Play and play occupation: a survey of paediatric occupational therapy practice in Ireland

Purpose – Play occupation has been identi ﬁ ed as an essential part of children ’ s lives, and it subsequently features in paediatric occupational therapy. However, few studies address the current place of play and play occupation in occupational therapy practice. This study aims to address this gap in knowledge by exploring paediatric occupational therapists ’ perspectives on the place of play and play occupation in occupational therapy practicein Ireland. Design/methodology/approach – A cross-sectional online survey was conducted to gather data about the current use of play in the occupational therapy for children under 12 years. Convenience sampling and snowball recruitment techniques were used to recruit paediatric occupational therapists. Data were analysed using descriptivestatistics andqualitativecontentanalysis. Findings – In total, 65 therapists responded to the survey (estimated response rate, 32%). Results are organised into four sections: demographics and practice context, play assessment practices, use of play in practice and perceived barriers to play-centred practice. Respondents reported that they valued play as a childhood occupation. However, the survey ﬁ ndings identi ﬁ ed that the primary focus was on play as a means to an end. Lack of education on play (research, theory and interventions) and pressures in the workplace have been identi ﬁ edas barriers toplay-centred practice. Research limitations/implications – Findings indicate that there is a mismatch between therapists valuing play as an occupation and how play is used in occupational therapy practice. Unless clari ﬁ cations are made about play occupation as being different to skills acquisition in childhood, play occupation will continue to get overlooked as an authentic concern of occupation-centred practice. Thus, play as occupation deserves further attention from educators, researchers and practitioners as a means of strengthening occupation- centred practice, inparticularplay-centred practiceinthe paediatriccontext. Originality/value – Play hasbeen described as an importantoccupation in childhood, and consequently, it features in paediatric occupational therapy. However, little is known about the current place of play in occupational therapy practice. This study addresses this gap by considering the current place of play in occupationaltherapy practicein ﬁ ndings from national in


Introduction
Play is recognised in Irish paediatric occupational therapy as an important domain of childhood and an essential focus in working with children with disabilities and their families (Buchorn and Lynch, 2010;Lynch and Moore, 2016). Although we are not the only profession concerned with the many-faceted phenomenon of play, occupational therapy provides a unique perspective of play as an occupation, with meaning and importance in its own right (Miller Kuhaneck et al., 2013). From this perspective, play as an occupation refers to the form of play that is meaningful to the child, typically freely chosen, intrinsically motivated and internally controlled (Skard and Bundy, 2008). In international terms, this is also known as free-play of play for play sake [Committee on the Rights of the Child (CRC), 2013]. However, despite the profession's promotion of our role in play and the suggestion that play is one of the most important occupations of childhood, there is evidence that practitioners tend to have a limited focus on play as an occupation (Couch et al., 1998;Miller Kuhaneck et al., 2013). For example, almost two decades ago, Couch et al. (1998) surveyed paediatric occupational therapists regarding their use of play in the USA and found that play was addressed inconsistently in the evaluation and treatment of preschool-aged clients: play was primarily used as a modality to achieve a desired performance or behavioural outcome. Moreover, Miller Kuhaneck et al. (2013) found a similar result when they replicated and expanded upon the original Couch et al. (1998) survey on the current roles of play in occupational therapy practice with children of age three to seven years in the USA. Despite advancements over the 15-year period in terms of promoting play practice and research, play was used primarily as a means of eliciting improvement in another area, such as fine motor skills (Miller Kuhaneck et al., 2013). Results of their studies once more called for a change in practice if we are to fully embrace our role in play (Couch et al., 1998;Miller Kuhaneck et al., 2013). To explore this issue, information on current practice patterns in occupational therapy is needed, including education and training, assessment and intervention approaches and directions for research. To date, there is no known research published on the current place of play in occupational therapy practices in an Irish context. This research paper draws from a larger study that aimed to contribute to this gap in knowledge by replicating and expanding upon the original Miller Kuhaneck et al. (2013) survey: examining the current place of play in occupational therapy practice across three European countries -Ireland, Sweden and Switzerland . This paper reports the findings from the national sample in Ireland.

