Play and dance therapy: a review of theories, techniques and didactic methodologies for the motor recovery of children with disabilities

Introduction

This research project originated from the observation that there are still problems for individuals with disabilities at both the physical and social level: in fact, while on the theoretical level of the scientific debate, it is widely accepted that all individuals with special needs should receive support and have the opportunity to improve their psycho-physical state, in reality teachers and caregivers encounter obstacles.

In 2006, the United Nations General Assembly promoted the Convention on the Rights of Persons with Disabilities:

The disability is no longer conceived as an objective condition, but it is generated by the close connection with the characteristics of the social and cultural organisation of reference (Gaspari, 2017). The focus is placed on the overcoming various obstacles that children with disabilities can encounter in interpersonal relations: educational personnel must be aware of the influence that the social organisation has on the individual in a situation of disability (Cottini, 2017). From this perspective, social inclusion of children with disabilities is realised when there is an opportunity to create relationships with other children through play as a fundamental activity for learning about the world at a developmental age (United Nations, General Assembly, 2006).

The research project LUDI. Play for children with disabilities (Allodi & Zappaterra, 2019) investigated if the dimension of play is an integral part of daily life of individuals with disabilities with the focus on the concept of “Play for the sake of play”, which can be defined as the set of all those playful actions whose aim and object is play itself: the concept of “Play for the sake of play” has been widely recognised as fundamental, but at the same time individuals with disabilities find it difficult to have a fulfilling experience of play, also due to a lack of places and trained staff (Allodi & Zappaterra, 2019).

In order to make play accessible to all, there is the possibility of using technological devices such as the PALMIBER: a robotic vehicle that adapts to the subject’s level of mobility, so the children with disability can drive and move in space autonomously, interact with objects and take part in play activities with companions independently (Raya et al., 2015). The IROMEC robot acts as a mediator in social exchanges, helping children with disabilities to have a fulfilling experience of symbolic play and to understand respect for their turn and greater awareness of space and body (Besio et al., 2008). Finally, there are movement sensors (Kinect-sensors) that allow the projection of real children’s movements onto figures represented on the screen: during play sessions, the muscles of the hemiplegic limbs are activated in subjects with infantile cerebral palsy (Howcroft et al., 2012); in subjects with Autism Spectrum Disorder, play intensifies communicative exchanges as well as the ability to relate to peers and therapists. Participants also experienced positive emotions and attitudes of curiosity towards new technologies (Stancheva-Popkostadinova & Andreeva, 2018).

In addition to play, a further strategy for promoting the well-being of individuals with disabilities and promoting cohesion and a sense of belonging to a group concerns dance-therapy. In 1945, the dance teacher Marian Chace first used dance as a treatment for psychosis in a patient at St. Elizabeth’s Hospital in Washington DC, U.S. She wrote a report entitled “Classes in Rhythmic Movement,” in which she described her efforts to relate psychological theory to dance lessons (Cruz, 2016).

In March 1966, the American Dance Therapy Association (ADTA) was founded with the aim of investigating whether and to what extent movement and dance could have positive-curative repercussions for people with disabilities. Studies on dance therapy have studied the neuro-psychology/physiology/rehabilitation dimension, but also treatments for both physical and psychological trauma and the use of dance therapy in people with psychiatric and other disorders, such as depression and cancer treatment (Cruz, 2016).

Szymanska-Kierlandczyk proves that dance is present in all spheres of human life. The special qualities of dance contribute to human development and have an impact on a person’s psycho-physical well-being. Dance often exhibits therapeutic properties. Dance absorbs the sense of sight, movement and balance. The pyramidal system, the extrapyramidal system and the cerebellum are involved in the movement activity. Dancing activates the entire brain: the sensory, cognitive and emotional executive functions (Szymańska-Kierlańczyk, 2022).

Dance-therapy is considered a science. As shown in research, movements can reflect the personality of the subject. During dance therapy sessions, a relationship is created between the therapist and the patient, and a change in movement patterns also results in a change in thought patterns. Furthermore, as dance therapy does not require the use of speech, it is also effective in all those situations where language difficulties are present: by means of movement, the child with disabilities can express needs while feeling accepted (Panagiotopoulou, 2011).

The aim of the following systematic review is to analyse the effectiveness of alternative techniques to medical-pharmacological treatment, such as play sessions and dance therapy, in improving the living conditions of persons with developmental disabilities.

