Playful Occupational Therapy Intervention for Children and

AOTA Annual Conference April 27 2012 Indianapolis IN

ldquoPlayful OT Intervention for Children and Adolescents with Autismrdquo Copyright copy 2012 by Susan L Spitzer Heather Miller Kuhaneck amp Elissa Longo 1

Playful Occupational Therapy

Intervention for Children and

Adolescents with Autism

Innovative Creative and Evidence-

Based Strategies for Success

copy Susan L Spitzer PhD OTRL Heather Miller Kuhaneck PhD OTRL FAOTA

Elissa Longo OTD OTRL

Introduction to Speakers Susan L Spitzer PhD OTRL

Adjunct Assistant Professor of Clinical Occupational

Therapy University of Southern California

Private Practice Pasadena CA

Heather Miller Kuhaneck PhD OTRL FAOTA

Clinical Assistant Professor Sacred Heart University

Elissa Longo OTD OTRL

Sacred Heart University

Learning Objectives Understand the evidence supporting a playful approach

to occupational therapy intervention with children and

adolescents with autism

Identify opportunities for innovative creative and

evidence-based playful occupational therapy

intervention with children and adolescents with autism

Consider ways to implement playful occupational

therapy in onersquos own clinic and school setting

The Importance of Play

Child Development

In studies of typical children play has been associated with

Divergent and convergent thinking (Fisher 1992 Russ

Robbins amp Christiano 1999 Wyver amp Spence 1999)

Associative fluency or the ability to suggest alternative uses

for an object (Dansky amp Silverman 1973)

Creativity (Howard-Jones Taylor amp Sutton 2002 Saracho

2002)

Flexibility in approach to problem solving (Pepler amp Ross

1981)

Metacognition and self-regulation strategies (Whitebread

Coltman Jameson amp Lander 2009)

LO Understand the evidence supporting a playful approach to occupational therapy intervention with children and adolescents with autism

The Importance of Play Autism

Documented neurological deficits in multiple

brain areas in autism

Animal research suggests that play impacts

these brain regions


Through brain plasticity- play

could provide environmental

enrichment of the sort that

improves function and changes

developmental trajectories

The Importance of Play

Family- amp Child-Centered Care

ldquoFamily-centered service recognizes that each family is unique

that the family is the constant in the childrsquos life and that they

are the experts on the childrsquos abilities and needs The family

works together with service providers to make informed

decisions about the services and supports the child and family

receive In family-centered service the strengths and needs of

all family members are consideredrdquo(King et al 2004)

FCC is about maximizing parents ability to foster their childrsquos

development and well being

Often what families care about = play and friendships




The State of Play in OT What we did 10+ years

ago (Couch Dietz amp

Kanny (1998)

What do we do now

(Brown et al 2005

Howard 2002 Kramer

et al 2009 Kuhaneck amp

Tanta in preparation

Rodger et al 2006

Saleh et al 2008)


The State of Play in OT

Barriers Reported barriers

Funding sources

Contextual factors(ie

school based practice)

Removing barriers

Goal writing

Education of others

Family members as allies

LO Consider ways to implement playful occupational therapy in onersquos own clinic and school setting

Play-Based amp Occupation-Focused

Intervention in Occupational Therapy (Kuhaneck Spitzer amp Miller 2010)

Play amp Pediatric OT Play as an occupation (Parham 2008)

The missing piece of meaning

Play in natural environments daily life

Contextual influences

Physical safety

Space for play

Time for play

Availability of developmentally appropriate amp preferred play

materials

Appropriate social interaction


Intervention in Occupational Therapy (contrsquod) (Parham 2008)

Best practice

We must become more comfortable with play as a

GOAL rather than a means to achieve some other goal

But- we must be able to explain to others why play is

important

For some children especially those with autism being

able to play IS an important goal- as we will now see

Capabilities and difficulties of

children with autism

in relation to play


bull Play Skills The StructureForm of Play bull Delayed or different in quality amp quantity- Spitzer (2008)

Play difficulties in children

with autism Object play

Both extreme preoccupation with and

atypical use of objects is noted

(Baranek et al 2005 Ozonoff et al

2008 Rowland amp Schweigert 2009

Williams 2003 Williams Costall amp

Reddy 1999 Williams Kendell-

Scott amp Costall 2005)

Objects hold the potential for fear

and anxiety (Grandin 1997)





with autism Functional Play

No differences in frequency

Differences in quality and

total time spent in this realm

(Charman et al 1997

Jarrold Boucher amp Smith

1996 Lewis amp Boucher

1988 Williams 2003

Williams Costall amp Reddy

1999)

Play Difficulties in Children with

Autism Symbolic Play

Less likely to engage in pretend play

Spend less total time in pretend play

Impaired in production of novel

pretend acts

BUT - Are capable of pretending-

especially when elicited by an adult

(Charman amp Baron-Cohen 1997 Hobson

Lee amp Hobson 2009 Jarrold 2003

Jarrold et al 1996 Lewis amp Boucher

1988 Libby et al 1998)


Play difficulties in Children with

Autism Natural free play with peers Greater differences noted in play when

free play is observed (vs elicited play)

Interactions with others rare and when

they occur- are most often with adults

Play episodes are brief

In one study- preferred play and play

objects were sensorimotor in nature

(Holmes and Procaccino 2009 Holmes amp

Willoughby 2005 McGee Feldman and

Morrier 1997)


Play in Children with Autism

The Experience

The Experience of Play Motivation amp Mental Health

Play and individual meaning

Play and the self as an occupational being

The experience of play for children with autism

Spitzer (2008)


Assessment Examining

Personal Meaning in

Occupations of Children

with Autism

LO Identify opportunities for innovative creative and evidence-based playful occupational therapy intervention with children and adolescents with autism

Socially Framed Activities Self-care work school

Unconventional Activities

Spitzer (2010)

Assessment

Occupational Profile




Gathering Information about likes dislikes preferences

Observations

Interviewsreports

participation

Assessment



Identifying unconventional Occupations

Intentional actions

A set of actions

With meaning

Spitzer (2003b 2010)

Assessment



The Challenge of Identifying Meaning and Intention

The childrsquos perspective often is different due to

differences in

development

language amp

perception

Spitzer (2003a)

Assessment



An essential component

ldquoa sophisticated understanding of the unique qualities

of the activitiesrdquo (Fidler amp Velde 1999 p 2)

sensory experience physical characteristics childrsquos

skill other child characteristics

Detailsnuances of what amp how the child does the

activity are critical

Helps identify what is the occupation

Assessment

Child-Specific Activity Analysis


Framing the Occupation

Note Adapted with permission from ldquoWith and Without Words Exploring Occupation in Relation to Young Children with Autismrdquo by Susan L Spitzer 2003 Journal of Occupational Science 10(2) p 74 Copyright 2003 by Journal of Occupational Science