Literature review
Play is a universal (Takata, 1971) yet complex phenomenon (Vanderkooij, 1989). Indeed, there is little consensus in the literature with regards to the categorisation and definition of children's play (Bracegirdle, 1992;Read, 1996). Although it is impossible to define play as a particular set of actions or behaviours, there is general agreement that play is intrinsically motivated, internally controlled and free from the constraints of reality (Bundy, 1991;Ferland, 1997;Parham and Fazio, 2008;Sturgess, 2003). Yet, play is inherently unproductive with no extrinsic goal (Garvey, 1977), that is, the process of engagement is more important than the product (Bundy, 1997;Moore and Lynch, 2017). Play is established as a fundamental occupation in early childhood in particular, as it significantly contributes to development, health and well-being (CRC, 2013;Cole-Hamilton and Gleave, 2011;Ginsburg, 2007;Thomas and Harding, 2011). From this perspective, play is considered as being different to leisure. Play is a primary occupation in childhood and it should, therefore be a major focus for occupational therapists (Bundy, 1997).
Occupational therapists are challenged to address a mandate: to implement occupationbased and occupation-focused services to the clients we serve (Fisher, 2013). Since the inception of the profession of occupational therapy, engagement in occupation has been valued as a primary therapeutic agent in therapy as well as the goal of intervention (Fisher, 2013;Gritzer and Arluke, 1985;Pettigrew et al., 2017;Quiroga, 1995;Upham, 1917). However, a paradigm shift occurred in the 1940s in the USA, whereby the profession deviated from a holistic occupation-based approach and became aligned with a more biomedical model of practice (Jackson, 1998). According to Kielhofner and Burke (1977), this change of focus was due to external pressure on the profession to adopt a more scientific approach to practice. However, Wilcock (2005) criticised occupational therapy for getting overly distracted by evidence-based practice, standardised assessments, activities of daily living and equipment selection. She called for the profession to once again embrace the ethic of having occupation as the basis of practice (Wilcock, 2005).
Historically, play as an occupation experienced a similar journey. Although little is known about the place of play in occupational therapy in Ireland, in the USA, play was used from the outset for a variety of purposes such as diversion, development of skills or remediation (Knox, 2010). However, over time, as occupational therapy practitioners became progressively more concerned with scientific and technical aspects of intervention, play and leisure were thought to be unscientific and inappropriate for use in practice (Primeau, 2009). Greater emphasis was bestowed upon more "scientific" measurable approaches that involved measuring motor skills and adapting equipment. Being referred to as "play ladies", as they had previously been, was now something many occupational therapists found humiliating (Bundy, 1991(Bundy, , 1997Parham and Primeau, 1997). But with the influence of occupational science and the work of Reilly (1974), play occupation and play research became once more a central concern in occupational therapy. Tools were developed to support therapy practice (e. g. Play History, Takata, 1974;Knox Playscale, Knox, 1974), while Bundy went on to devote many years of research to the development of the Test of Playfulness (Skard and Bundy, 2008). Despite this, there remained a significant concern that occupational therapists were not addressing the role of play relative to occupation (e.g. player) (Bundy, 1991;Florey, 1981;Parham, 1996). Furthermore, surveys of paediatric therapy practice continue to confirm the fact that play as occupation is rarely a goal in therapy, due to barriers in service delivery models, insurance issues, education on play and continuing concerns about attitudes towards play in therapy practice (Couch et al., 1998;Miller Kuhaneck et al., 2013).
Despite this growing body of evidence, there is a dearth of knowledge from a European perspective on occupation-centred practice, let alone the place of play. Within Ireland, occupation-based, paediatric occupational therapy is established but is also only emerging (Buchorn and McKay, 2008;Buchorn and Lynch, 2010). This is a reflection of the context of recent recessionary times, a pressurised and ever-changing health sector, alongside continual demands for expertise in complex areas. To date, paediatric occupational therapists in Ireland rely heavily on practice guidelines from the UK and further afield, for example. However, through the production of national frameworks such as the occupational therapy competencies document, practice is guided to be occupation-centred, evidence-based and socio-culturally appropriate, with an aim of increasing not just health and well-being but also social participation [The Association of Occupational Therapists of Ireland (AOTI), 2008]. Within this context, there is evidence of advances in occupation-focused approaches in children's services (e.g. Bergin and Keegan, 2016), with more specific focus also on participation in occupation (Killeen et al., 2015;O' Dea and O' Connell, 2016). Furthermore, the place of play within Irish occupational therapy research is becoming more evident (Mac Cobb et al., 2013;Moore and Lynch, 2015). In addition, there is emerging evidence of family perspectives on the place of play occupation. From research to date, we know that play is valued highly by Irish families, including families of children with disabilities (Coughlan and Lynch, 2011;Mac Cobb et al., 2013). Overall, it appears that there is a growing awareness of our need as experts in occupation, to embed occupation more centrally in practice and in particular to explore ways to enable play in the lives of children and their families.
This current study aimed to replicate and expand upon the original Miller Kuhaneck et al. (2013) survey, to examine the current place of play in occupational therapy practice across three European countries -Ireland, Sweden and Switzerland. This paper reports the findings from the national sample in Ireland. The following research questions were addressed: RQ1. How is play used in occupational therapy practice for children up to 12 years of age in Ireland?
RQ2. What are the perceived barriers in the provision of play-centred occupational therapy practice in Ireland?

