develop fundamental life skills, and experience belonging. However, few studies have explored outdoor free play among autistic preschoolers in natural settings from a neurodivergent-informed perspective.

Objective: To explore the play preferences, opportunities, and challenges in outdoor play for autistic preschoolers.

Design: In this qualitative study, the authors used a multimethod approach to data collection using visual, verbal, and projective techniques and thematic analysis to identify and describe outdoor play occupation as expressed by autistic preschoolers.

Setting: Home, community, and preschool environments in a city in Ireland.

Participants: Seven autistic children and their parents, from seven diverse preschool settings in Ireland.

Results: Two overarching themes were identified: (1) outdoor play preferences and meaning and (2) the physical and social environments of outdoor play. The findings suggest that autistic preschoolers demonstrate distinctive play styles and preferences when playing freely outdoors, with physical and social barriers to outdoor play existing in community and educational contexts.

Conclusions and Relevance: The findings suggest that autistic preschoolers’ outdoor play styles and preferences require support from adult advocates. Although the importance of relationships and social play cannot be overlooked, infrastructural accommodations for parents and schools are required if we are to create supportive and inclusive outdoor play environments and opportunities for freedom of expression for autistic children.

Plain-Language Summary: This study explored the distinctive outdoor play preferences, opportunities, and challenges for autistic preschoolers. The findings show that autistic preschoolers face physical and social barriers to outdoor play and that they need parents, schools, and communities to create supportive and inclusive play environments and opportunities for freedom of expression.

This study found that autistic preschoolers face physical and social barriers to outdoor play and that they need parents, schools, and communities to create supportive and inclusive play environments and opportunities for freedom of expression.

Importance: There is a need for tools to measure adults’ playfulness in reference to parent–child joint play.

Objective: To (1) develop items for the Scale of Parental Playful Attitude (PaPA), (2) evaluate evidence for validity based on content, and (3) evaluate evidence for validity based on the response process.

Design: A mixed-methods design with three phases: (1) development of the first draft of the PaPA (based on the literature, focus groups, and semistructured interviews), (2) review by experts and revision of the first draft, and (3) cognitive interviews with parents.

Setting: Various (e.g., schools, a university).

Participants: Phase 1 had 32 participants: 13 parents of children ages 2.5–6 yr without major diagnosed conditions; 8 parents of autistic children age 4–7 yr; and 11 preschoolers age 3–5 yr. Phase 2 involved 10 experts. Phase 3 had 5 participants: 3 mothers and 2 fathers of children ages 2.5–6 yr; 1 child was autistic.

Outcomes and Measures: Interview protocols and experts’ review form.

Results: Phase 1 involved the initial item development. Extrinsic motivation and barriers to play emerged as important areas to include. Experts’ review enhanced representation of the construct of playfulness. Content validity index values ranged from .78 to 1.00. Cognitive interviews provided insights into parents’ comprehension of PaPA items.

Conclusions and Relevance: Validity related to test content and the response process was supported. Additional sources of validity testing are necessary.

Plain-Language Summary: Adult playfulness is critical for both the child and the parent, especially for developing a deeper connection. The Scale of Parental Playful Attitude (PaPA) assesses parents’ self-perceptions of their playfulness when playing with their child. The study authors developed the PaPA (in both English and Spanish) to address a lack of tools for assessing how parents perceive their own playfulness relative to their child’s playfulness. Understanding how parents perceive their own playful attitudes can create opportunities for occupational therapists to guide parents to approach play with an attitude that is as attuned as possible to their child’s playfulness. Future validity studies are needed to support the clinical use of the PaPA.

The Scale of Parental Playful Attitude (PaPA) assesses parents’ self-perceptions of their playfulness when playing with their child.

Occupational therapists view play through a unique lens. Considering play as a human occupation, and one to which all people have a right, places occupational therapists among a special group of professionals championing play. This State of the Science article seeks to increase awareness regarding the occupational therapy profession’s contributions and to situate those contributions within the larger body of literature on play while also promoting further study of play as an occupation.

This State of the Science article seeks to increase awareness regarding the occupational therapy profession’s contributions and to situate those contributions within the larger body of literature on play while also promoting further study of play as an occupation.

