Play is considered the main occupation for children. Pediatric occupational therapists utilize play either for evaluation or intervention purpose. However, play is not properly measured by occupational therapists, and the use of play instrument is limited. This systematic review was aimed at identifying play instruments relevant to occupational therapy practice and its clinimetric properties. A systematic search was conducted on six databases (Academic Search Complete, CINAHL, MEDLINE, Psychology and Behavioral Science Collection, Scopus, and ASEAN Citation Index) in January 2020. The quality of the included studies was evaluated using Law and MacDermid’s Appraisal for Clinical Measurement Research Reports, and psychometric properties of play instruments were evaluated using Terwee’s checklist while the clinical utility is extracted from each instrument. Initial search identifies 1,098 articles, and only 30 articles were included in the final analysis, extracting 8 play instruments. These instruments were predominantly practiced in the Western culture, which consists of several psychometric evidences. The Revised Knox Preschool Play Scale is considered the most extensive and comprehensive play instrument for extrinsic aspect, whereas the Test of Playfulness + Test of Environmental Supportiveness Unifying Measure is a promising play instrument for intrinsic aspect on play, where both instruments utilize observation. My Child’s Play is a potential questionnaire-based play instrument. However, the current development of play instruments in the occupational therapy field is immature and constantly evolving, and occupational therapists should exercise good clinical reasoning when selecting a play instrument to use in practice.
Occupational therapy for children is found as one of the largest practice areas globally [
Using standardized play assessment can facilitate practitioners in identifying appropriate play activities to be set either as a goal or as a medium of intervention. However, utilization of standardized occupational therapy play instrument even as a research outcome is limited either on occupational therapy intervention [
Psychology, speech therapy, physiotherapy, and special education are other disciplines that have interest on play other than occupational therapy. Several instruments were developed by other professions, and several reviews investigated the psychometric properties of these instruments [
A study found that occupational therapists used various types of assessments to evaluate play, but some are not purported for play [
Kuhaneck and colleagues [
This systematic review was registered on INPLASY (Registration Number: 202040156) and PROSPERO (
A systematic search was conducted on six electronic databases, namely, Academic Search Complete, CINAHL, MEDLINE, Psychology and Behavioral Science Collection, Scopus, and ASEAN Citation Index. Keywords were generated by discussion among authors and reviewing previous literatures. The following keywords were used: (“play” OR “play-based” OR “playthings”) AND (“evaluation” OR “assessment” OR “measurement” OR “battery” OR “test” OR “instrument”) AND (“validity” OR “reliability” OR “sensitivity” OR “precision” OR “specificity” OR “responsiveness” OR “psychometric”) with slight variation. Boolean operators, parenthesis, truncation, and wildcards were used whenever appropriate. For ASEAN Citation Index, only the word “play” was keyed in as the limited function of the search engine that does not allow for search string to be implemented. As the search number was overwhelming, restriction was imposed on keywords existent only in the title for play-related keywords. The search was conducted on 21 January 2020.
Manual search was conducted by screening the reference list of the included study. In addition, the identified instruments were searched for its original article. An innovative method using the “cited by” option in Google Scholar was performed on all original and included articles to allocate more potential articles [
Each retrieved study was evaluated for its eligibility according to the following inclusion and exclusion criteria. The inclusion criteria were (i) study on the instrument for leisure type of play (not competitive play or sports), (ii) instrument generally evaluating play, (iii) study investigating the psychometric property of the instrument, (iv) the instrument used solely on play (not part of a multidimensional instrument), and (v) the instrument relevant for the use of occupational therapy. The last criteria were determined by scrutinizing the instruments found either developed or involved occupational therapist by reviewing the authors of the instrument’s original study. Exclusion criteria were (i) not a primary study (i.e., review and editor note), (ii) no full text available, (iii) full text is not available in English, (iv) grey literature (e.g., thesis, book, and conference), and (v) nonpeer review journal article.
Duplicates were initially removed before the screening process. The first author screened the title for eligibility according to the predetermined criteria, followed by independent screening of the abstract and full text by both authors. The preconsensus agreement was calculated by comparing the final accepted articles between the two authors. Any disagreements were resolved through discussion between the two authors until consensus was achieved.