Design
This study used a cross-sectional survey design to gather information from occupational therapists working with children up to 12 years of age. A survey was chosen because it is a flexible and easy method of gathering data from a large sample size (Fink, 2009). Moreover, an internet-based survey was chosen, as internet surveys are associated with higher rates of participation when targeting professional groups (Borque and Fielder, 2003). The survey was uploaded to an internet survey site (Survey Monkey and Google Forms), and participants were provided with a link to the site via an email invitation, distributed by the Association of Occupational Therapists of Ireland (AOTI).

Sample
The sample for the study was chosen using non-probability convenience sampling. Participants were eligible for inclusion if they had been working with children (within the past two years) or were working as an occupational therapist with children up to 12 years of age in Ireland. Participants were recruited through membership of the AOTI. The AOTI identified 200 as an approximate number of practitioners (AOTI, personal communication, 2016). An invitation email was sent to potential participants (n = 200) outlining the aims and objectives of the study together with a link to the online survey. Snowball sampling methods were also used, inviting recipients to send the invitation to participate in the study to colleagues.

Instrument
Data for the study were gathered using an adapted version of a survey examining the current use of play in paediatric occupational therapy practice in the USA (Miller Kuhaneck et al., 2013), with permission from the lead author. The instrument was updated and expanded by the researchers with a more comprehensive list of assessments, theories and interventions, and it was designed to include children up to age 12 years. The modified survey was pilot-tested with a convenience sample, to test for clarity and potential online operational issues. Minor subsequent amendments were made following feedback from the pilot test. The final instrument consisted of 24 questions related to demographics, education on play, service provision and play and practice, including questions on values and attitudes towards play occupation. Fixed response category options were used to gather information about participants' demographic and clinical practice characteristics, while open-ended questions were used to generate understanding of values and attitudes towards play occupation and perceived barriers and/or facilitators to practice.

Procedures Ethical considerations. Ethical approval was granted by the Social Research Ethics
Committee, University College Cork, in 2016. All surveys were completed anonymously. From the outset, potential participants were advised that consent to participate in the study was presumed by their completion of the survey. Data analysis. Data were entered into one Microsoft Excel (2010) Spreadsheet. For the closed questions, descriptive statistics were generated (determining data frequencies and calculating percentages) to develop an overall picture of the current place of play in paediatric occupational therapy practice. Answers to open-ended questions were analysed using descriptive qualitative content analysis. Through a process of consensus, core categories were established.

Results
In total, 65 occupational therapists from all regions in the Republic of Ireland completed the survey. The regions were representative of Munster, Leinster and Connaught with higher distribution rates in urban settings, for example, Dublin and Cork. Based on the initial recruitment of participants (n = 200), this represents an estimated 32 per cent response rate. However, as the final number of participants who were invited to participate in the survey is not known, this may not represent an accurate response rate. In addition, owing to the anonymous nature of an online survey, no information was obtained regarding non-responders to the survey. Table I provides full details of respondents' demographics and practice context.