Importance: There is a need for a pediatric hand function test that can be used to objectively assess movement quality. We have developed a toy-based test, the Bead Maze Hand Function (BMHF) test, to quantify how well a child performs an activity. This is achieved by assessing the control of forces applied while drawing a bead over wires of different complexity.

Objective: To study the psychometric properties of the BMHF test and understand the influence of age and task complexity on test measures.

Design: A cross-sectional, observational study performed in a single visit.

Setting: Clinical research laboratory.

Participants: Twenty-three participants (ages 4–15 yr) were recruited locally. They were typically developing children with no illness or conditions that affected their movement.

Interventions/Assessments: Participants performed the BMHF test and the Box and Block test with both hands.

Outcomes and Measures: Total force and completion time were examined according to age and task complexity using a linear mixed-effects model. We calculated intraclass correlation coefficients to measure interrater reliability of the method and estimated concurrent validity using the Box and Block test.

Results: Total force and completion time decreased with age and depended on task complexity. The total force was more sensitive to task complexity. The Box and Block score was associated with BMHF completion time but not with total force. We found excellent interrater reliability.

Conclusions and Relevance: A familiar toy equipped with hidden sensors provides a sensitive tool to assess a child’s typical hand function.

Plain-Language Summary: We developed the Bead Maze Hand Function (BMHF) test to determine how well a child performs an activity with their hands. The BMHF test is a toy equipped with hidden sensors. Twenty-three typically developing children with no illnesses or conditions that affected their hand movement participated in the study. We asked the children to perform the BMHF test with both hands. Our study found that occupational therapists can reliably use the BMHF test to assess a child’s hand function.

The study results show that occupational therapists can reliably use the Bead Maze Hand Function test to assess a child’s hand function.

Importance: This pilot study evaluates a remote strategy-based intervention for individuals with multiple sclerosis who experience everyday memory impairments. The intervention can potentially inform cognitive rehabilitation for this population.

Objective: To investigate the feasibility and efficacy of an intervention (TELE-Self-GEN) to determine whether it can alleviate everyday memory impairments of individuals with multiple sclerosis.

Design: Pretest–posttest.

Setting: Community.

Participants: Ten adults with multiple sclerosis.

Intervention: Six synchronous treatment sessions were delivered online via Zoom. The treatment protocol embedded a memory strategy (self-generated learning) within a metacognitive framework, including self-awareness and self-management strategies. The treatment emphasizes when and how self-generation should be used.

Outcome: Measurements assessed feasibility and participants’ satisfaction with the intervention and its delivery method, as well as memory, everyday memory, and functional performance.

Results: Participants expressed high satisfaction with the virtual treatment, highlighting its convenience as a key factor. Treatment resulted in improvements in memory performance, perceived memory ability in daily life, and functional performance.

Conclusions and Relevance: Results provide initial proof of concept in the utilization of a remotely delivered, strategy-based treatment approach to improve memory performance and functional abilities. The pilot data support a larger randomized clinical trial of the TELE-self-GEN.

Plain-Language Summary: The results of this pilot study highlight the promising potential of TELE-self-GEN for people with multiple sclerosis (MS), who face memory challenges every day. This remotely delivered, strategy-based occupational therapy treatment approach, TELE-self-GEN, has the potential to significantly improve functional memory. The study participants reported improvements in their memory performance, perceived memory ability in daily life, and functional performance. These encouraging results serve as a foundation for more extensive clinical trials using TELE-self-GEN for people with MS.

The results of this pilot study highlight the promising potential of the TELE-self-GEN intervention for improving everyday memory challenges for people with multiple sclerosis.

Importance: Effective communication skills (CS) are essential for occupational therapists. The Gap–Kalamazoo Communication Skills Assessment Form (GKCSAF) is a standard tool for assessing the CS of medical residents. However, the interrater reliability for the nine CS domain scores ranges from poor to good. The intrarater reliability remains unclear.

Objective: To examine the inter- and intrarater reliability of the GKCSAF’s nine domain scores and total score among occupational therapy interns.

Design: Repeated assessments with the GKCSAF.

Setting: Medical center psychiatry department.

Participants: Twenty-five interns and 49 clients with mental illness, recruited from August 2020 to December 2021.