Included articles in the final analysis were narratively analyzed. Each article is extracted for study objective, study design, instrument investigated, number and characteristics of raters, number and characteristics of participants, country of the study, and findings on psychometric property. Extracted play instruments were then identified on its clinical utility focused on the application and administration aspects.
Two quality assessment tools were used. The quality of each article is assessed using a quality appraisal evaluation form by Law and MacDermid [
Quality Appraisal for Clinical Measurement Research Reports Evaluation Form [
The Terwee checklist is an assessment tool to determine the quality of psychometric properties of the instrument [
A total of 1,098 articles were retrieved; 1,043 were obtained from the electronic database search, and another 55 were later identified from the reference list of the included studies and list of relevant literature found using Google Scholar’s “cited by” option. Ultimately, as shown in Figure
Screening process.
Characteristic and psychometric reporting of individual studies.
Author | Year | Instrument | Objective | Study design | Country | Participant | Rater | Finding |
---|---|---|---|---|---|---|---|---|
Dender & Stagnitti [ | 2017 | IPPS | To explore the content and cultural validity for social aspect of the instrument | Qualitative | Australia | 6 pairs of indigenous children (i.e., 12 children) | — | The extension instrument is culturally accepted and nonjudgmental. |
Golchin et al. [ | 2017 | ChIPPA | To establish the reliabilities, content, and cross-cultural validity of the translated Persian version of the instrument | Cross-sectional (validity) | Iran | 5 occupational therapists | 2 researchers | Internal consistency is |
Stagnitti & Lewis [ | 2015 | ChIPPA | To investigate the predictive validity of the instrument on semantic organization and narrative retelling skills using SAOLA | Cross-sectional | Australia | 48 typical and at risk of learning difficulty children | 3 examiners | The instruments predicted 23.8% of semantic organization and 18.2% of narrative retelling skills. |
Dender & Stagnitti [ | 2011 | I-ChIPPA | To investigate the cultural appropriateness of the adapted instrument and its reliability | Qualitative | Australia | 23 indigenous Australian children (i.e., 12 pairs) | 4 indigenous children | Cultural adaptation is satisfactory. The toys were found to be gender-neutral ( |
Pfeifer et al. [ | 2011 | ChIPPA | To establish the cross-cultural validity and reliability of the translated Portuguese version of the instrument | Cross-sectional | Brazil | 14 typical children | 1 occupational therapy student and 1 supervisor | Validity is established where the play material and duration are appropriate with the Brazilian context. Intrarater reliability is good ( |
McAloney & Stagnitti [ | 2009 | ChIPPA | To investigate the concurrent validity of the instrument | Cross-sectional | Australia | 53 typical children | 1 researcher | Significant negative correlation was found between play and social. |
Uren & Stagnitti [ | 2009 | ChIPPA | To investigate the construct validity of the instrument | Cross-sectional | Australia | 41 children of typical or minor disabilities | 5 teachers | There is probable evidence on construct validity of the instrument Penn Interactive Peer Play Scale (PIPPS) and Leuven Involvement Scale for Young Children (LIS-YC) where several components were significantly moderately correlated. |
Swindells & Stagnitti [ | 2006 | ChIPPA | To investigate the construct validity of the instrument | Cross-sectional | Australia | 35 typical children | 2 researchers | Interrater reliability is strong ( |
Stagnitti & Unsworth [ | 2004 | ChIPPA | To establish test-retest reliability of the instrument | Longitudinal | Australia | 38 typical and developmental delay children | 1 researcher | Test-retest reliability is moderate to strong ( |