Firstly, three keywords are identified as coordinates for this research: disability, play, dance-therapy. Consequently, benchmarks like “physical disabilities”, “Intellectual disabilities”, “development”, “childhood”, “movement”, “play session”, “videogame”, “wellbeing”, “exercises” or “dance with music” are employed.

The search engines consulted were the university library system UrbIS (Urbino Integrated Search), EBSCOhost, PubMed, the American Journal of Dance (Springer Link), DIRImè, European Journal of Physical Education and Sport Science as well as book publications on the topic.

The inclusion criteria for the protocol selection was as follows:

Therefore, excluded from the survey were protocols involving participants attending secondary school and above, which had been written and published prior to 2010, and which did not adhere to the subject area of interest, or for which the research team had not implemented the “pre-test - intervention - post-test” technique.

As far as the presence of possible biases is concerned, reference is made to the confirmation bias: the research implementation process may in fact run the risk of inadvertent preference for protocols and studies supporting the assumption (i.e., “dance and play are alternative strategies with positive results in overcoming situations of disability”), rather than taking into consideration studies disproving the underlying assumption. Consequently, in an attempt to minimise this risk of bias, in the first consultation of each protocol, the reading was interrupted before reaching the results so as not to be influenced by the outcomes. Only at a second phase, the reading of the intervention protocols was completed.

A total of 30 protocols were considered, of which 11 were included in the review, while 19 were excluded.

Figure 1. Flow chart of the research phases.

Methods

The qualitative research conducted by Allodi and Zappaterra (2019) involved parents of children with intellectual disability (19%), autism spectrum disorder (17%), communication and speech disorders (15%), multiple disabilities (14%), motor disabilities (12%), visual impairment to the point of blindness (9%), hearing impairment to the point of deafness (8%) and other (6%) including Down syndrome, cerebral palsy, dyspraxia and attention deficit hyperactivity disorder. In addition, the 0-5 age range constitutes the 21% of subjects involved the 6-9 age range is the most numerous with 33%, followed by the 24% of children in the 10-13 range, ending with 22% of individuals aged between 14 and 18 years old. The two questionnaires about the children’s playing conditions show that when asked about the presence of adequate opportunities for play, 42% of children with disabilities answered “a little,” while 31% “No”. Furthermore, although the concept of Play for the sake of play is recognised as important by all family members, 64% of the relatives describe themselves as unhappy about the children’s play practices because they do not know how to interact with their sons and daughters. More specifically, the answers to the question “As a parent of a child with disabilities, please write the first three ideas/word that come to your mind when you think about your child’s play” were divided in two categories the “positive emotions” and the “negative emotions”: the first one contains words such as joy, respect, concentration, laughter, freedom; the second one includes concepts such as frustration, boredom, isolation, lack of concentration. It was pointed out that very often the playmates of people with disabilities are adults, rather than peers, due to the need for supervision by an adult, due to intellectual or motor difficulties that may occur. In conclusion, this qualitative research emphasises the need for children with disabilities to interact with peers and people of the same age, to increase the time available for play also because of the fact that they are often engaged in therapy or well-structured activities, and to take part in games that respect their level of psycho-physical development so they can experience fulfilling play situations.

When approaching the issue of electronic devices used to support muscle activation during play sessions, Stancheva-Popkostadinova & Andreeva (2018) used the Kinect-sensor with children with Autism Spectrum Disorder (ASD) (3), hearing impairments (3) and cerebral palsy (4). Concerning the children with ASD, the play phase lasted between 6 and 10 minutes: they understood the instructions, implemented the correct movements to complete the delivery, their attention was adequately supported, and they also interacted verbally to ask for support during play. All three children with hearing impairment sustained the game for about 12 minutes, during which they understood the rules and they were easily involved in the actions: their attention was adequate throughout the duration of the game, and they were well-focused on guiding the figure on the screen. As for the children with cerebral palsy, they played for 10 minutes: the two with mild impairment played continuously and interacted with adults (one of them even tried to move his right hand affected by paralysis), while the other two children with moderate impairment were in constant need of support from professionals, and their movements were insecure. As a result, it can be stated that favourable outcomes were found: the children had an opportunity to work on gross motor skills in presence of disabilities while having fun.