Outcomes and Measures: The transcripts of 50 evaluation interviews between clients and interns were used. Three independent raters assessed each transcript twice, at least 3 mo apart.

Results: The GKCSAF demonstrated poor interrater reliability for the nine domain scores (weighted κ = .08–.30) and the total score (intraclass correlation coefficient [ICC] = .22, 95% confidence interval [CI] [.10, .35]). The GKCSAF showed poor to intermediate intrarater reliability for the nine domain scores (weighted κ = .27–.73) and fair reliability for the total score (ICC = .69, 95% CI [.60, .77]).

Conclusions and Relevance: The GKCSAF demonstrates poor interrater reliability and poor to intermediate intrarater reliability for the nine domain scores. However, it demonstrates fair intrarater reliability in assessing the overall CS performance of occupational therapy interns. Significant variations were observed when different raters assessed the same interns’ CS, indicating inconsistencies in ratings. Consequently, it is advisable to conservatively interpret the CS ratings obtained with the GKCSAF.

Plain-Language Summary: It is essential for occupational therapists to effectively communicate with clients. The Gap–Kalamazoo Communication Skills Assessment Form (GKCSAF) is a standard tool that is used to assess the communication skills of medical residents. The study authors used the GKCSAF with occupational therapy interns in a medical center psychiatry department to assess how effectively they interviewed clients with mental illness. This study aids occupational therapy personnel in the interpretation of GKCSAF results. The study findings also highlight the importance of developing reliable and standardized measures to assess communications skills in the field of occupational therapy.

The authors used the Gap–Kalamazoo Communication Skills Assessment Form with occupational therapy interns in a medical center psychiatry department to assess how effectively they interviewed clients with mental illness.

Importance: Veterans receiving inpatient psychiatric services with limitations in activities of daily living (ADLs) benefit from occupational therapy, yet disparities in access are unknown.

Objective: To investigate whether ADL limitations, an indicator of occupational therapy need, was associated with inpatient psychiatric occupational therapy utilization in the Veterans Health Administration (VHA) and whether this relationship differs by facility characteristics.

Design: Secondary analysis of VHA data. Modified Poisson regression modeled occupational therapy utilization as a function of ADL limitations, facility characteristics, and covariates. Interactions estimated whether the relationship between ADL limitations and occupational therapy utilization differed across facility characteristics.

Setting: VHA inpatient psychiatric setting.

Participants: Veterans receiving VHA inpatient psychiatric care from 2015 to 2020 (N = 133,844).

Outcomes and Measures: Occupational therapy utilization.

Results: Veterans with ADL limitations were more likely to receive occupational therapy. Veterans receiving care in facilities with higher complexity and greater inpatient psychiatric care quality were more likely to receive occupational therapy. Additionally, Black veterans were less likely to receive occupational therapy relative to their White, non-Hispanic counterparts. Interactions indicated that the extent to which ADL limitations drove access to occupational therapy utilization was weaker within facilities with higher complexity and care quality.

Conclusions and Relevance: Veterans with ADL limitations were more likely to access inpatient psychiatric occupational therapy, suggesting that such services are generally allocated to veterans in need. However, findings indicate disparities in access across patient-level (e.g., Black race) and facility-level (e.g., facility complexity) factors, informing efforts to eliminate barriers to accessing these valuable services.

Plain-Language Summary: This is the first study, to our knowledge, to examine disparities in access to inpatient psychiatric occupational therapy in the Veterans Health Administration (VHA). The study findings show that access to inpatient psychiatric occupational therapy is partly driven by the needs of the patient. However, nonclinical factors, such as a patient’s race and the characteristics of the facility at which they receive care (complexity, number of psychiatric beds available, and the quality of psychiatric care), are also important drivers of access. Identifying factors influencing access to these valuable services is the first step in developing strategies that reduce barriers to access for veterans in need.

This is the first study to examine disparities in access to inpatient psychiatric occupational therapy in the Veterans Health Administration.

Importance: Clinicians and researchers can leverage clinical documentation of therapy services for quality improvement and research purposes. However, documentation is often institution specific and may not adequately capture the dose of therapy delivered, thus limiting collaboration.