Stagnitti et al. [ | 2000 | ChIPPA | To ascertain the discriminant validity and interrater reliability of the instrument | Cross-sectional | Australia | 82 typical and preacademic problem children | 3 occupational therapists | Interrater reliability is excellent ( |
Sposito et al. [ | 2019 | Knox PPS | To verify the reliabilities of the Brazilian version of the instrument | Cross-sectional | Brazil | 135 typical children | 2 undergraduate occupational therapy students | Overall, the internal consistency is good ( |
Pacciulio et al. [ | 2010 | Knox PPS | To investigate the reliability and repeatability of the Brazilian version | Cohort | Brazil | 18 typical children | 2 examiners (one is the researcher; no further detail) | Strong intrarater correlation between the two occasions ( |
Lee & Hinojosa [ | 2010 | Knox PPS | To establish the interrater and concurrent validity of the revised version of the instrument | Cross-sectional | United States of America | 61 children with autism | 2 researchers | Interrater reliability is excellent ( |
Jankovich et al. [ | 2008 | Knox PPS | To establish the interrater and construct validity of the revised version of the instrument | Cross-sectional | United States of America | 38 typically developing children | 2 occupational therapy students | Interrater agreement is high (81.8%–100%). Higher agreement was achieved on observation of older than younger children. Construct validity showed higher agreement between chronological and average play age for older than younger children. |
Harrison & Keilhofner [ | 1986 | Knox PPS | To determine the interrater and test-retest reliability and validity of the original instrument | Cross-sectional (interrater; concurrent validity) | United States of America | 60 disabled preschool children | 3 observers (detail not mentioned) | Overall interrater reliability is substantial ( |
Bledsoe & Sheperd [ | 1982 | Knox PPS | To determine the inter-rater, test-retest reliability and validity of the revised instrument | Cross-sectional (inter-rater; concurrent validity) | United States of America | 90 typical children | 2 researchers cum observers | Overall, the inter-rater and test-retest yielded satisfactory correlation. |
McDonald & Vigen [ | 2012 | McDonald Play Inventory | To examine the content, construct and discriminative, validity, internal consistency, and test-retest reliability of the instrument | Cross-sectional (validities, internal consistency) | United States of America | 124 children | Self/proxy-rating | Content validity is overall moderately correlated between items. Construct validity found that the instrument can discriminate between typical and disabled children. Concurrent validity between parent-child rating has low to moderate correlation ( |
Schneider & Rosenblum [ | 2014 | My Child’s Play | To describes the development, reliability, and validity of the instrument | Cross-sectional | Israel | 334 mothers | — | Concurrent validity with Parent as a Teacher Inventory is fair ( |
Lautamo & Heikkilä [ | 2011 | PAGS | To investigate the interrater reliability of the instrument | Cross-sectional | Finland | 78 typical and atypical children | 12 professionals (teachers, occupational therapist, physiotherapist) | MFR on expected agreement (44.1%) and the observed agreement (50.8%) with Rasch kappa of 0.12. |
Lautamo et al. [ | 2011 | PAGS | To evaluate the validity of the instrument for use with children with language impairment over typical children | Cross-sectional | Finland | 156 typical and language impairment children | Proxy-rating (teachers, special education teachers, nurses, physiotherapist, occupational therapist) | The analysis found significant difference between the two groups, but 80% of the items are considered stable. |