Samples' demographics and practice context
Most of the respondents worked in a rehabilitation clinic/centre (69.2 per cent, n = 45) and had more than nine years of experience in paediatric occupational therapy (49.2 per cent, n = 32). The majority of respondents worked with children of age between 6 and 12 years (66.1 per cent, n = 41). Only two respondents (3.2 per cent, n = 2) provided paediatric occupational therapy to children of age less than three years. Most respondents (67.6 per cent, n = 182) worked with children with neurodevelopmental conditions (autism spectrum disorder; developmental coordination disorder and intellectual disability). Each participant (n = 65) was asked to list the common diagnostic groups that they work with, giving a total of 182 responses. In addition, respondents were asked the main reasons for referral to occupational therapy. The primary reason was for functional problems such as self-care, handwriting and sensory issues, and for specific diagnostic assessments. Few listed play difficulties as a reason for referral. The few times play was listed, it was associated with social/emotional difficulties, rather than referrals specifically for play occupation. The majority of respondents had neither received specialist occupational therapy training in play (70.8 per cent, n = 46) nor had they completed research focusing on play (92.3 per cent, n = 60). However, the primary source of knowledge on play, came from taking continual professional development (CPD) courses such as sensory integration (SI), DIR floortime, ADOS, with one respondent listing a postgraduate certificate in psychodynamic counselling as the source of learning about play.
Samples' assessment, intervention and evaluation practices Information was sought relating to participants' use of assessment tools. The survey tool offered respondents 32 assessment tool options along with a choice of "other". Respondents reported using a broad range of assessments (16). Table II provides details of respondents' assessment practices. The Preferences for Activities of Children (PAC) was used most frequently (20.0 per cent, n = 13) followed by the Children's Assessment of Participation and Enjoyment (CAPE) (13.8 per cent, n = 9) and the Vineland Adaptive Behaviour Scales (13.8 per cent, n = 9). Each participant (n = 65) was asked to list other standardised assessment tools in Table I. use, giving a total of 103 responses: responses included the use of tools such as the Beery Visual-Motor Integration test, as a means of observing play. However, more than half of respondents (52.3 per cent, n = 34) did not use any standardised assessments. For these respondents, the majority identified using observation and non-specific play assessments, with some respondents reporting that they did not have access to standardised play assessments, as a reason for this. The majority of respondents noted on a Likert scale that having available assessment tools was very important in assessing play (35.9 per cent, n = 23).
Participants were asked how they had learned to evaluate play. The majority of respondents noted that they had learned to evaluate play during their "education/training" (49.2 per cent, n = 32) and through CPD courses (43.1 per cent, n = 28). Some identified CPD in other disciplines as sources of education (16.9 per cent). When asked to provide more details on other sources of education, 16 respondents (24.6 per cent, n = 16) noted that they had learned to evaluate play through "other practitioners" and to a lesser degree through "clinical supervision", "self-directed reading" and "trying out different approaches with children". Being informed by other disciplines about play (e.g. psychology) was deemed as important as occupational therapy theories about play.
In addition, information was sought regarding participants' use of models of practice and frames of reference. The most commonly used models of practice and frames of reference were closely linked to the client groups and reason for referral. To substantiate, with the most prevalent client groups diagnosed with neurodevelopmental conditions, the most commonly used frame of reference was SI (29.2 per cent, n = 19) followed by developmental (21.5 per cent, n = 14) and person-environment-occupation model (PEO) (21.5 per cent, n = 14). A significant majority consider environmental adaptations and influences on the way the child plays and where play takes place (96.9 per cent, n = 63).

Use of play in current occupational therapy practice
Participants were asked to describe what play means to them in their daily work. Three core themes were identified in respondents' responses: play as a means to an end, play as a primary occupation of childhood and play as a reward. Play as a means to an end included comments such as: "I use play in my daily work with children as my major tool in therapy, to form interpersonal relationships with children, to foster development and growth and to achieve targeted therapeutic goals"; and as a means to establish contact (therapeutic relationship) with children: "I would see play as a really important occupation of the children who I work with. For me in my daily work, play often means the way that I can interact and engage with children [. . .]". Play as a child's primary occupation included comments such as: "play is an important part of children's' daily lives. It is where they begin to explore the world and try to figure things out"; "engagement in activity for fun"; and "child chosen activity for enjoyment". Play was also identified as a reward, in other words, as a way to motivate children to engage in therapy: "It is a way of engaging and teaching children" and "all interventions are facilitated through play to engage the child appropriately".
In addition, participants were asked about their current use of play in occupational therapy practice. The majority of respondents reported using play as a means to an end (61.5 per cent, n = 40), in home/school programmes (20 per cent, n = 13) or as a reward (10.8 per cent, n = 7). The least common use of play was play as an aim (7.7 per cent, n = 5). Figure 1 provides details of respondents' use of play in practice.
Furthermore, participants were asked hypothetically if they were to have more choice, would they include more focus on play. The majority of respondents answered "yes" (75.4 per cent, n = 49), noting desires to work more in natural settings, such as community play settings; have more training on play; have assessment tools available; have more time, have less waitlist pressures and to be supported to work with play for play sake: "Yes, absolutely! We would focus more on play for play sake, rather than just the independence-skills/academic skills". One noted however: "No, I am very lucky, the majority of my practice is through play".
Perceived barriers in the delivery of occupational therapy services Information was sought relating to participants' perceptions of the perceived barriers in the delivery of play-centred occupational therapy. The majority of respondents noted significant barriers including: overburdened workloads (waiting lists; caseloads); a lack of resources (standardised evaluation tools; educational opportunities; time; space; equipment); play being perceived as a "waste of time" among parents and teachers unless play is being used for skills acquisition; and "working in a system that prioritises assessments and diagnoses rather than intervention" along with a "a lack of knowledge of outcome measures in the area of play".