Objective: To implement documentation of pediatric occupational and physical therapy dose from one institution to another institution. Dose documentation includes the frequency, intensity, time, and type of interventions delivered (FITT Epic^® Flowsheet) at each session.

Design: Prospective time-series quality improvement study.

Setting: Two large urban pediatric hospitals.

Participants: Occupational and physical therapy staff members.

Intervention: Staff training and feedback loops utilizing existing groups.

Outcomes and Measures: The process measure (number of available staff trained and using the FITT Epic Flowsheet over time) and the outcome measure (percentage of FITT Epic Flowsheets used for treatment visits each month) were analyzed using a statistical process control chart. The balancing measure (percentage of notes closed before 7 p.m. on the same day as the encounter) was analyzed using mean per month across three time periods.

Results: Fifty-seven staff members (68%) attended formal training. On average, clinicians documented 90% of sessions using the FITT Epic Flowsheet after implementation. There was no change observed in the balancing measure.

Conclusions and Relevance: Documentation of dose was spread from one institution to another. Shared documentation will facilitate future collaboration for quality improvement and research purposes. Occupational therapy practitioners and leaders should consider implementing documentation with common dose elements.

Plain-Language Summary: Occupational therapy documentation is often institution specific and may not adequately capture the dose of therapy (frequency, intensity, time) or types of interventions that were delivered, thus limiting opportunities for collaboration between institutions. This article adds to the literature on administrative supports for clinical and quality improvement research by illustrating a specific example of how documentation of dose can be shared from one institution to another. The data show that clinicians at one institution started using a new style of documentation using the FITT Epic^® Flowsheet and shared discrete dose elements with another institution, creating new opportunities for collaboration. Shared documentation can facilitate future collaboration for quality improvement and research purposes.

This article adds to the literature on administrative supports for clinical and quality improvement research by illustrating a specific example of how documentation of dose can be shared from one institution to another.

Importance: Patient-reported outcome measures provide insights into intervention effects on patients. The Canadian Occupational Performance Measure (COPM) emphasizes identifying priorities in daily activity engagement and evaluating an individual’s perception of changes over time.

Objective: To assess the responsiveness of the COPM and the minimal clinically important difference (MCID) among patients with frozen shoulders.

Design: Prospective, single-blind, randomized controlled trial.

Setting: Two physical medicine and rehabilitation clinics.

Participants: Ninety-four patients with frozen shoulders enrolled in a previous study.

Outcomes and Measures: Baseline and 3-mo evaluations of the COPM and other measures. Responsiveness was assessed using effect size (ES) and standardized response mean (SRM). The MCID values were determined through a distribution-based approach, which used the 0.5 standard deviation and ES methods, and an anchor-based approach, which used the receiver operating characteristic curve method.

Results: The ES and SRM results indicated that the COPM had high responsiveness. The distribution-based MCID values for COPM Performance and COPM Satisfaction were 1.17 and 1.44, respectively. The anchor-based MCID values were 2.5 (area under the curve [AUC] = 0.78, 95% confidence interval [CI] [0.64–0.91]) and 2.1 (AUC = 0.76, 95% CI [0.60–0.91]), respectively.

Conclusions and Relevance: The findings suggest that the COPM is a responsive outcome measure for patients with frozen shoulder. The established MCID values for the COPM can be valuable for interpreting changes in patient performance and satisfaction, thus aiding clinical interventions and research planning.

Plain-Language Summary: This is the first study to review the effectiveness of the Canadian Occupational Performance Measure (COPM) to determine the success of occupational therapy interventions for people with a frozen shoulder. The findings suggest that the COPM is an effective and valuable tool for clients with a frozen shoulder to understand their experiences and treatment priorities and to detect meaningful changes in their performance and satisfaction after an occupational therapy intervention.

This is the first study to review the effectiveness of the Canadian Occupational Performance Measure (COPM) to determine the success of occupational therapy interventions for people with a frozen shoulder.

Importance: Since the first descriptions of autism, difficulties with affective contact (e.g., interpersonal exchanges of feelings between individuals) have been considered a common feature of autism spectrum disorder, and these difficulties frequently manifest in occupational therapy interventions.

Objective: To (1) explore how autistic young adults describe their emotions and (2) suggest ways to improve the affective contact between autistic clients and their therapists.