Lautamo et al. [ | 2005 | PAGS | To determine the construct validity of the instrument | Cross-sectional | Finland | 93 typical and atypical children | Proxy-rating (teachers, special education teachers, nurses, occupational therapist) | The construct validity of the instrument is established by internal scale validity, and person response validity achieved strong goodness of fit value. |
Behnke & Fetkovich [ | 1984 | Play History Interview | To determine reliability in terms of interrater and test-retest and validity of the Play History Interview | Cross-sectional (interrater; concurrent validity) | United States of America | 30 parents with nondisabled or disabled children | 2 researchers cum raters | Concurrent validity with Minnesota Child Development Inventory is overall moderate to strong. |
Sturgess & Ziviani [ | 1995 | Playform | To explore the consistency on rating the instrument between three groups of rater | Cross-sectional | Australia | 13 children | — | Qualitatively, the rating between the three groups is relatively similar; parents scored slightly more positive than the children, but teachers are the most positive. |
Bundy et al. [ | 2009 | T-TUM | To investigate the translatability of the instrument to practice known as T-TUM (ToP+TOES Unifying Measure) | Cross-sectional | United States of America | 265 atypical children | — | At least 92% of the outcomes were within the limit for goodness of fit. The reliability enhanced to |
Brentnall et al. [ | 2008 | ToP | To evaluate the validity of instrument rating over different lengths and point of time | Cross-sectional | United States of America | 20 typical children | 3 researchers cum raters | Different time points have no significantly different observation outcome ( |
Rigby & Gaik [ | 2007 | ToP | To investigate the stability of the instruments over three different settings | Cohort | United States of America | 16 children with cerebral palsy | 1 researcher | The score showed significant difference across the three settings (i.e., home, community, and school) ( |
Hamm [ | 2006 | ToP + TOES | To examine the validity and reliability of the instruments with children with and without disabilities | Cross-sectional | United States of America | 40 children with and without disabilities | 2 trained raters | Interrater agreement is 100%. Item response validity is 100%, and internal scale validity is 100%. There is less playfulness but higher correlation of the instrument with children with disabilities than without disabilities. |
Bronson & Bundy [ | 2001 | ToP + TOES | To evaluate the validity of the two instruments | Cross-sectional | United States of America | 160 children with and without disabilities | 10 raters (not specified) | The reliability is acceptable: |
Bundy et al. [ | 2001 | ToP | To investigate the construct and concurrent validity and interrater reliability of the instrument | Cross-sectional | United States of America | 124 children (typical and special education) in total | 26 occupational therapists | Construct validity explained 93% of the items unidimensional construct on playfulness. Concurrent validity with Children’s Playfulness Scale was found to be moderate ( |
Okimoto et al. [ | 1999 | ToP | To investigate the reliability and validity of the instrument | Cross-sectional | United States of America | 54 videotaped mother-CP-child dyad | 3 occupational therapists | The reliability is 97.5% fit within the acceptable range. The instrument was found to be sensitive to change. |
ChIPPA: Child-Initiated Pretend Play Assessment; I-ChIPPA: Indigenous ChIPPA; IPPS: Indigenous Play Partner Scale; Knox PPS: Revised Knox Preschool Play Scale; PAGS: Play Assessment for Group Setting; ToP: Test of Playfulness; TOES: Test of Environmental Supportiveness; T-TUM: ToP-TOES Unifying Measure.
Quality of individual studies was measured using Law and MacDermid’s Quality Appraisal Tool, and the result is presented in Table
