PLAY

AND
AUTISM

Marisa Lobo Biddappa M.A. M.Phil.

 WHAT IS PLAY?

Play is a natural medium of a child’s expression. It refers to any activity

engaged in for the enjoyment it gives without consideration of the end result.
 DEFINITION OF PLAY

Play is pleasurable and enjoyable

Play has no goal imposed on it from outside
Play is spontaneous and voluntary
Play involves some active engagement on the part of the player

Garvey 1977
 CHARACTERISTICS OF PLAY

• Play follows a predictable pattern of development

• Play is influenced by culture and tradition
• Play becomes more social as the child grows
• Number of playmates decrease with age
• Number of play activities decrease with age
• Play becomes more gender based as the child grows
• Play becomes more organized as the child grows
• Play turns from active to passive as the child grows
• Play is predictive of a child’s adjustment
  

CONTRIBUTIONS OF PLAY
Physical Development Communication Skills
Dev. of motor skills, muscles, exercise Encourages communication
Outlet for surplus energy Initiate communication
 
Outlet for Pent up Emotions Interaction & Socialization
Outlet for release of tensions due to Learn to interact, establish relationships
restrictions placed by environment sort problems
 
Outlet for Needs and Desires Source of Learning
Needs and desires can be achieved By exploring, manipulating,
in play e.g. leadership experimenting they learns new things
 
Stimulant to Creativity Dev. of Self Insight
Through experimentation they discover new Learn what their capabilities are
things that they can transfer to the outside world More realistic concept of self

Age and Sex Appropriate Roles Moral Standards and Values

Learn to accept app. age and sex role Learn what is right and wrong
Learn to belong to a group Taking turns, fairness
Enjoying victory, accepting defeat
Dev. of Desirable Personality Traits
Learn to be cooperative, truthful, fair, good sports, tolerant and fun to be with
 KINDS OF PLAY

Active Play Passive Play (Amusements)

Actively participates in the activity Derives pleasure with

Building blocks, running, minimal expenditure of energy
playing a game watching others play, reading,
watching television
 STAGES IN PLAY

• Explorative Play - Sensory – Motor - 3months – 6 months

• Imitative Play – 9 months
• Independent Play - Functional and Parallel Play – 9 months – 2 years
• Pretend Play – 2 years – 2 years 6 months
• Peer Play - Reciprocal Play – 2 years 9months – 3 years
• Cooperative Play – 3 years 6 months – 4 years
• Group Play - rule based games – 5 years
• Organized Sport – 8 years
 INGREDIENTS OF PLAY

SOCIAL
COMMUNICATION
INTERACTION

PLAY

IMAGINATION
 PROBLEMS IN COMMUNICATION

•Difficulty in both expressing and understanding the content of

speech – verbal and non – verbal
•Difficulty in relating experiences
•Difficulty in pragmatic speech i.e. functional communication – real
dialogue where two people have a two way conversation, relate
incidents, give interpretations of it , where two sets of impressions are
tuned → common behaviour
 PROBLEMS IN SOCIALIZATION
•Difficulty in understanding the social world
•Difficulty in understanding the thoughts, feelings and
intentions of others,
•An unwillingness to allow others to share experiences - Lack of
spontaneous seeking to share enjoyment, interests, or
achievements with other people → Lack of social or emotional
reciprocity
•Difficulty in understanding non - verbal cues – facial expression, tone
of voice, etc.
•Difficulty in imitation, interaction and joint attention
•Failure to develop peer relationships app. to developmental level
The physical approach The social approach

A ‘chew on, shake, explore’ world A ‘communicating with’ world

Regularity Regularity
Cause-effect Intention
Activity Activity
Exploring oneself through action Exploring oneself through (sensorimotor
activity) mirroring (sharing and attuning emotions)
Exploring behaviour Playing behaviour
(manipulating the object) (relating to the object)
Processing information Processing information
Cognitive – perceptual Emotional – empathetic
Concrete Abstract – dynamic
The effect The effect
Realization Experience
(understanding function) (understanding context)
Beyer, and Gammeltoft,2000
 PROBLEMS IN IMAGINATION

•Difficulty in understanding the meaning of imaginary situations,

often leading to repetitive, obsessive behaviour that means something
only to the child

•Difficulty in forming flexible scripts and tend to be dependent on

events occurring in the same way every time → unexpected events may
throw the child off this familiar and inflexible script – internal images
of well known daily routines

•Need to establish stable perceptual images as they find it difficult to

see beyond the things they see or hear → ‘echo like’ behaviour i.e.
same behaviour and rituals performed again and again- Stereotyped
Behaviour