Discussion
This study is the first to explore the place of play in paediatric occupational therapy services in an Irish context to date. The overall findings show that the majority of respondents have not completed any occupational therapy courses on play, few use formal standardised play assessments, play is used primarily as a means to an end and therapists perceive significant barriers impacting on their ability to provide play-centred practice.
Results show that therapists valued play as a core occupation in childhood, as a means of engaging the child in therapy and as a reward. This is similar to the existing data from studies in the USA (Couch et al., 1998;Miller Kuhaneck et al., 2013) and from Sweden and Switzerland . When play was a focus of assessment, there is evidence of a broad range of play assessments in use, including interest profiles, activity preferences checklists and volitional questionnaires, which although small in number, demonstrates an emerging occupation-centred, occupation-focused perspective (Buchorn and McKay, 2008;Buchorn and Lynch, 2010;Fisher, 2013). This is despite the fact that the main reasons for referral were due to functional difficulties other than play. Furthermore, the predominant perspective on the place of play in occupational therapy, is that it is the primary way to work with children.
However, findings revealed a discrepancy between play as occupation and the place of play in occupational therapy. Therapists reported that they valued play as an occupation. However, for Play and play occupation the most part, therapists were not focusing on play as an aim or play as an outcome of their intervention. Instead, play was typically used as a means to elicit alternative outcomes (e.g. motor skill development) or as a reward. On further analysis, it appears that these respondents were aware of this conundrum, as the majority reported their desire to include more focus on play if they had the choice. Barriers to doing so related significantly to time and waitlist pressures alongside parental expectations and a lack of parental understanding about play. Play was being perceived as a "waste of time" among parents and teachers unless play is being used for skills acquisition and "working in a system that prioritises assessments and diagnoses rather than intervention". Therapists own lack of knowledge and education on play assessment, theory and evidence for interventions was noted also. So although respondents in this study recognise that occupational therapists have an important role in enabling play, this does not translate into playcentred practice, due to the culture of the workplace, in addition to professional issues of knowledge, skills and access to play resources. From this study, it appears that, there is a need to expand and develop educational and research opportunities on play occupation at pre-professional and post-professional levels. While the findings of the present study revealed that the majority of respondents had reported to learning about play during pre-professional occupational therapy education, few had participated in post-professional education. Estes and Pierce (2012) maintain that therapists can transcend medical-model-based practice by maintaining a strong intrinsic professional identity centred on core constructs of occupation. They acclaim that this identity is formed and sustained during professional education and/or reading current literature on occupationcentred practice (Estes and Pierce, 2012). While therapists did engage in educational opportunities to expand their knowledge on play (CPD courses, for example, in SI, and nonspecific learning opportunities, for example, peer mentoring), play occupation is not always at the core of these learning opportunities. Expanding and developing educational opportunities on play occupation in the Irish context would serve to help align Irish paediatric occupational therapy practice more with our professional mandate to be occupation-centred (AOTI, 2008).
In our quest to be occupation-centred Tanta and Knox (2015) emphasised that assessment of play should be part of every occupational therapy evaluation to assess an individual's competence in his/her occupational performance and to plan occupation-centred intervention. However, play assessment has been identified in the past as an area of concern in occupationcentred practice. For example, previous researchers have identified that few therapists routinely evaluate play (Crowe, 1989;Lawlor and Henderson, 1989). In this study, the majority of respondents chose non-standardised tools, which typically included informal checklists on play and play observation. Such findings are consistent with findings from previous studies (Couch et al., 1998;Miller Kuhaneck et al., 2013). Indeed, non-standardised tools for assessing play have been noted as the assessment method of choice as they allow for assessing play in context (Bundy, 2011). While such approaches were applied by therapists in the present study, few therapists set play goals. Thus, further research is needed to establish formal standardised assessment tools that are able to more accurately capture play occupation in context and guide the establishment of specific goals for enabling play occupation.
One key issue that arises in this study, is the need to explore more specifically an understanding of occupation. An assumption that has become firmly entrenched within occupational therapy's models is that occupations can be divided into three categories: self-care, work and play/leisure (Kielhofner, 2002). However, Pierce (2001, p. 252) observed: "as occupational scientists have begun to examine these categories more closely [. . .] they appear to be simplistic, value-laden, decontextualized, and insufficiently descriptive of subjective experience". Subjective experiences of play occupation derive from researching with children. When play is considered as an occupation from a child's perspective, play includes characteristics such as intrinsic motivation (Florey, 1971, Parham, 1996 of value to the player, with no extrinsic goal (Garvey, 1977). From a child's perspective, play is about fun, friendships, happiness and having safe places to play (Kilkelly et al., 2016;Moore and Lynch, 2017). Considering this, play occupation may not include working on skills through therapistled sessions, practicing skills . So although it may appear that paediatric occupational therapists use play predominantly in practice, it is more accurate to say that this is a form of play skill or play activity, but less likely to be actual play occupation . This position on play as occupation in contrast to play as skill warrants further interrogation. Furthermore, it begs the question: How do we address the play occupation needs of the children we serve?
One way to reconnect with play occupation, is to be guided by the General Comment (CRC, 2013) that highlights issues of play deprivation in children, including those with disabilities, and urges the international community to take play seriously. Furthermore, the World Federation of Occupational Therapists' (WFOT) (2006) Position Statement on human rights is an important initiative that serves as a professional guideline. Addressing play deprivation as a rights-based issue requires new approaches to problems and new conceptual tools for occupational therapy and rehabilitation (Galheigo, 2011). From this perspective, we argue that there is a need to broaden service delivery models to include a more universal approach in service provision (Moore and Lynch, 2015). For example, play occupation can be a goal in therapy through educating local communities or parent groups on enabling play and designing environments for play. We argue that occupational therapists have significant and valuable contributions to make to enable participation in play, and assert that we need to embrace play as occupation: "play as an aim, play as a right, and play for participation" (Lynch and Moore, 2016, p. 520).