Quality assessment on each included study using Law and MacDermid [
Studies | Instrument◊ | Evaluation criteria† (score: 2 = good, 1 = moderate, 0 = poor, N/A = not applicable) | Total score (%) | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Item 1 | Item 2 | Item 3 | Item 4 | Item 5 | Item 6 | Item 7 | Item 8 | Item 9 | Item 10 | Item 11 | Item 12 | |||
Dender & Stagnitti [ | IPPS | 2 | 2 | 2 | 1 | 1 | N/A | 2 | 2 | 2 | 2 | 0 | 2 | 82 |
Golchin et al. [ | ChIPPA | 2 | 2 | 1 | 2 | 2 | 1 | 2 | 1 | 1 | 2 | 2 | 1 | 79 |
Stagnitti et al. [ | ChIPPA | 2 | 2 | 2 | 1 | 0 | N/A | 2 | 2 | 2 | 2 | 0 | 2 | 77 |
Stagnitti & Lewis [ | ChIPPA | 2 | 2 | 2 | 0 | 0 | N/A | 2 | 2 | 2 | 2 | 0 | 1 | 68 |
Uren & Stagnitti [ | ChIPPA | 2 | 1 | 2 | 0 | 0 | N/A | 2 | 2 | 2 | 2 | 0 | 1 | 64 |
Swindells & Stagnitti [ | ChIPPA | 2 | 0 | 2 | 0 | 0 | N/A | 2 | 2 | 1 | 2 | 2 | 1 | 64 |
Stagnitti & Unsworth [ | ChIPPA | 1 | 1 | 1 | 0 | 0 | 2 | 2 | 2 | 2 | 2 | 1 | 1 | 63 |
Dender & Stagnitti [ | I-ChIPPA | 1 | 2 | 2 | 1 | 0 | N/A | 1 | 1 | 1 | 2 | 0 | 2 | 59 |
Pfeifer et al. [ | ChIPPA | 2 | 1 | 1 | 1 | 0 | N/A | 2 | 2 | 1 | 1 | 0 | 2 | 59 |
McAloney & Stagnitti [ | ChIPPA | 1 | 1 | 2 | 0 | 0 | N/A | 2 | 2 | 2 | 1 | 1 | 1 | 59 |
Sposito et al. [ | Knox PPS | 2 | 2 | 1 | 1 | 2 | N/A | 2 | 1 | 1 | 2 | 0 | 2 | 73 |
Jankovich et al. [ | Knox PPS | 2 | 2 | 2 | 1 | 0 | N/A | 2 | 2 | 2 | 1 | 0 | 2 | 73 |
Lee & Hinojosa [ | Knox PPS | 2 | 2 | 2 | 1 | 0 | N/A | 1 | 1 | 1 | 2 | 0 | 2 | 64 |
Bledsoe & Sheperd [ | Knox PPS | 2 | 2 | 2 | 2 | 1 | 0 | 1 | 1 | 2 | 1 | 0 | 1 | 63 |
Harrison & Keilhofner [ | Knox PPS | 1 | 2 | 1 | 2 | 0 | 1 | 1 | 1 | 2 | 1 | 0 | 1 | 54 |
Pacciulio et al. [ | Knox PPS | 2 | 1 | 1 | 1 | 0 | N/A | 1 | 1 | 1 | 1 | 0 | 1 | 45 |
McDonald & Vigen [ | McDonald Play Inventory | 2 | 2 | 1 | 2 | 1 | 0 | 2 | 1 | 2 | 1 | 0 | 1 | 63 |
Schneider & Rosenblum [ | My Child’s play | 1 | 1 | 1 | 2 | 1 | N/A | 2 | 0 | 1 | 2 | 1 | 2 | 64 |
Lautamo et al. [ | PAGS | 2 | 2 | 2 | 0 | 1 | N/A | 2 | 2 | 2 | 2 | 2 | 2 | 86 |
Lautamo & Heikkilä [ | PAGS | 2 | 1 | 2 | 0 | 1 | N/A | 2 | 2 | 2 | 2 | 1 | 2 | 77 |
Lautamo et al. [ | PAGS | 2 | 1 | 2 | 0 | 1 | N/A | 2 | 1 | 2 | 2 | 2 | 2 | 77 |
Behnke & Fetkovich [ | Play history interview | 2 | 2 | 2 | 2 | 0 | 0 | 2 | 1 | 2 | 1 | 0 | 2 | 67 |
Sturgess & Ziviani [ | Playform | 2 | 2 | 1 | 0 | 0 | N/A | 1 | 2 | 1 | 0 | 0 | 1 | 45 |
Bundy et al. [ | T-TUM | 1 | 2 | 2 | 1 | 1 | N/A | 2 | 2 | 2 | 2 | 1 | 2 | 82 |
Bronson & Bundy [ | ToP + TOES | 2 | 2 | 2 | 2 | 1 | N/A | 2 | 2 | 1 | 1 | 1 | 2 | 82 |
Hamm [ | ToP + TOES | 2 | 2 | 2 | 2 | 0 | N/A | 2 | 2 | 1 | 1 | 1 | 2 | 77 |
Bundy et al. [ | ToP | 2 | 2 | 2 | 2 | 1 | N/A | 2 | 2 | 1 | 1 | 0 | 2 | 77 |
Brentnall et al. [ | ToP | 2 | 1 | 2 | 1 | 0 | 2 | 1 | 2 | 2 | 2 | 1 | 2 | 75 |
Rigby & Gaik [ | ToP | 2 | 2 | 2 | 0 | 0 | N/A | 2 | 2 | 1 | 1 | 0 | 1 | 59 |
Okimoto et al. [ | ToP | 2 | 2 | 1 | 0 | 0 | N/A | 1 | 1 | 2 | 1 | 0 | 1 | 50 |
†Item 1: relevant background on psychometric properties and research question; item 2: inclusion/exclusion criteria; item 3: specific psychometric hypothesis; item 4: appropriate scope of psychometric properties; item 5: appropriate sample size; item 6: appropriate retention/follow-up; item 7: specific descriptions of the measures (administration, scoring, interpretation procedures); item 8: standardization of methods; item 9: data presented for each hypothesis or purpose; item 10: appropriate statistical tests; item 11: appropriate secondary analyses; and item 12: conclusions/clinical recommendations supported by analyses and results. ◊ChIPPA: Child-Initiated Pretend Play Assessment; I-ChIPPA: Indigenous ChIPPA; IPPS: Indigenous Play Partner Scale; Knox PPS: Revised Knox Preschool Play Scale; PAGS: Play Assessment for Group Setting; ToP: Test of Playfulness; TOES: Test of Environmental Supportiveness; T-TUM: ToP-TOES Unifying Measure.