•Persistent preoccupation with parts of objects

 PROBLEMS WITH SENSORY PROCESSING

Difficulty in sensory processing - in the areas of visual, auditory,

tactile, taste, olfactory and vestibular processing → avoiding eye
contact, oversensitivity to certain vivid colours, sounds, textures,
being picky eaters, resistance to being held or cuddled, throwing
head back without any sense of what may be behind it

Difficulty in filtering out the variety of sensory input they are

bombarded with
OBSERVATIONS OF PLAY AMONG CHILDREN WITH
AUTISM
Kanner in1943 first observed the limited ability of play that characterizes those with
Autism.

Three explanations as to why children with ASD do not play:

Difficulty with lower levels of play i.e. manipulation (stacking) and relational play
(waving). They have limited experiences in these categories because of their lack of
curiosity and need to explore → Repetitive, persistent behaviour and self stimulatory use
of proximal senses(sucking, licking etc).

Cognitive theory- impairment in the child’s representational thought, the ability to form
and manipulate symbols.

Conative theory- suggests that elicited play of children with Autism is less impaired
than their spontaneous play. This implies that children with Autism can pretend, but do
not do so spontaneously, perhaps because of repeated failures.

Roeyers and van Berckelaer –Onnes,1994

Very few children with Autism use symbolic play, Wing, 1970 and the few who showed
signs of symbolic play, played in a very stereotypical manner -Wing and Gould,1979.

Production of pretense in children with Autism has been assessed under two general
setting conditions: (a) unstructured, spontaneous conditions, and (b) structured,
prompted, or elicited conditions. All studies show an impairment in the production of
pretend play in children with Autism (in comparison to mental - aged matched controls)
in unstructured, spontaneous conditions .
(Baron- Cohen, 1987; Lewis & Boucher, 1988; Riguet, Taylor, Benaroya, & Klein, 1981;
Sigman & Ungerer, 1984).

After general or specific prompts are given, children with Autism tend to produce some
pretend play, although in many studies the group differences remain .
(Riguet et al., 1981; Sigman & Ungerer, 1984)
‘Theory of Mind’ hypothesis was introduced, Baron-Cohen, Leslie and Frith,1985.It showed the
link between the child’s ability to pretend play and his potential ability to understand his
own behaviour as well as other people’s.

According to Leslie's (1987) theory pretend play involves metarepresentation,(deliberate

disregard for reality, where the child is simultaneously aware of a real situation and
creates an image of it being something else) the cognitive basis of the young child's
developing theory of mind—both of which are impaired in Autism - Jarrold, Carruthers,
Smith, & Boucher, 1994)

Lewis and Boucher (1988) suggested that since prompting increases the amount of both
functional and pretend play, this supports either a generativity or a motivational deficit
theory, and that the production of pretend acts per se (and presumably the accompanying
representational thinking) is not impaired in Autism.
Children with Autism have problems in generating pretend play rather than in the
mechanics of pretence itself. They can play if highly structured or if prompts are used.
They also found that child with ASD had impaired levels of functional play
Jarrold, Boucher and Smith, 1996

Sensory motor play dominates beyond the verbal mental age, at which it normally
declines for a child without Autism
Jordan and Libby, 1997

Child with Autism show a lack of spontaneous play in free settings, not because of a
complete inability to play, but may be due at least in part to the fact that they find play
difficult, so they experience repeated task failure. This in turn leads to frustration and a
pervasive lack of motivation to play
Stahmer,1999
The difficulty that children with ASD in pretend play arises from difficulties they have
in both the fluid organization of thought processes and in communicating these
thoughts to others .
Sherratt, 1999

Play in children with Autism is repetitive.

Wolberg 1999

Children with Autism did not normally engage in elaborated functional play and
produced fewer different actions than control groups like kids with Down’s Syndrome
and typical kids. Their play is impoverished e.g. Placing a spoon in a pot but not
stirring it).
Williams, Reddy and Costell,2001
 HYPOTHESES

Motivational Hypotheses Competence Hypotheses

Do not understand pretend play do not use pretend play

Lack emotional involvement unable to form images

Do poorly in free play situations unable to attribute an actual

Better in structured situations mental life with its own wishes and imagination to a
toy