Assessment

What is the Occupation

The What and How

BehavioralMaterial Content

observations of obvious and subtle

behaviors and use of materials

The Why Subjective

Meaning

making connections

to infer amp interpret meaning

Meaning and Intention in Occupation

(Williams 1998 Spitzer 2001 2003b)

Assessment

Clinical Reasoning amp

Interpretation

Details from

Activity Analysis

What was

includedexcluded

Was it choice skill

or context

Why do it

Meaning




Case examples ldquoPlaying withrdquo Dirt for Mike amp Alex

Assessment


Interpretation

Being Playful

Therapeutic Use of Self in

Pediatric OT for Children with

Autism


Communication

Understanding the Child

Communicating that Therapy is fun

Kuhaneck Spitzer amp Miller (2010)

Being Playful

Therapeutic Use of Self


Suspend adult assumptions (ie superiority) (Curtin

2001 Fine amp Sandstrom 1988)

Level power differencesinequalitymdashavoid being an

authority figure minimize stopping and directing of the

client let them show us (Curtin 2001 Fine amp

Sandstrom 1988)

Look for effectimpact of adult presence (Fine amp

Sandstrom 1988)

From Spitzer (2004) adapted from Spitzer (2003)

Being Playful



Assume all actions are potentially communicative (Durig

1996)

Attend to communication through occupational

engagement especially shared occupations (Grandin amp

Scariano 1986 Spitzer 2003a Williams 1992)

Look for individualized communication strategies around

shared routines physical environment likes and dislikes

and bodily expressions (Goode 1980 1994 Spitzer

2003a)


Being Playful



Develop a shared history with the clientmdashunderstand

their favorite objects and preferences and participate in

activities with them (Goode 1980 1994 Spitzer 2003a)

Interview other people knowledgeable about the client

Follow the clientrsquos directionsmdashat times let them lead

usldquopassive obediencerdquo (Goode 1980)


Being Playful





Imitate physically simulate or imagine the individualrsquos

sensory experience of the occupation to ldquofeelrdquo the

experience (Goode 1980 Spitzer 2003a)

Sharpen conscious awareness of various auditory

visual tactile and kinesthetic sensations (Spitzer

2003a)


Being Playful



Being Playful

Communicating that Therapy is

Fun Eyes

Face

Body

Touch

Voice (vocalizations)

Use a playful tone

Vary pitch loudness rhythm

Repeat sounds

Imitate sounds and ways that sounds are used by child


Being Playful


Fun


Language

Minimize directive language

Imitate childrsquos words

Match language to childrsquos development

song melody rhythm or different voice (eg accent)

ldquokid playrdquo words phrases and sounds

humor jokes and mischievous tone

ldquoTalkingrdquo of inanimate objects


Being Playful


Fun


Empathy amp Rapport

Empathymdashinformed caring

Rapport amp Therapeutic Relationshipmdashworking alliance or

bond (Tickle-Degnen 2002)

Being Playful

Demonstrating Empathy amp

Rapport


Being Playful


Rapport in Play Sharing Controlmdashpartners

Spontaneity amp Flexibility

Managing Challenges in Play

Focusing on Future Possibilities



occupational therapy literature on therapeutic use of self

OTs report relationship to outcomes (Cole amp McLean 2003

Gahnstrom-Strandqvist Tham Josephsson amp Borell

2000 Hasselkus amp Dickie 1994 Rosa amp Hasselkus 1996

Taylor Lee Kielhofner amp Ketkar 2009)

Correlated with clientsrsquo perceived outcomes (Law 1998

Darragh Sample amp Krieger 2001 Palmadottir 2003

Being Playful Evidence

L O Understand the evidence supporting a playful approach to occupational therapy intervention with children and adolescents with autism

interdisciplinary research on adultndashchild play adult

actions can influence play in general

Greater complexitylevel more engagement longer play

episodes (Fiese 1990 Haight amp Miller 1992 Sorce amp

Emde 1981 Slade 1987)

Feedback amp encouragement to use interactive strategies

more frequentlymore competent play (Belsky Goode amp

Most 1980)




actions can influence play in children with disabilities

Amount of play playfulness (Lawson Parrinello amp Ruff

1992 Daunhauer Coster Tickle-Degnen amp Cermak 2007

Chiarello Huntington amp Bundy 2006 Evans amp Meyer

1999)



Autism amp Adult-Child Play

Nadel Martini Field Escalona and Lundy (2008)

looked at approached and touched adults more frequently when adult more often looked at the child smiled at the child moved toward the child had relaxed body tone made sounds imitated the child and was playful

Tiegerman amp Primavera (1981)

frequency amp duration of object manipulation was greatest when the adult imitated the child by using both the materials and methods of play that the child chose rather than different action or object

Skaines Rodger amp Bundy (2006)

adult structure of play increased playfulness



Playful Strategies

Selecting Adapting amp Creating

Activities that Children

Want to Do

Playful Strategies Using Personal Interests amp Preferences to Reframe

ldquoWorkrdquo into ldquoPlayrdquo (in therapy amp daily life)

Embedding ldquoPlayrdquo in ldquoWorkrdquo

Expanding Current Occupations

Adapting Individual Interests into Shared Social

Activities

L O Identify opportunities for innovative creative and evidence-based playful occupational therapy intervention with children and adolescents with autism



Reframing ldquoWorkrdquo into ldquoPlayrdquo


The What and How


The Why Subjective

Meaning

Reframing ldquoWorkrdquo into ldquoPlayrdquo What they Like to Do (more

like play)

Visual feedback

Construction

Sensory properties

Sensorimotor engagement

Favorite toys

Narratives from favorite stories or movies

(Spitzer 2008)

What They Need to Do (often more work)

ADLsSelf-Care

Sleep

Education

ldquoPlayrdquo

Social Participation



Video Case Self-Care



The Work of Self-CareDressing


Reframing ldquoWorkrdquo into ldquoPlayrdquo The Work of Writing

Materials (sensory objects etc)

A passiontopic (food cars geography presidents)