Eight original occupational therapy play instruments were extracted from the 30 included articles. The included instruments are (i) Child-Initiated Pretend Play Assessment (ChIPPA; including Indigenous Play Partner Scale), (ii) Revised Knox Preschool Play Scale (Knox PPS), (iii) McDonald’s Play Inventory (MDPI), (iv) My Child’s Play (MCP), (v) Play Assessment for Group Setting (PAGS), (vi) Playform, and (vii) Play History Interview (PHI) and Test of Playfulness (ToP, including Test of Environmental Supportiveness (TOES) and ToP-TOES Unifying Measure (T-TUM)). One occupational therapy instrument—Play Skills Inventory [
• Adult Playfulness Scale • Children’s Active Play Imagery Questionnaire • Children’s Developmental Play Instrument • Children’s Play Therapy Instrument • Children’s Playfulness Scale • Enjoyment of Lunchtime Play Survey Cards • Fair Play Questionnaire • Howes Peer Play Scale • Lowenfeld World Technique • Lunzer’s Play Scale • Mature Make-Believe Play Observational Instrument • Modified Revised Class Play • Parten’s Social Play Hierarchy • Penn Interactive Peer Play Scale • Perception of Play Questionnaire for Older People • Play Behaviour Observation System • Play Performance Scale • Playfulness Scale for Adults • Singer’s Observational Play Instructions and Imaginative Play Predisposition Interview • Symbolic Play Test • The Play Checklist • The Social Play Record • The test of Pretend Play (a.k.a. Warwick Symbolic Play Test) • Transdisciplinary Play-Based Assessment-Child Development Resources
Instruments found usually investigated for concurrent and construct validity and interrater and test-retest reliability. Some instruments such as Knox PPS have been investigated on the same psychometric properties (e.g., interrater reliability and concurrent validity) over time. Homogeneity on the study location was identified where majority of the instruments have been investigated at the origin country. Most of the origin countries are Caucasian-dominant countries that are heavily influenced by the Western culture. The summary on psychometric evidences of each instrument extracted from individual studies is presented in Table
Summary of the quality of psychometric properties of the instruments.
Instrument tool | Terwee checklist [ | ||||||||
---|---|---|---|---|---|---|---|---|---|
Content validity | Internal consistency | Criterion validity | Construct validity | Reproducibility | Responsiveness | Floor or ceiling effect | Interpretability | ||
Agreement | Reliability | ||||||||
ChIPPA | +a, +b, +c | ?b | 0 | ? | ?, ?b | ?, ?a, ?b | 0 | 0 | 0 |
Knox’s PPS | ? | ?d | 0 | ? | ? | +, ?d | 0 | 0 | 0 |
McDonald Play Inventory | 0 | ? | 0 | — | 0 | ? | 0 | 0 | 0 |
My Child’s Play | + | + | 0 | + | 0 | 0 | 0 | 0 | 0 |
PAGS | + | 0 | 0 | + | 0 | + | 0 | 0 | 0 |
Play History Interview | ? | 0 | 0 | ? | ? | ? | 0 | 0 | 0 |
Playform | + | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
ToP + TOES, T-TUM | +e, +f, +g | +f, +g | 0 | +e, +f, +g | ?e, ?f | ?e, ?f | 0 | 0 | ?f, +g |
aBrazilian-Portuguese ChIPPA; bIranian ChIPPA; cIndigenous Play Partner Scale (I-PPS); dKnox’s Play Scale; eTest of Playfulness (ToP); fTest of Environmental Supportiveness (TOES); gToP-TOES Unifying Measure (T-TUM).