Emotional component cognitive component

 WHY IS PLAY DIFFICULT?
• Communication difficulties
• Problems with meaning
• Difficulty accepting direction from an adult
• Problems with imitation, interaction and joint attention
• Problems with generalization of skills
• Problems with flexibility
• Problems with imagination
• Problems with sensory processing
↓
Lack of varied , spontaneous make believe play or social imitative play appropriate to
developmental level
DSM IV Tr
 WHY IS JOINT PLAY DIFFICULT?
•Problems in imitation, interaction and joint attention

•Difficulty accepting direction from others and the resulting ‘exposure anxiety’ that
this can cause

•Problems with flexibility e.g. set way of playing e.g. lining up cars

•Problems with imagination e.g. no pretend play

•Problems with meaning- difficulty imagining that items can represent other things
e.g. a stick could be an airplane

•Problems with generalization – applying a skill learnt to a different context

•Difficulty in both understanding and expressing language

•Problems with sensory processing- sensory overload - not being able to filter out
input and focus on the activity at hand
 WHY IS TURN-TAKING DIFFICULT?

In order to take turns we need to:

• Be able to share the same material
• Be aware that the other person is part of the game
• Be aware that they are integral to the game
• Judge when it is our turn and be patient
• Be aware of what they are doing
• Try ultimately to predict what they are thinking and what they might do next
 STUDIES ON PLAY AS INTERVENTION
• Children's ability to use language coincides with the emergence of predictable
symbolic play schemes. Children don't use language fully until they can play in
symbolic ways. Carol Westby,1980.

• Play has had a very small role in the education and treatment of children with
ASD. Wolberg,1999

• Symbolic pretend play has much to offer in the remediation of the core difficulties
that are experienced by children with ASD, as it offers a rich and meaningful
environment for the manipulation of symbolic representations, which is something
these children find difficult.
Sheratt,1999
• Symbolic pretend play may result in learning and changes to the brain, develops
flexibility of thought, develops social skills they often lack by opportunities that create
a shared understanding of pleasure experienced in play episodes. Sheratt and Peters, 2002

•Make believe play can develop thought flexibility and reduce conceptual
fragmentation in children with ASD. If play is taught it may help to reduce repetitive,

rigid behavioural problems and encourage communication and interaction.

Sherratt and Peter, 2002

• Play Project shows that the bond between parent and child can be used to bring
children through a once- hidden doorway into the warmth of a relationship. 50% of
the
children improve significantly, 25% show moderate improvement and 25% (usually
with other physical or developmental problems) show little improvement.

The logic is simple: rather than force a child to join the world, parents are taught to
enter the child’s world and, over time, to become a trusted guide to the outside.
Solomon , 2007 Play Project
A pilot randomized controlled trial of DIR/Floortime™ parent training intervention was
designed by Pajareyan and Nopmaneejumruslers,2011 to test the efficacy of adding
home-based Developmental, Individual-Difference, Relationship-Based
(DIR)/Floortime™ intervention to the routine care of preschool children with ASD.
Measures of functional, emotional development and symptom severity were taken.

It was found that after the parents added home-based DIR/Floortime™ intervention at an
average of 15.2 hours/week for three months, the intervention group made significantly
greater gains in all three measures employed in the study: Functional Emotional
Assessment Scale (FEAS), Childhood Autism Rating Scale and the Functional
Emotional Questionnaires. This study confirms the positive results obtained by a
previous DIR pilot study.
Solomon et al., 2007
A study was conducted for 102 pre-school children diagnosed with an ASD at age 2 who
attended an inclusive toddler program (described by Stahmer and Ingersoll, 2004) until age 3.
Outcomes on standardized developmental assessments indicate significant improvement,
in developmental level, adaptive behavior and communication. Thirty-one of the
children (31%) were functioning in the typically developing range when they exited the
program at age 3, after an average of 8 months of intervention. Predictors of positive
outcomes included length of time in the program, level of words and gestures used at
entry and higher externalizing and lower internalizing behavior CBCL scores at entry.
Stahmer, Akshoomoff and Cunningham, 2011.
 PLAY BASED INTERVENTION
Play skills interventions may be implemented using non-directive or directive approaches.
Nondirective teaching aims at a wide range of play skills, including play-related
communication and social interaction.
A directive teaching style focuses on specific play techniques, e.g.the functional use of toys.
This may include teaching skills in isolation in the following sequence:
1. Select a motivating toy.
2. Observe other children using the toy to determine appropriate use of the toy.  
3. Give the toy to the child.
4. Observe the child interact with the toy.
5. Prompt the child to interact with the toy in an appropriate manner.
6. Provide physical prompts(e.g., put your hand on the child’s hand and direct the use
of the toy) to show the child how the toy works.
7. Model the desired behavior using the toy or ask another child to model the use of the toy.
8. Proceed to a more intrusive prompt, if needed. Stop if the child is using the toy in an
acceptable manner.
9. Provide verbal prompts or direction to the child while he or she is using the toy (e.g.,
“Push the car to Pat”).
10. Positive reinforcement (e.g., verbal praise, identified reinforcers) should be implemented
along with the prompting and used to reinforce the desired play behaviors.
Terpstra, Higgins, and Pierce, 2002
 FLOORTIME