Design: Virtual focus group interviews.

Setting: Online (Qualtrics) survey and Zoom focus groups.

Participants: Autistic adults (N = 24) who met the following inclusion criteria: self-reported diagnosis of autism spectrum disorder or Asperger syndrome, age 18–35 yr, able to understand English, and able to participate in a focus group or individual interview using verbal or written communication.

Results: Two themes were noted and are presented in this article: (1) Autistic people experience complex emotions and (2) autistic people’s emotions are often (mis)measured and (mis)understood.

Conclusions and Relevance: The findings indicate that autistic people experience diverse, complex, and intense emotions and that these are connected to occupation. This suggests that occupational therapists must be attuned to the emotional dimension of occupation when working with autistic clients and that autistic clients may benefit from the use of embodied language to reference their emotions. Occupational therapists can help autistic clients recognize their bodily changes when experiencing emotions and to better identify and regulate their emotions. The results also show that there were many cases nonautistic people misinterpreted the emotions of autistic people on the basis of their facial expressions or words.

Plain-Language Summary: This article provides information about the emotional experiences of autistic people. The study found that autistic people experience complex emotions and that those emotions are often misinterpreted or misunderstood. The author provides information on how occupational therapists can use a neurodiversity-affirming and person-centered approach to support the emotional experiences of people in the autism community.

Positionality Statement: In this article, identity-first language is used when referring to autistic adults. This deliberate choice aligns with the principles of the neurodiversity-affirming movement. Autistic self-advocates have indicated a preference for this style of language over person-first language. The author would also like to acknowledge their positionality. As both a neurodivergent researcher and a self-advocate for the disabled community, this style of language aligns with their own experiences of and beliefs about their disability.

This study explored how autistic young adults describe their emotions and suggests ways that occupational therapists can be more attuned to the emotional dimension of occupation when working with autistic clients.

Importance: Ayres Sensory Integration^® is an evidence-based, manualized occupational therapy intervention for autism that is delivered in person. A telehealth adaptation could bridge service gaps for families who may have challenges accessing services.

Objective: To create a telehealth adaptation of the evidence-based manualized protocol of Ayres Sensory Integration using best practice for telehealth guidelines and to obtain input on the adaptation from experts.

Setting: Online survey of U.S. telehealth experts and occupational therapy clinicians in fall and winter 2022.

Participants: Two telehealth experts and six occupational therapy clinicians.

Outcomes and Measures: Two Qualtrics surveys focused on perceived feasibility and acceptability, resources included, and clarity of instructions.

Results: Telehealth experts and occupational therapy clinicians rated the Ayres Sensory Integration telehealth adapted manual as easy to follow, aligned with telehealth best practices, and feasible for remote delivery. Suggestions for additional adaptations included adding resources for technology troubleshooting, intervention planning, rapport building, and continuing education.

Conclusions and Relevance: Suggested adaptations were made; the manual is ready for feasibility testing.

Plain-Language Summary: This report is the first to describe a telehealth adaptation of Ayres Sensory Integration^®. The manual provides comprehensive training and resources to support clinicians in delivering sensory integration, telehealth-based interventions to autistic children. Two telehealth experts and six occupational therapy clinicians rated the Ayres Sensory Integration telehealth adapted manual as easy to follow, aligned with telehealth best practices, and feasible for remote delivery. The manual will be available to clinicians after feasibility and pilot testing.

This report is the first to describe a telehealth adaptation of Ayres Sensory Integration^®.

Evidence Connection articles provide a clinical application of systematic reviews developed in conjunction with the American Occupational Therapy Association’s Evidence-Based Practice Program and illustrate how research evidence from systematic reviews can be used to inform and guide clinical decision-making. Each article in this series summarizes the evidence from published systematic review briefs on a given topic and presents an application of the evidence to a related clinical case. This Evidence Connection article presents a case report of a person with dementia who is transitioning to a new setting. The occupational therapy evaluation and intervention process is described. Systematic review briefs on interventions for people with Alzheimer’s disease and related dementias were published in Volume 77 (Supplement 1) of the American Journal of Occupational Therapy.

This Evidence Connection article presents a case report of a person with dementia who is transitioning to a new setting, including a description of the occupational therapy evaluation and intervention process.