Several instruments are observation-based (i.e., ChIPPA, ToP, Knox’s PPS, and Play Assessment for Group Settings) and evaluated by observing the children in play activities either in real situations or recorded videos, while some are perception-based by rating a questionnaire (i.e., McDonald’s Play Inventory, My Child’s Play, and Playform), and another is subjective-based instrument that retrieves information from a qualitative interview (i.e., Play History Interview). Most instruments focused on extrinsic elements, such as developmental, behavior and attitude, and skills and performance, except for ToP that views the intrinsic factor (e.g., motivation) of play.
In terms of availability, majority of the instruments are not commercially available. Only the ChIPPA, Knox PPS, and ToP are made commercial. However, ChIPPA is the costliest, whereas the other two are at an affordable range. For the other instruments, contacting the author to obtain the original instrument may be required. The utility description of each instrument is presented in Table
Usability of the instruments.
Instrument | Description | Procedure | Population | Administration | Duration | Scoring | Training requirement | Accessibility |
---|---|---|---|---|---|---|---|---|
Child-Initiated Pretend Play Assessment (ChIPPA) | Assessment of the quality of a child’s ability to self-initiate pretend play. | Observation on two play scenarios [15 minutes each, (i) conventional imaginative play using toys, (ii) symbolic play using “junk” materials]. | Children age 3–7 years old | Therapist observation | 30 minutes | Actions observed were coded and then counted to be translated into raw score. The raw score is then calculated in and transformed into percentage according to norm reference. | Self-learning through manual (75-minute video) | Require purchase |
Extension of I-ChIPPA: | The extension (i.e., IPPS) provides an added evaluation on social aspect in play. | The IPPS added the observation on playing in pair. | For indigenous Australian | Similar to original instrument | Simultaneously with the original evaluation duration | Additional scoring on initiative playing in pair for social context. | Additional reading on the journal article | Part of the original purchase |
Knox’s Preschool Play Scale | The instrument has been evolved over time. The instrument is to evaluate children’s developmental play ages. | Consist of 4 dimensions (space management, material management, pretense/symbolic, participation) and 12 categories of play behaviors. 30-minute observation each for inside and outside play. | Children age 0 – 6 years old. | Observation | 1 hour | Each category (a.k.a. factor) is scored with either a+ when the behavior was present, a− when the behavior was absent, or NA when no opportunity to observe. The scoring is according to age, and play development is scored by transforming into mean score on factor/dimension. | Not required. Self-training by reading the manual | Require purchase |
McDonald Play Inventory | The instrument is to measure play frequency and play style. | The instrument consists of two parts. Part one (i.e., MPAI) has four categories, and part two (i.e., MPSI) has six domains with a total of 80 items. | Children age 7–11 years old | Self-reported (children) | 15 minutes (without assistance) | Each item was scored on a five-point Likert scale. Total score is calculated by summing-up the individual scores for each part. | No training required | May need to contact the author |
My Child’s Play | The instrument is to measure parent’s perception on child’ play performance. | The instrument has four categories with a total of 45 items. | Children age 3–9 years old | Proxy-administered (parents) | Not mentioned | Each item was scored on a five-point Likert scale. Total score is calculated by summing-up the individual scores. Higher score indicates better outcome. | No training required | May need to contact the author. Possible to replicate from the article |
Play Assessment for Group Settings (PAGS) | The instrument is to evaluate attitude on organized and imaginative play. | The instrument has 38 items and evaluated by observation during play activities in several occasions. | Children age 2–8 years old | Professional rater | No specific duration | Each item was scored on four-point Likert scale. The raw score is totaled from the individual items and then computed and transformed to logits. | No to minimal training (or self-training) | May need to contact the author. Possible to replicate from the article |
Play History Interview | A semistructured qualitative questionnaire to identify play experiences, interactions, environments, and opportunities. | Five epochs: | Children age 0–16 years old | Therapist interviewing the caregivers | Not specified | Qualitative response on each epoch—materials (what), action (how), people (with whom), setting (where). | Encourage to be trained | May need to contact the author. Difficult to reproduce from the journal article |