The DIR/Floortime model is based on the idea that EMOTION is critical to the growth
of the mind and brain. 
What is Floortime?
• A specific technique where for 20 or more minutes you get down on
the floor with your child.
• A general philosophy that characterizes all the interactions with the child, because
all interactions have to incorporate the features of Floortime as well as the particular
goals of that interaction, be it speech therapy, OT or a set of educational goals .
Greenspan, 1998
 Main emphasis
• Following the child's lead
• Joining the child's world and pull him into a shared world in order to help him
master each of his Functional Emotional Developmental Capacities - fundamentals of
relating, communicating, and thinking.

Follow the child's lead means

- Tune into his emotional world
- Follow his emotions
-  What is of interest to your child?
- What gives him pleasure?

The ultimate goal is

- 1.To help him to be an empathetic, creative, logical, reflective individual
- 2. To help the child master his Functional Emotional Developmental Capacities – his
basic social, emotional, intellectual, language, and academic abilities.
SIX CORE DEVELOPMENTAL CAPACITIES
Six Core Developmental Capacities
Attending

Using ideas
Relating
Logically

6 Core
Developmental
Capacities

Using Ideas Purposeful

Creatively Communication

Problem-
solving
Interactions
Floortime involves this polarity, or this dialectic, or this tension between following the
child’s lead, entering his world and pulling him into your own world, finding his pleasures
and his joys. Then creating challenges that help the child move up to higher levels of
relating, communicating, and thinking.

That means paying attention to the child’s individual differences in terms of the way they
process sounds and sights and movements and modulate sensations, and also paying
attention to the family patterns and therapists to your own personalities so you know how
you have to stretch to work with a particular child so you can enter their world and tailor
your interactions to their nervous system. Greenspan, 1998
Play provides a medium through which children develop
skills, experiment roles and interact with others,
children with Autism are disadvantaged in their use of
play for these purposes - Boucher - 1999
 FACTORS INFLUENCING PLAY IN ASD

Structure - Helps the child to understand the sequence of skills, activities or ideas
necessary towards attainment of an agreed goal.
Systematically breaking a play activity into component parts, so that it is no longer a
jumble of language, objects and actions that has no meaning for your child.

Affect - There needs to be an inherent pleasure in play or it ceases to be play

Interests - The child must have interest in manipulation of materials to make the play
experience personally meaningful. Use something that has an inherent meaning to the
child – string, bubbles, spinning top

Non representational Materials - Strings, play dough etc. should be used in balance with
representational materials (toy animals, dolls)
Continuity – There should be some expectation of the process in teaching pretend play
to enable the children to switch into pretence

Appropriate Language- Language and instructions should be kept simple and to the
minimum

Social Play- This may involve learning new skills from a more able player, gaining a
desired object from someone else or sharing a sense of enjoyment from the actions of
others
 8 BASIC PRINCIPLES
Warm
and
Friendly
Alert
Places to recognize
necessary feelings &
limits reflect them
back

Deep Accept
respect for Play child
the child’s for what
ability
Therapist he is

Does not
Feeling
attempt to
of
direct the
Permissiveness
child’s action Does not
hurry
the child
or the
therapy
HOW DO WE TEACH CHILDREN WITH AUTISM TO PLAY?

•Create the right environment

•Confine play area to a specific place
•Use only 3 - 4 items of play
•Keep instructions simple and clear
•Start with short periods of time
•Use picture prompts to communicate
•Help them make choices
•Use lot of positive reinforcements
•Use items your child is interested in to start with
• Create a sense of shared play by letting him see that how he plays has a direct
effect on how you play
• Be aware that limiting his access to a toy he likes will increase his motivation to
play with it
• Be aware that direct and confrontational interactions may cause him anxiety
• Develop a collection of techniques to use when he resists play
• Start with controlled indoor table top/carpet play, generalize it to other
situations, theme based play
• Be subtle and gently work on his ‘in-built’ aversion to sharing his experience of
the world
 HOW DO I START???