In correlation, the following study, conducted by Howcroft et al. (2012) aimed to measure the muscle activation in 17 children with cerebral palsy aged 8–12 years during dance, tennis, boxing and bowling sessions using movement sensor. After each child has played all four sports, the measurements taken during the post-tests showed an increase in muscle strength. This was particularly the case with boxing and dance sessions as these sports engage the lower limbs in a more active manner, and which require a tighter rhythm of movement patterns, depending on the ability to move arms and legs simultaneously. At the same time, bowling was found to be the sport with the least muscular involvement as it requires simpler movements of the lower limbs and torso, followed by oscillations of the dominant arm. In conclusion, regarding the OMNI and PACES questionnaires, the researchers found a high level of involvement and enjoyment during the physical activity, which are determining factors for successful interventions.

The two following protocols being part of the DIRimè Project (Developmental-Individual-Relationship based model and Integration of Developmental Models), applied during play sessions, investigated the social behaviour of children with autism spectrum disorders by actively involving family members (Mirzakhani et al., 2022; Mahoney and Solomon, 2016), as autism spectrum disorder can be defined as “A multifactorial disorder: a consequence of the influence of genetic and environmental factors” (Prokopiak, 2022).

The study carried out by Mirzakhani et al. (2022) involved 60 children with ASD, aged 6-8, and their respective family members throughout a three-month period during which parents took part in play sessions. Although the Floor-time programme proved to be more fruitful than the Son-Rise one, the GARS-2 and ASSP scales showed that there were overall positive outcomes with a non-statistically significant variation between post-test and follow-up, demonstrating the stability of the improvements obtained over the time. More specifically, the research team found a significant decrease with respect to the stereotyped behaviour observed; these two approaches proved to be useful in increasing the communication skills of ASD subjects with a consequent improvement in the ability to establish social relationships. The second study about the DIRimè project conducted by Mahoney and Solomon (2016) included home-game sessions interspersed with hospital-game sessions, engaging 112 ASD 3-6-years-old children for one year. In post-tests, using the ADOS-G scale, positive effects were found on the children’s social involvement compared to the control group participants, while the CBRS and FEAS scales revealed a positive reciprocal influence between the responsive/affective behaviour of family members and improvements in the affective area of children with ASD. Therefore, in the long term, it can be stated that the difficulties typical of the Autistic Spectrum Disorder regarding social relationships can be improved through an intervention that actively involves the family environment and that is pervasive of the ASD subject’s daily life.

In the second part of the systematic review, the following studies are reported regarding the effectiveness of dance-therapy protocols. Takahashi et al. (2022) have outlined a dance-therapy protocol for 21 children with intellectual disabilities, ageing 3 to 6 years, carried out in a rehabilitation setting (control group: n.10 subjects; experimental group: n.11 subjects). After a cycle of 10 one-hour dance sessions, the HHD post-test registered an increase in the strength of the extensors of both knees for all 11 participants. Concerning the “one-leg stand” test, measurements of 9 of the 11 participants are considered: the results show that seven of the nine measurements considered increased the time during which they are able to be in balance on one leg only, while five out of nine gained less than one second on both legs. The third measurement, the TUG test, showed that, among of the eight eligible results, three children showed an increase in the time spent to carry out the movements, while five showed a decrease: as a consequence, the results of this test are not statistically significant. To conclude, the improvements in muscular and static balance, the decrease in maladaptive behaviour and anxiety-related disorders were possible thanks to specific DMT (Dance-Movement Therapy) interventions, such as listening to music, a continuous weight shift with a consequent change in the centre of gravity, improving the ability to maintain balance and the ability to synchronise their movements with those of the dance-experts. In addition, the risk of injury is significantly reduced.

The aim of this following dance-therapy intervention (Takahashi et al., 2020) is to evaluate the effectiveness of dance in improving the well-being of children with Williams syndrome, a rare genetic disorder that causes intellectual impairment, cardio-vascular abnormalities and physical-motor difficulties. Due to the very low incidence rate, only 4 children were involved ageing 5 to 10 years. During the post-tests sessions, the posturography shows a decrease in the total length of body oscillations (the measurements were taken both with closed and open eyes). Regarding the HHD test, all four participants showed improvements in the extensor muscles, while three out of four showed improvements in the knee flexor muscles. Two participants increased their left plantar flexor strength, while one on the right one. Two participants enhanced the dorsiflexion ability of the left ankle, none on the right one and three out of four participants recorded an increase in muscle strength in hip extension. The post-test TUG showed that only one participant (a 5-year-old girl) decreased the recorded time by 1.45s, while the other three participants recorded a change of <1s. In conclusion, being aware of the small sample due to the rarity of the syndrome and the fact that this kind of intervention was not preceded by other previous specific studies, it can be stated that this report proposes methodologies with related highly valuable results, encouraging for future research since improvements have been identified, especially with regard to the ability to maintain balance and increase the strength of the knee muscles.