Playform | The instrument is to evaluate child’s play competency. | The instrument has 20 items. | Children age 5–7 years old | Self-administered (children) | Average 15 minutes (range 10–25 minutes) | Scored each item on three-point Likert scale (“not very well,” “quite well,” “very well”). Total score is by counting the “very well” response. | No training required | May need to contact the author. Unable to reproduce from the journal article |
Test of Playfulness (ToP) | The instrument is to evaluate intrinsic and internal component that reflects a child’s transaction in a play context. | The instrument has four elements with a total of 29 items. | 6 months–18 years old | Therapist observation | 15 minutes | Each item was scored on four-point Likert scale. The score is then totaled overall from raw score and converted into a measure score. | Self-training by reading the manual | Require purchase |
Extension of ToP: | The instrument is to evaluate the element of environment that influences play. | The instrument has 17 items and focuses on five elements. | 15 months–12 years old | Similar to original instrument | Simultaneously with the original evaluation duration | Each item was scored on four-point Likert scale. The score is then totaled overall from raw score and converted into a measure score. | Self-training by reading the manual | Part of the original purchase |
This review found various play instruments where only a small number were developed by an occupational therapist. Some of the instruments were also mentioned and described in the previous reviews [
Several occupational therapy play instruments are recommended based on occasion. The Revised Knox Preschool Play Scale is considered the gold standard for occupational therapy play assessment and suitable to be used to evaluate extrinsic aspect of play. The Revised Knox Preschool Play Scale is an all-rounder that covers an extensive number of domains. Moreover, it is the most common play instrument tool used by occupational therapists and considered easy to administer [
Play is an activity that may be influenced by geosociocultural environment surrounding a person [
Authorship bias may exist from included studies, and this may compromise the report quality of the article. Involvement of the developer or creator of the instrument in the included studies may have contributed toward bias on the discussion of findings such as emphasizing on positive arguments and suppressing negative outcomes [
The clinical utility is another aspect that should be considered besides the psychometric property of an instrument. Although this review did not extensively search for clinical utility, majority of instruments embedded a report on the clinical utility of instruments such as the ChIPPA (see Pfeifer et al. [
Majority of play instruments focused on preschool and school-aged children; limited for newborns, infants, and toddlers; and negligible for adolescents. While play is known as the dominant activity for children, its essence is available across lifespan [
Play has been argued as a complex construct and influenced by relative multidimensionality. Only a study by Rigby and Gaik [
In practice, practitioners require an instrument that can provide information on extensive number of aspects, requires minimal training and low administrative burden, and is easy to interpret [
This systematic review has several limitations to be noted. First, articles included were only obtained from journal publications, and therefore, evidence on psychometric properties of the instrument may not be comprehensive. Several psychometric evidences such as content validity may be available in the manual instrument book such as ChIPPA [
Several play assessments are available for occupational therapists used in practice. Outcome from standardized play instrument may convince stakeholders and clients to change their perception on play as a main goal for children rehabilitation. However, the current development of play instruments is immature and constantly evolving. Available instruments are constantly developed and continue to be improved. Nevertheless, several instruments such as the Revised Knox Preschool Play Scale are suitably used as a comprehensive play evaluation for extrinsic perspective of play. The Test of Playfulness + Test of Environmental Supportiveness Unifying Measure is promising in evaluating intrinsic perspectives of play. As both instruments utilized an observation approach, My Child’s Play is a potential instrument for a questionnaire-based reported outcome. However, practitioners need to consider several aspects such as client’s needs, support, and facility condition and exercise good clinical reasoning when selecting an instrument for use.
The authors declare no conflict of interest.
The protocol for this systematic review was registered on INPLASY (202040156) and is available in full on