Theme of interest--Silly or ldquoinappropriaterdquo or ldquotrickyrdquo



The Work of Writing

Writing Work Car Writing Game




Reframing ldquoWorkrdquo into ldquoPlayrdquo The Work of Writing More examples


Reframing ldquoWorkrdquo into ldquoPlayrdquo The Work of ldquoPlayrdquo Activities Soccer


ldquoHorses vs Wolvesrdquo


The Case of Beneficial ldquoOff-Taskrdquo Behavior


Embedding ldquoPlayrdquo in

ldquoWorkrdquoVideo Case



ldquoWorkrdquoVideo Case Part II



Lack of interests

Narrow Interests

Limited Interests amp Social Play





Lack of Interests

Create occupational appeal (Munier Myers amp Pierce

2008) then gradually grade and adapt

A way to ldquoget-inrdquo


Expanding Current

Occupations Video Case



Narrow Interests amp Opposition to Other Things

Combine elements of what the child likes with elements of

what they need to do

Start where the child is

Explain and negotiate Example cards

Kuhaneck Spitzer amp Miller (2010) Spitzer (2008)


Expanding Current




Narrow Interests (amp Opposition to Other Things)



bull Recognizing amp Extending Hints of Play Kuhaneck Spitzer amp Miller (2010) Spitzer (2008)

Case Examples




Expanding Current Occupations Recognizing amp Extending Hints of Play

Construction amp Destruction ldquoDonrsquot Break the Icerdquo


Adapting Individual Interests into

Shared Social Activities

Example Tag Games Follow-the-____ Leader Games

Example New Pretend Games


Application to Adolescents

Many of the strategies we have discussed can be

adapted for use with older children and adolescents

Adolescents also need play leisure opportunities and

the ability to socialize with peers

Case Studies Play in

Adolescents with ASD Reframing Work into Play

Reporter Daniel amp Paul

Ari from the Future

Ideas for Play in Adolescents

with ASD Video games or themes

Elements to rename Alert Program ldquospeedsrdquo

Sports or sport themes

Create a new ldquosportrdquo

Made-up games to promote social interactionnegotiation

Social media combined with the work of keyboarding

Other personal interests

Explain to a peer to share

Bring a favorite item

Card ldquoGamesrdquomdashcommercially available or have them make-up

Focusing on Outcomes We will be more likely to work with children in a playful

fashion and to work on play specifically if we assess

and write goals for play

Sample play goals and objectives for children with

autism

Common concerns with reimbursement and otherrsquos

perceptions

Supporting the importance of play using evidence



Play Evidence Evidence on Effectiveness Incorporating Play

Play is an effective modality in OT (amp other interventions)

for developing skills in children with disabilities (for

example Case-Smith 2000 Esdaile 1996 OrsquoConnor amp

Stagnitti 2011 Olson Heaney amp Soppas-Hoffman 1989

Sakemiller amp Nelson 1998 Sparling Walker amp

Singdahlsen 1984)

Play-based approaches are valued by parents (Stahmer et

al 2011)


Play Evidence Evidence on Effectiveness Incorporating Personal

Interests

Research supports that including child choice preference

or interest can be an effective strategy for promoting

engagement in toy play and social play in children with

autism (ie Baker Koegel amp Koegel 1998 Koegel Dyer

amp Bell 1987 Reinhartsen Garfinkle amp Wolery 2002

Vismara amp Lyons 2007)


Play Evidence Future Research on Incorporating Personal Interests amp

Play

Is it more effective

For which outcomes


Life should be more than compliance and

actions and expression should be more than

training and a means to an end Life should at

some point be a rewarding end in itselfrdquo Donna Williams (1996 p 128)

an adult with autism

Thank you children amp their families colleagues mentors friends family amp you

Questions amp Answers



References Baker MJ Koegel RL amp Koegel L K (1998)

Increasing the social behavior of young children with

autism using their obsessive behaviors Journal of the

Association for Persons with Severe Handicaps 23(4)

300-308

Baranek G T Barnett C R Adams E M Wolcott N

A Watson L R amp Crais E R (2005) Object play in

infants with autism Methodological issues in

retrospective video analysis American Journal of

Occupational Therapy 59(1) 20-30

Bauminger Namp Shulman C (2003) The development

and maintenance of friendship in high-functioning

children with autism maternal perceptions Autism

7(1) 81-97

Bauminger N Solomon M amp Rogers SJ (2010)

Predicting friendship quality in autism spectrum

disorders and typical development Journal of Autism

and Developmental Disorders 40(6) 751-61

Bauminger N Solomon M Aviezer A Heung K

Gazit L Brown J amp Rogers SJ (2008) Children

with autism and their friends a multidimensional study

of friendship in high-functioning autism spectrum

disorder Journal of Abnormal Child Psychology 36(2)

135-50

Belsky J Goode M K amp Most R K (1980) Maternal

stimulation and infant exploratory competence Cross-

sectional correlational and experimental analyses

Child Development 51 1168ndash1178

Blunden P (2001) The therapeutic use of play In L

Loughler (Ed) Occupational Therapy for Child and

Adolescent Mental Health London Harcourt

Brown S (2009) Play How it shapes the brain opens

the imagination and invigorates the soul New York

Penguin Books

BrownT G Rodger S Brown A amp Roever C (2005)

A comparison of Canadian and Australian paediatric

occupational therapists Occupational Therapy

International 12 137ndash161 doi 101002oti

Case-Smith J (2000) Effects of occupational therapy

services on fine motor and functional performance in

preschool children American Journal of Occupational

Therapy 54 372ndash380

Chiarello L A Huntington A amp Bundy A (2006) A

comparison of motor behaviors interaction and

playfulness during mother-child and father-child play

with children with motor delay Implications for early

intervention practice Occupational amp Physical Therapy

in Pediatrics 26(12) 129ndash152

Cole M B amp McLean V (2003) Therapeutic

relationships re-defined Occupational Therapy in

Mental Health 19(2) 33ndash56

Catmur C Walsh V amp Heyes C (2009) Associative

sequence learning the role of experience in the

development of imitation and the mirror system

Philosophical Transactions of the Royal Society Series

B - Biological Sciences 364 2369-2380

Charman T Swettenham J Baron-Cohen S Cox A

Baird G amp Drew A (1997) Infants with autism An

investigation of empathy pretend play joint attention

and imitation Developmental Psychology 33(5) 781-

789

Charman T amp Baron-Cohen S (1997) Brief report

Prompted pretend play in autism Journal of Autism and

Developmental Disorders 27(3) 325-332

Couch K J Deitz J C amp Kanny E M (1998) The role

of play in pediatric occupational therapy American

Journal of Occupational Therapy 52 111ndash117

Curtin C (2001) Eliciting childrenrsquos voices in qualitative

research American Journal of Occupational Therapy

55 295ndash302

Dansky J L amp Silverman I W (1973) Effects of play on

associative fluency in preschool-aged children

Developmental Psychology 9 38ndash43

Darragh A R Sample P L amp Krieger S R (2001)

ldquoTears in my eyes lsquocause somebody finally

understoodrdquo Client perceptions of practitioners

following brain injury American Journal of Occupational


Daunhauer L A Coster W J Tickle-Degnen L amp

Cermak S A (2007) Effects of caregiver-child

interactions on play occupations among young children

institutionalized in Eastern Europe American Journal of

Occupational Therapy 61 429ndash440



Desha L Ziviani J amp Rodger S (2003) Play

preferences and behavior of preschool children with

autistic spectrum disorder in the clinical environment

Physical and Occupational Therapy in Pediatrics

23(1) 21-42

Diamond A Barnett WS Thomas J amp Munro S (2007)