Have 4-5 boxes (different themes- Different sounds, shapes, water play, family, doctor
etc.) which you can rotate every day because children with Autism -
•Have poor attention span
•Will not know what toys are in the box
•Have communication difficulties
•Have problems in imagination
•Varying toys brings in flexibility and prevents your child from getting obsessed on
having one item which he expects and needs to see every day
 WHAT KIND OF TOYS SHOULD I USE?
• Do not look at the age level- Know your child’s level, strengths and deficits
• Cause and effect toys are good for motivating children with Autism
• Items should not be frustrating for your child to use
• Size should be one that your child can handle easily
• Minimum amount of details visually-plain tea sets
• Realistic items – Children with ASD tend to relate to them better
cooking set, dolls etc.
• Puzzles, stacking boxes should be easy to fit
• Reinforcers – The ones your child shows interest in or is obsessed
with should be used as reinforcers – bubbles, spinning tops
 HOW DO I PLAY?
Be alert to his level of communication, readiness to interact, use the approach that is
right for your child.

Indirect parallel play with duplicate items the child enjoys, copy what he does no matter
how inappropriate, copy the noises, change them, give gentle commentaries, stop to
watch his reaction, respond to any signs that he wants to carry on.

A game schedule with a clear indication of content and order will help.
Content should be simple and motivating as the social aspect is so challenging.
 SOME METHODS TO TEACH PLAY SKILLS

Modelling
Mirroring
Play routines
Play scripts
Action songs
Integrated play groups
(Thomas & Smith, 2004)

Social narratives and visual sequences

(Beyer & Gammeltoft, 2000; Sherratt, 1999)

LEGO play and LEGO based interactive play groups (LeGoff, 2004, 2006)
Peer trainers and peer examples
(Bass & Mulick, 2007)
The play strategies should focus on the following :
• Play theme –Familiar routines (scripts) that evoke recognition and motivation e.g.
morning routine
• Attention, expectation and shared focus - setting the stage, play material . Child’s
attention and interest are increased by integrating several senses – colour of the box,
sound of things inside
• Imitation and mirroring – identical sets of toys to inspire attention, and motivation , to
imitate child’s actions, reinforce the child’s own initiative, adult can guide
• Parallel play, dialogue in play – two sets of miniature objects (cooking set, dolls)
• Scripts and social stories –story sequence in pictures corresponding to the toys. Child
acts out the story with toys
• Taking turns – Can use a hat initially to indicate whose turn it is
• Games and rules in playing – taking turns to indicate and play with their choice of toy
for a fixed time, proceed to games with a feely bag, ball games, simple board games-
Dominoes, Picture Lotto See Beyer & Gammeltoft, 2000
 WHAT WE CANNOT DO…

•We cannot shout, scream or cajole the Autism out of our child
•We cannot make him ‘join us back in our world’ by forcing our attention
•We cannot allow our feelings of anger and hurt to express themselves
•We cannot use the same behaviour strategies we might use on a non-Autistic
child
•We cannot use the same motivating strategies for good behaviour
•We cannot expect that if we devote years to the ‘recovery’ of
our child that he will grow into an adult without Autism
•We cannot compare our child to both his typical and ASD peers – his
experience is unique
 HOW TO REDUCE STRESS WHILE YOU PLAY
•Understand your child and respect his unique experience

•Structure - Use visual prompts to mentally prepare your child. Work on attaining
one element of a particular play activity giving him a chance to interpret the activity
and give it meaning

•Motivation-Create situations that will motivate him to communicate with you – use
reinforcers

•Preparation – Plan out your activity and keep things ready before you start playing.

•Individuality – Get into your child’s thinking, don’t pull him down a typical path of
learning, find other pathways and meet him half way. Have goals and open your
mind to all the possibilities that his potential may hold, but never lose sight of the
individual he is.
 •Communication and interaction - Make him know that his attempts at
communication and interaction are successful for him
•Indirect Learning- Be aware that direct confrontational interactions may cause him
anxiety- use puppets and toys as a third party to talk to your child
•Use music, rhymes and commentaries to help bring your child into the world
• Be alert to times when your child is receptive or needs to pull back. Watch the triggers
that cause him stress, watch for sensations that are interfering with his interactions
that he cannot communicate to you
•Bring out the child in you and enjoy what you are doing. Engage yourself in the
activity as if it were purely for your own pleasure.
•Make a schedule for yourself so that you have time for your child, your spouse and
yourself – you need to de –stress!
Through play find an ‘emotional space’ that you can both
occupy at the same time or some of the time with laughter
and responsiveness.