In the following study, conducted by McGuire et al. (2019), the experimental group consisted of six children with Down Syndrome aged 7 to 13 years. After the conclusion of a 20-minute dance session, in order to verify the extent of improvements/worsening of the psycho-physical conditions of the subjects involved, the research team used the measuring instruments from the pre-tests (GMFM-88 and COPM). With regard to the GMFM-88 scale, dimensions D-E, improvements were observed in all participants, with particular emphasis on case no. 5, (a 4-year-old girl with DS who also attended swimming lessons). On the COPM scale, improvement was recorded for five participants out of six with an average deviation of 2.36 points for the “Performance” section and of 3.36 points for the “Satisfaction” section. On the contrary, for the sixth participant (a 13-year-old girl) there was a deterioration in performance of 1.2 points and in satisfaction by 0.2 points. In conclusion, for individuals with DS, this protocol identified an adapted dance programme as a good basis on which to set future interventions with a focus on the improvement of gross-motor skills.

The ninth study was carried out by López-Ortiz et al. (2016) and included 11 children with Cerebral Palsy ageing 7 to 14 years (control group: n.6 subjects; experimental group: n.5 subjects). Firstly, one week and then one month after the end of the dance-therapy, the post-tests were administered using the same rating scales: the PBS scale recorded statistically significant improvements in the ability to maintain static and dynamic balance. Conversely, the QUEST test did not show statistically significant results, since either the situation remained unchanged or there were minimal increases in upper limb movement and control skills. In conclusion, it was observed that a greater improvement in the execution of the movements concerns younger subjects than the other children involved: this aspect reflects a trend, already highlighted in the scientific literature, whereby subjects with CP, for the first 7 years, are capable of significant improvements in their development of physical abilities, followed by a stabilisation.

Aithal et al. (2021) investigated the use of dance-therapy to promote the wellbeing of 26 ASD 8-13-year-old children using the crossover method:

The last research, conducted by Marouli et al. (2021) investigated the effectiveness of Greek traditional dance in 8 ASD 6-14-year-old children (control group: n.4 subjects; experimental group: n.4 subjects). Using the BOT-2 scale, all participants in the experimental group increased their performance on both the item “Tapping feet and finger” by 3.5 points on average and “Standing on a balance beam” by 1.8 points on average. Three out of four participants reported an average increase of 1.5 points for “Copying a square”, by 1 point on “Walking forward on a line” and by 2.25 points on “Jumping with one leg”. For the two items “Drawing a line on a zigzag path” and “Folding a paper” no improvement was noted, while, conversely, in ‘Transferring pennies’ an optimisation of the gesture was reported for all participants in control group A. Thus, although the sample taken is not large, it can be stated that the traditional Greek dance-therapy programme had positive effects on movements involving static and dynamic balance, gross gross-motor skills and motor co-ordination, while fine motor skills were found to be still deficient.

Summary and conclusion

With regard to play, electronic devices have been shown to be effective in supporting both whole-body muscle activation accompanied by improved communicative exchanges (Howcroft et al., 2012; Stancheva-Popkostadinova & Andreeva, 2018); Furthermore, in the two DIRimè projects aimed at ASD subjects, the involvement of family members has been shown to be effective in improving the quality of behaviours enacted by subjects with Autism Spectrum Disorder (Mahoney & Solomon, 2016; Mirzakhani et al., 2022).

The interventions realised through dance-therapy sessions have shown that, when the goal of improving physical performance is achieved, an increase in the subjects’ state of well-being is also noted. This is possible, in fact, thanks to the solid body-mind connection, present in every subject regardless of the presence or absence of deficits (Aithal et al., 2021).

Consequently, motor activity, in this particular case experienced through dance and play, must no longer be conceived only as a rehabilitative methodology at a muscular level, but its social impact must also be taken into account: if a person with disabilities is able to move more easily and have control over his or her movements, he or she will also be able to participate in social life in a more fulfilling manner.

Finally, with regard to future research developments, it is desirable to involve an increasing number of participants in individual studies and to add a control group where possible so as to extrapolate the results onto a large scale (McGuire et al., 2019).

Hereafter is reported a table summarising all the protocols considered, the children involved, the type of intervention and the type of evidence registered (Table 1).