Preschool program improves cognitive control

Science 318 1387-1388

Donnelly J amp Bovee J (2003) Reflections on play

Recollections from a mother and her son with Asperger

syndrome Autism 7(4) 471-476

Durig A (1996) Autism and the crisis of meaning Albany

NY State University of New York Press

Elkind D (2007) The power of play Cambridge MA De

Capo Press Ginsburg K R and the Committee on

Communications and the Committee on Psychosocial

Aspects of Child and Family Health (2007) The

importance of play in promoting healthy child

development and maintaining strong parent-child

bonds Pediatrics 119 182-191

Esdaile S A (1996) A play focused intervention involving

mothers of preschoolers American Journal of


Evans I M amp Meyer L H (1999) Modifying adult

interactional style as positive behavioural intervention

for a child with Rett syndrome Journal of Intellectual amp

Developmental Disability 24 191ndash205

Fiese B H (1990) Playful relationships A contextual

analysis of mother-toddler interaction and symbolic

play Child Development 61 1648ndash1656

Fidler G S amp Velde B P (1999) Activities Reality and

symbol Thorofare NJ Slack

Fine G A amp Sandstrom K L (1988) Knowing children

Participant observation with minors Newbury Park CA

Sage

Fisher E P (1992) The impact of play on development A

meta-analysis Play and Culture 5 159ndash181

Flanigan A (2001) Occupational therapy with

adolescents In L Loughler (Ed) Occupational Therapy

for Child and Adolescent Mental Health London

Harcourt

Gahnstrom-Strandqvist K Tham K Josephsson S amp

Borell L (2000) Actions of competence in

occupational therapy practice Scandinavian Journal of


Garciacutea-Villamisar D A and Dattilo J (2010) Effects of a

leisure programme on quality of life and stress of

individuals with ASD Journal of Intellectual Disability

Research 54 611ndash619 doi 101111j1365-

2788201001289x

Goode D A (1980) The world of the congenitally deaf-

blind In J Jacobs (Ed) Mental retardation A

phenomenological approach (pp 187ndash207)

Springfield IL Charles C Thomas

Goode D (1994) A world without words The social

construction of children born deaf and blind

Philadelphia Temple University Press

Grandin T (1997) Thinking the Way Animals Do

httpwwwgrandincomreferencesthinkinganimalsht

ml

Grandin T amp Scariano M M (1986) Emergence

Labeled autistic Novato CA Arean Press

Guest A amp Schneider B (2003) Adolescentsrsquo

extracurricular participation in context The mediating

effects of schools community and identity Sociology of

Education 76 89-109

Haight W L amp Miller P J (1992) The development of

everyday pretend play A longitudinal study of mothersrsquo

participation Merrill-Palmer Quarterly 38 331ndash349

Hasselkus B R amp Dickie V A (1994) Doing

occupational therapy Dimensions of satisfaction and

dissatisfaction American Journal of Occupational


Hobson R P amp Lee A (1999) Imitation and

identification in autism Journal of Child Psychology

and Psychiatry 40(4) 649-659

Holmes R M amp Procaccino J K (2009) Autistic

childrenrsquos play with objects peers and adults in a

classroom setting In C D Clark (Ed) Transactions at

play Play and culture studies Volume 9 (pp 86ndash103)

New York University Press of America Inc



Holmes E amp Willoughby T (2005) Play behavior of

children with autism spectrum disorders Journal of

Intellectual amp Developmental Disability 30 156ndash163

Howard-Jones P A Taylor J R amp Sutton L (2002)

The effect of play on the creativity of young children

during subsequent activity Early Child Development

and Care 172 323ndash328

Howard L (2002) A survey of paediatric occupational

therapists in the United Kingdom Occupational

Therapy International 9 326ndash343 doi 101002oti172

Jarrold C (2003) A review of research into pretend play

in autism Autism 7(4) 379-390

Jarrold C Boucher J amp Smith P (1993) Symbolic play

in autism A review Journal of Autism and

Developmental Disorders 23 281-309

King G Law M King S Hurley P Hanna S Kertoy

M Rosenbaum P amp Young N (2004) Childrenrsquos

Assessment of Participation and Enjoyment (CAPE)

and Preferences for Activities of Children (PAC) San

Antonio TX Harcourt Assessment

Koegel RL Dyer K amp Bell LK (1987) The influence

of child-preferred activities on autistic childrenrsquos social

behavior Journal of Applied Behavior Analysis 20(3)

243-252

Kramer J Bowyer P OrsquoBrien J Kielhofner G amp

Maziero-Barbosa V (2009) How interdisciplinary

pediatric practitioners choose assessments Canadian

Journal of Occupational Therapy 76(1) 56-64

Kuhaneck HM Spitzer S L amp Miller E (2010)

Activity Analysis Creativity and Playfulness in

Pediatric Occupational Therapy Making Play Just

Right Boston MA Jones and Bartlett Publishers

LLC

Kuhaneck amp Tanta in preparation

Kuo MH Orsmond GI Cohn ES amp Coster WJ

(2011) Friendship characteristics and activity patterns

of adolescents with an Autism Spectrum Disorder

Autism doi 1011771362361311416380

Law M (1998) Does client-centered practice make a

difference In M Law (Ed) Client-centered

occupational therapy (pp 19ndash27) Thorofare NJ Slack

Lawson K R Parrinello R amp Ruff H A (1992)

Maternal behavior and infant attention Infant Behavior

and Development 15(2) 209ndash229

Lewis V amp Boucher J (1988) Spontaneous instructed

and elicited play in relatively able autistic children

British Journal of Developmental Psychology 6 325ndash

338

Lewis V amp Boucher J (1995) Generativity in the play of

young people with autism Journal of Autism and


Libby S Powell S Messer D amp Jordan R (1997)

Imitation of pretend play acts by children with autism

and Down syndrome Journal of Autism and


Loughler L (2001) Occupational therapy in child and

adolescent mental health In L Loughler (Ed)

Occupational Therapy for Child and Adolescent Mental

Health London Harcourt

McGee G G Feldman R S amp Morrier M J (1997)