Implications for occupational therapy
Knowledge gained from the present research can positively affect occupational therapy practice, education and research.
This study highlights the need to be more occupation-centred in practice, i.e. playoccupation-centred rather than skills-centred in paediatric practice. In terms of our professional mandate, it is essential that we find ways to continue to become more occupation-centred in our practice (Clyne et al., 2008). In terms of education, there is a need to further explore how play occupations are addressed in occupational therapy curricula in Ireland. Furthermore, there is a need to expand and develop CPD educational opportunities regarding play occupation. This study warrants further research on play occupation in an Irish context as a means to inform evidence-based practice.

Limitations
Although this study provides a first account of the use of play in paediatric occupational therapy practice in Ireland, there are a number of limitations which impact upon the extent to which the findings of the study can be generalised. First, this study adopted a convenience snowball sampling technique and as a result it is not possible to provide an accurate account of the response rate to the survey. Second, as a result of the sampling strategy no information was gathered on non-responders to the survey. Given that non-responders may be systematically different to responders the results should be interpreted accordingly.

Conclusion
While there is a growing body of research to support occupation-centred practice, this study highlights the need for substantial investment in occupational therapy services if the knowledge generated by research is to be translated to practice. Despite decades of continued research and writing on the purpose and importance of play occupation, the findings of this study depict that there is minimal evidence of the place of play occupation in paediatric occupational therapy in Ireland. Unless clarifications are made about play occupation as being different to skills acquisition in childhood, play occupation will continue to get overlooked as an authentic occupation . If play remains undervalued as a goal in itself, it is inevitable that play will be replaced by more measurable alternatives. Given that play is the primary occupation of childhood, and the acknowledged role of play in contributing to children's health, education and well-being, it remains imperative that play be embraced as a legitimate occupation and a focus of intervention for the children we serve. Thus, play as occupation deserves further attention from educators, researchers and practitioners as a means of strengthening occupation-centred practice, in particular play-centred practice in the paediatric context.