Benchmarks of social treatment for children with

autism Journal of Autism and Developmental

Disorders 27 353-364

Munier V Myers C T amp Pierce D (2008) Power of

object play for infants and toddlers In L D Parham amp

L S Fazio (Eds) Play in occupational therapy for

children (2nd ed pp 219ndash249) St Louis MO Mosby

Elsevier

Nadel J Martini M Field T Escalona A amp Lundy B

(2008) Children with autism approach more imitative

and playful adults Early Child Development and Care

178(5) 461-465

OrsquoConnor C amp Stagnitti K (2011) Play behavior

language and social skills The comparison of a play

and a non-play intervention within a specialist school

setting Research in Developmental Disabilities 32

1205-1211



Olson L Heaney C amp Soppas-Hoffman B (1989)

Parent-child activity group treatment in preventive

psychiatry Occupational Therapy in Health Care 6

29ndash43

Orsmond GI amp Kuo HY (2011) The daily lives of

adolescents with an autism spectrum disorder

Discretionary time use and activity partners Autism

15(5) 579-99

Ozonoff S Macari S Young G S Goldring S

Thompson M amp Rogers S J (2008) Atypical object

exploration at 12 months of age is associated with

autism in a prospective sample Autism 12 457ndash472

Palmadottir G (2003) Client perspectives on

occupational therapy in rehabilitation services

Scandinavian Journal of Occupational Therapy 10

157ndash166

Panksepp J (2010) Science of the Brain as a Gateway

to Understanding Play American Journal of Play 2

Panksepp J (2007) Can PLAY Diminish ADHD and

Facilitate the Construction of the Social Brain Journal

of the Canadian Academy of Child and Adolescent

Psychiatry 16(2) 57-66

Parham L D (2008) Play and occupational therapy In L

D Parham amp L S Fazio (Eds) Play in occupational

therapy for children (2nd ed pp 3ndash42) St Louis MO

Mosby

Pelligrini A (2009) The role of play in human

development Oxford Oxford University Press

Pepler D J amp Ross H S (1981) The effects of play on

convergent and divergent problem solving Child

Development 52 1202ndash1210

Preissler M A (2006) Play and autism Facilitating

symbolic understanding In D G Singer R M

Golinkoff amp K Hirsch-Pasek (Eds) Play = Learning

New York Oxford University Press

Reinhartsen D B Garfinkle A N amp Wolery M (2002)

Engagement with toys in two-year-old children with

autism Teacher selection versus child choice

Research and Practice for Persons with Severe

Disabilities 27(3) 175ndash187

Richler J Bishop SL Kleinke JR amp Lord C (2007)

Restricted and repetitive behaviors in young children

with autism spectrum disorders Journal of Autism and


Rodger S Brown G T Brown A amp Roever C (2006)

A comparison of paediatrics occupational therapy

university program curricula in New Zealand Australia

and Canada Physical and Occupational Therapy in

Pediatrics 26 153-80

Rodger S Brown G T amp Brown A (2005) Profile of

paediatric occupational therapy practice in Australia

Australian Occupational Therapy Journal 52 311ndash325

doi 101111j1440-1630200500487x

Rosa S A amp Hasselkus B R (1996) Connecting with

patients The personal experience of professional

helping Occupational Therapy Journal of Research

16 245ndash260

Rowland C M amp Schweigert P D (2009) Object

lessons How children with autism spectrum disorders

use objects to interact with the physical and social

environments Research in Autism Spectrum

Disorders 3(2) 517-527

Russ SW Robins AL amp Christiano BA (1999)

Pretend play Longitudinal prediction of creativity and

affect in fantasy in children Creativity Research

Journal 12 129ndash139

Sakemiller L M amp Nelson D L (1998) Eliciting

functional extension in prone through the use of a

game American Journal of Occupational Therapy

52(2) 150-157

Saleh M N Korner-Bitensky N Snider L Malouin F

Mazer B Kennedy E amp Roy MA (2008) Actual vs

best practices for young children with cerebral palsy a

survey of paediatric occupational therapists and

physical therapists in Quebec Canada Developmental

Neurorehabilitation 11(1) 60-80

Saracho O N (2002) Young Childrenʼs Creativity and

Pretend Play Early Child Development and Care

172(5) 431-438

Skaines N Rodger S amp Bundy A (2006) Playfulness

in children with autistic disorder and their typically

developing peers British Journal of Occupational




Slade A (1987) A longitudinal study of maternal

involvement and symbolic play during the toddler

period Child Development 58 367ndash375

Sorce J F amp Emde R N (1981) Motherrsquos presence is

not enough Effect of emotional availability on infant

exploration Developmental Psychology 17 737ndash745

Sparling J W Walker D F amp Singdahlsen J (1984)

Play techniques with neurologically impaired

preschoolers American Journal of Occupational


Spitzer S L (2001) No words necessary An

ethnography of daily activities with children who dont

talk Unpublished doctoral dissertation University of

Southern California Los Angeles

Spitzer S L (2003a) Using participant observation to

study the meaning of occupations of young children

with autism and other developmental disabilities

American Journal of Occupational Therapy 57(1) 66ndash

76

Spitzer S L (2003b) With and without words Exploring

occupation in relation to young children with autism

Journal of Occupational Science 10(2) 67ndash79

Spitzer S L (2008) Play in children with autism

Structure and experience In L D Parham amp L S

Fazio (Eds) Play in occupational therapy for children

(2nd ed pp 351ndash374) St Louis MO Mosby Elsevier

Spitzer S L (2010) Common and Uncommon Daily

Activities in Children with an Autism Spectrum

Disorder Challenges and Opportunities for Supporting

Occupation In H Miller Kuhaneck amp R Watling (Eds)

Autism A Comprehensive Occupational Therapy

Approach (3rd ed pp 203-233) Bethesda MD

American Occupational Therapy Association

Stahmer A C Brookman-Frazee L Lee E Searcy K

amp Reed S (2011) Parent and multidisciplinary provider

perspectives on earliest intervention for children at risk

for autism spectrum disorders Infants amp Young

Children 24(4) 344-363

Taylor RR Lee SW Kielhofner G amp Ketkar M

(2009) Therapeutic use of self A nationwide survey of

practitionersrsquo attitudes and experiences American

Journal of Occupational Therapy 63 198-207

Tickle-Degnen L (2002) Client-centered practice

therapeutic relationship and the use of research

evidence American Journal of Occupational Therapy

56 470ndash474

Tiegerman E amp Primavera L (1981) Object

manipulation An interactional strategy with autistic

children Journal of Autism and Developmental

Disorders 11(4) 427-438

Vismara L A amp Lyons G L (2007) Using perseverative

interests to elicit joint attention behaviors in young

children with autism Theoretical and clinical

implications for understanding motivation Journal of

Positive Behavior Interventions 9(4) 214ndash228

Vroman K (2010) In transition to adulthood the

occupations and performance skills of adolescents In

Case- Smith J amp OrsquoBrien J (Eds) Occupational

Therapy for Children (6th edition pp 84-107) Maryland

Heights MO Mosby -Elsevier

Whitebread D Coltman P Jameson H amp Lender R

(2009) Play cognition and self regulation What

exactly are children learning when they learn through

play Educational amp Child Psychology 26 40ndash52

Williams D (1992) Nobody nowhere The extraordinary

autobiography of an autistic New York Times Books

Williams D (1996) Autism An Inside-Out Approach

Bristol PA Jessica Kingsley Publishers

Williams D (1998) Autism and sensing The unlost

instinct Philadelphia Jessica Kingsley Publishers

Williams E Kendell-Scott L amp Costall A (2005)

Parentsrsquo experiences of introducing every day object

use to their children with autism Autism 9 495ndash514

Williams E (2003) A comparative review of early forms

of object-directed play and parent-infant play in typical

infants and young children with autism Autism 7(4)

361-377

Williams E Costall A amp Reddy V (1999) Children with

autism experience problems with both objects and

people Journal of Autism and Developmental

Disorders 29(5) 367-378

Williams E Reddy V amp Costall A (2001) Taking a

closer look at functional play in children with autism

Journal of Autism and Developmental Disorders 31(1)

67-77



Wolfberg P J (1999) Play and imagination in children

with autism New York Teachers College Press

Wulff S B (1985) The symbolic and object play of

children with autism A review Journal of Autism and


Wyver Shirley R amp Spence Susan H (1999) Play and

divergent problem solving Evidence supporting a

reciprocal relationship Early Education and


Ziviani J Boyle M amp Rodger S (2001) An introduction

to play and the preschool child with autistic spectrum

disorder British Journal of Occupational Therapy

64(1) 17-22



The State of Play in OT What we did 10+ years

ago (Couch Dietz amp

Kanny (1998)

What do we do now

(Brown et al 2005

Howard 2002 Kramer

et al 2009 Kuhaneck amp

Tanta in preparation

Rodger et al 2006

Saleh et al 2008)


The State of Play in OT

Barriers Reported barriers

Funding sources

Contextual factors(ie

school based practice)

Removing barriers

Goal writing

Education of others

Family members as allies



Intervention in Occupational Therapy (Kuhaneck Spitzer amp Miller 2010)

Play amp Pediatric OT Play as an occupation (Parham 2008)

The missing piece of meaning

Play in natural environments daily life

Contextual influences

Physical safety

Space for play

Time for play

Availability of developmentally appropriate amp preferred play

materials

Appropriate social interaction


Intervention in Occupational Therapy (contrsquod) (Parham 2008)

Best practice

We must become more comfortable with play as a

GOAL rather than a means to achieve some other goal

But- we must be able to explain to others why play is

important

For some children especially those with autism being

able to play IS an important goal- as we will now see

Capabilities and difficulties of

children with autism

in relation to play


bull Play Skills The StructureForm of Play bull Delayed or different in quality amp quantity- Spitzer (2008)


with autism Object play

Both extreme preoccupation with and

atypical use of objects is noted

(Baranek et al 2005 Ozonoff et al

2008 Rowland amp Schweigert 2009

Williams 2003 Williams Costall amp

Reddy 1999 Williams Kendell-

Scott amp Costall 2005)

Objects hold the potential for fear

and anxiety (Grandin 1997)









(Charman et al 1997



1988 Williams 2003


1999)






pretend acts


















Morrier 1997)



The Experience





Spitzer (2008)



Personal Meaning in


with Autism




Spitzer (2010)

Assessment






Observations

Interviewsreports

participation

Assessment




Intentional actions

A set of actions

With meaning


Assessment





differences in

development

language amp

perception

Spitzer (2003a)

Assessment











Assessment





Assessment


The What and How




The Why Subjective

Meaning

making connections




Assessment


Interpretation

Details from

Activity Analysis

What was

includedexcluded

Was it choice skill

or context

Why do it

Meaning





Assessment


Interpretation

Being Playful



Autism


Communication




Being Playful








Sandstrom 1988)


Sandstrom 1988)


Being Playful




1996)







2003a)


Being Playful










Being Playful










2003a)


Being Playful



Being Playful


Fun Eyes

Face

Body

Touch


Use a playful tone


Repeat sounds



Being Playful


Fun


Language









Being Playful


Fun


Empathy amp Rapport




Being Playful


Rapport


Being Playful
























Most 1980)








1999)












Playful Strategies



Want to Do






Activities






The What and How


The Why Subjective

Meaning


like play)

Visual feedback

Construction

Sensory properties


Favorite toys


(Spitzer 2008)


ADLsSelf-Care

Sleep

Education

ldquoPlayrdquo















The Work of Writing




















Lack of interests

Narrow Interests






Lack of Interests





Expanding Current











Expanding Current








Case Examples




















Ari from the Future
















autism


perceptions










Singdahlsen 1984)


al 2011)



Interests









Play


For which outcomes















300-308









7(1) 81-97










135-50










Penguin Books



























789









55 295ndash302




















23(1) 21-42



Science 318 1387-1388



























Sage






Harcourt









2788201001289x










ml






Education 76 89-109









































243-252









LLC





Autism doi 1011771362361311416380










338




















Elsevier




178(5) 461-465





1205-1211






29ndash43




15(5) 579-99








157ndash166










Mosby



























doi 101111j1440-1630200500487x




16 245ndash260













52(2) 150-157









172(5) 431-438

























76



















Children 24(4) 344-363








56 470ndash474




Disorders 11(4) 427-438



























361-377




Disorders 29(5) 367-378




67-77















64(1) 17-22








(Charman et al 1997



1988 Williams 2003


1999)






pretend acts


















Morrier 1997)



The Experience





Spitzer (2008)



Personal Meaning in


with Autism




Spitzer (2010)

Assessment






Observations

Interviewsreports

participation

Assessment




Intentional actions

A set of actions

With meaning


Assessment





differences in

development

language amp

perception

Spitzer (2003a)

Assessment











Assessment





Assessment


The What and How




The Why Subjective

Meaning

making connections




Assessment


Interpretation

Details from

Activity Analysis

What was

includedexcluded

Was it choice skill

or context

Why do it

Meaning





Assessment


Interpretation

Being Playful



Autism


Communication




Being Playful








Sandstrom 1988)


Sandstrom 1988)


Being Playful




1996)







2003a)


Being Playful










Being Playful










2003a)


Being Playful



Being Playful


Fun Eyes

Face

Body

Touch


Use a playful tone


Repeat sounds



Being Playful


Fun


Language









Being Playful


Fun


Empathy amp Rapport




Being Playful


Rapport


Being Playful
























Most 1980)








1999)












Playful Strategies



Want to Do






Activities






The What and How


The Why Subjective

Meaning


like play)

Visual feedback

Construction

Sensory properties


Favorite toys


(Spitzer 2008)


ADLsSelf-Care

Sleep

Education

ldquoPlayrdquo















The Work of Writing




















Lack of interests

Narrow Interests






Lack of Interests





Expanding Current











Expanding Current








Case Examples




















Ari from the Future
















autism


perceptions










Singdahlsen 1984)


al 2011)



Interests









Play


For which outcomes















300-308









7(1) 81-97










135-50










Penguin Books



























789









55 295ndash302




















23(1) 21-42



Science 318 1387-1388



























Sage






Harcourt









2788201001289x










ml






Education 76 89-109









































243-252









LLC





Autism doi 1011771362361311416380










338




















Elsevier




178(5) 461-465





1205-1211






29ndash43




15(5) 579-99








157ndash166










Mosby



























doi 101111j1440-1630200500487x




16 245ndash260













52(2) 150-157









172(5) 431-438

























76



















Children 24(4) 344-363








56 470ndash474




Disorders 11(4) 427-438



























361-377




Disorders 29(5) 367-378




67-77















64(1) 17-22




Observations

Interviewsreports

participation

Assessment




Intentional actions

A set of actions

With meaning


Assessment





differences in

development

language amp

perception

Spitzer (2003a)

Assessment











Assessment





Assessment


The What and How




The Why Subjective

Meaning

making connections




Assessment


Interpretation

Details from

Activity Analysis

What was

includedexcluded

Was it choice skill

or context

Why do it

Meaning





Assessment


Interpretation

Being Playful



Autism


Communication




Being Playful








Sandstrom 1988)


Sandstrom 1988)


Being Playful




1996)







2003a)


Being Playful










Being Playful










2003a)


Being Playful



Being Playful


Fun Eyes

Face

Body

Touch


Use a playful tone


Repeat sounds



Being Playful


Fun


Language









Being Playful


Fun


Empathy amp Rapport




Being Playful


Rapport


Being Playful
























Most 1980)








1999)












Playful Strategies



Want to Do






Activities






The What and How


The Why Subjective

Meaning


like play)

Visual feedback

Construction

Sensory properties


Favorite toys


(Spitzer 2008)


ADLsSelf-Care

Sleep

Education

ldquoPlayrdquo















The Work of Writing




















Lack of interests

Narrow Interests






Lack of Interests





Expanding Current











Expanding Current








Case Examples




















Ari from the Future
















autism


perceptions










Singdahlsen 1984)


al 2011)



Interests









Play


For which outcomes















300-308









7(1) 81-97










135-50










Penguin Books



























789









55 295ndash302




















23(1) 21-42



Science 318 1387-1388



























Sage






Harcourt









2788201001289x










ml






Education 76 89-109









































243-252









LLC





Autism doi 1011771362361311416380










338




















Elsevier




178(5) 461-465





1205-1211






29ndash43




15(5) 579-99








157ndash166










Mosby



























doi 101111j1440-1630200500487x




16 245ndash260













52(2) 150-157









172(5) 431-438

























76



















Children 24(4) 344-363








56 470ndash474




Disorders 11(4) 427-438



























361-377




Disorders 29(5) 367-378




67-77















64(1) 17-22




Assessment


Interpretation

Being Playful



Autism


Communication




Being Playful








Sandstrom 1988)


Sandstrom 1988)


Being Playful




1996)







2003a)


Being Playful










Being Playful










2003a)


Being Playful



Being Playful


Fun Eyes

Face

Body

Touch


Use a playful tone


Repeat sounds



Being Playful


Fun


Language









Being Playful


Fun


Empathy amp Rapport




Being Playful


Rapport


Being Playful
























Most 1980)








1999)












Playful Strategies



Want to Do






Activities






The What and How


The Why Subjective

Meaning


like play)

Visual feedback

Construction

Sensory properties


Favorite toys


(Spitzer 2008)


ADLsSelf-Care

Sleep

Education

ldquoPlayrdquo















The Work of Writing




















Lack of interests

Narrow Interests






Lack of Interests





Expanding Current











Expanding Current








Case Examples




















Ari from the Future
















autism


perceptions










Singdahlsen 1984)


al 2011)



Interests









Play


For which outcomes















300-308









7(1) 81-97










135-50










Penguin Books



























789









55 295ndash302




















23(1) 21-42



Science 318 1387-1388



























Sage






Harcourt









2788201001289x










ml






Education 76 89-109









































243-252









LLC





Autism doi 1011771362361311416380










338




















Elsevier




178(5) 461-465





1205-1211






29ndash43




15(5) 579-99








157ndash166










Mosby



























doi 101111j1440-1630200500487x




16 245ndash260













52(2) 150-157









172(5) 431-438

























76



















Children 24(4) 344-363








56 470ndash474




Disorders 11(4) 427-438



























361-377




Disorders 29(5) 367-378




67-77















64(1) 17-22








2003a)


Being Playful



Being Playful


Fun Eyes

Face

Body

Touch


Use a playful tone


Repeat sounds



Being Playful


Fun


Language









Being Playful


Fun


Empathy amp Rapport




Being Playful


Rapport


Being Playful
























Most 1980)








1999)












Playful Strategies



Want to Do






Activities






The What and How


The Why Subjective

Meaning


like play)

Visual feedback

Construction

Sensory properties


Favorite toys


(Spitzer 2008)


ADLsSelf-Care

Sleep

Education

ldquoPlayrdquo















The Work of Writing




















Lack of interests

Narrow Interests






Lack of Interests





Expanding Current











Expanding Current








Case Examples




















Ari from the Future
















autism


perceptions










Singdahlsen 1984)


al 2011)



Interests









Play


For which outcomes















300-308









7(1) 81-97










135-50










Penguin Books



























789









55 295ndash302




















23(1) 21-42



Science 318 1387-1388



























Sage






Harcourt









2788201001289x










ml






Education 76 89-109









































243-252









LLC





Autism doi 1011771362361311416380










338




















Elsevier




178(5) 461-465





1205-1211






29ndash43




15(5) 579-99








157ndash166










Mosby



























doi 101111j1440-1630200500487x




16 245ndash260













52(2) 150-157









172(5) 431-438

























76



















Children 24(4) 344-363








56 470ndash474




Disorders 11(4) 427-438



























361-377




Disorders 29(5) 367-378




67-77















64(1) 17-22



















Most 1980)








1999)












Playful Strategies



Want to Do






Activities






The What and How


The Why Subjective

Meaning


like play)

Visual feedback

Construction

Sensory properties


Favorite toys


(Spitzer 2008)


ADLsSelf-Care

Sleep

Education

ldquoPlayrdquo















The Work of Writing




















Lack of interests

Narrow Interests






Lack of Interests





Expanding Current











Expanding Current








Case Examples




















Ari from the Future
















autism


perceptions










Singdahlsen 1984)


al 2011)



Interests









Play


For which outcomes















300-308









7(1) 81-97










135-50










Penguin Books



























789









55 295ndash302




















23(1) 21-42



Science 318 1387-1388



























Sage






Harcourt









2788201001289x










ml






Education 76 89-109









































243-252









LLC





Autism doi 1011771362361311416380










338




















Elsevier




178(5) 461-465





1205-1211






29ndash43




15(5) 579-99








157ndash166










Mosby



























doi 101111j1440-1630200500487x




16 245ndash260













52(2) 150-157









172(5) 431-438

























76



















Children 24(4) 344-363








56 470ndash474




Disorders 11(4) 427-438



























361-377




Disorders 29(5) 367-378




67-77















64(1) 17-22





The What and How


The Why Subjective

Meaning


like play)

Visual feedback

Construction

Sensory properties


Favorite toys


(Spitzer 2008)


ADLsSelf-Care

Sleep

Education

ldquoPlayrdquo















The Work of Writing




















Lack of interests

Narrow Interests






Lack of Interests





Expanding Current











Expanding Current








Case Examples




















Ari from the Future
















autism


perceptions










Singdahlsen 1984)


al 2011)



Interests









Play


For which outcomes















300-308









7(1) 81-97










135-50










Penguin Books



























789









55 295ndash302




















23(1) 21-42



Science 318 1387-1388



























Sage






Harcourt









2788201001289x










ml






Education 76 89-109









































243-252









LLC





Autism doi 1011771362361311416380










338




















Elsevier




178(5) 461-465





1205-1211






29ndash43




15(5) 579-99








157ndash166










Mosby



























doi 101111j1440-1630200500487x




16 245ndash260













52(2) 150-157









172(5) 431-438

























76



















Children 24(4) 344-363








56 470ndash474




Disorders 11(4) 427-438



























361-377




Disorders 29(5) 367-378




67-77















64(1) 17-22


















Lack of interests

Narrow Interests






Lack of Interests





Expanding Current











Expanding Current








Case Examples




















Ari from the Future
















autism


perceptions










Singdahlsen 1984)


al 2011)



Interests









Play


For which outcomes















300-308









7(1) 81-97










135-50










Penguin Books



























789









55 295ndash302




















23(1) 21-42



Science 318 1387-1388



























Sage






Harcourt









2788201001289x










ml






Education 76 89-109









































243-252









LLC





Autism doi 1011771362361311416380










338




















Elsevier




178(5) 461-465





1205-1211






29ndash43




15(5) 579-99








157ndash166










Mosby



























doi 101111j1440-1630200500487x




16 245ndash260













52(2) 150-157









172(5) 431-438

























76



















Children 24(4) 344-363








56 470ndash474




Disorders 11(4) 427-438



























361-377




Disorders 29(5) 367-378




67-77















64(1) 17-22




Lack of Interests





Expanding Current











Expanding Current








Case Examples




















Ari from the Future
















autism


perceptions










Singdahlsen 1984)


al 2011)



Interests









Play


For which outcomes















300-308









7(1) 81-97










135-50










Penguin Books



























789









55 295ndash302




















23(1) 21-42



Science 318 1387-1388



























Sage






Harcourt









2788201001289x










ml






Education 76 89-109









































243-252









LLC





Autism doi 1011771362361311416380










338




















Elsevier




178(5) 461-465





1205-1211






29ndash43




15(5) 579-99








157ndash166










Mosby



























doi 101111j1440-1630200500487x




16 245ndash260













52(2) 150-157









172(5) 431-438

























76



















Children 24(4) 344-363








56 470ndash474




Disorders 11(4) 427-438



























361-377




Disorders 29(5) 367-378




67-77















64(1) 17-22



















Ari from the Future
















autism


perceptions










Singdahlsen 1984)


al 2011)



Interests









Play


For which outcomes















300-308









7(1) 81-97










135-50










Penguin Books



























789









55 295ndash302




















23(1) 21-42



Science 318 1387-1388



























Sage






Harcourt









2788201001289x










ml






Education 76 89-109









































243-252









LLC





Autism doi 1011771362361311416380










338




















Elsevier




178(5) 461-465





1205-1211






29ndash43




15(5) 579-99








157ndash166










Mosby



























doi 101111j1440-1630200500487x




16 245ndash260













52(2) 150-157









172(5) 431-438

























76



















Children 24(4) 344-363








56 470ndash474




Disorders 11(4) 427-438



























361-377




Disorders 29(5) 367-378




67-77















64(1) 17-22









Singdahlsen 1984)


al 2011)



Interests









Play


For which outcomes















300-308









7(1) 81-97










135-50










Penguin Books



























789









55 295ndash302




















23(1) 21-42



Science 318 1387-1388



























Sage






Harcourt









2788201001289x










ml






Education 76 89-109









































243-252









LLC





Autism doi 1011771362361311416380










338




















Elsevier




178(5) 461-465





1205-1211






29ndash43




15(5) 579-99








157ndash166










Mosby



























doi 101111j1440-1630200500487x




16 245ndash260













52(2) 150-157









172(5) 431-438

























76



















Children 24(4) 344-363








56 470ndash474




Disorders 11(4) 427-438



























361-377




Disorders 29(5) 367-378




67-77















64(1) 17-22







300-308









7(1) 81-97










135-50










Penguin Books



























789









55 295ndash302




















23(1) 21-42



Science 318 1387-1388



























Sage






Harcourt









2788201001289x










ml






Education 76 89-109









































243-252









LLC





Autism doi 1011771362361311416380










338




















Elsevier




178(5) 461-465





1205-1211






29ndash43




15(5) 579-99








157ndash166










Mosby



























doi 101111j1440-1630200500487x




16 245ndash260













52(2) 150-157









172(5) 431-438

























76



















Children 24(4) 344-363








56 470ndash474




Disorders 11(4) 427-438



























361-377




Disorders 29(5) 367-378




67-77















64(1) 17-22







23(1) 21-42



Science 318 1387-1388



























Sage






Harcourt









2788201001289x










ml






Education 76 89-109









































243-252









LLC





Autism doi 1011771362361311416380










338




















Elsevier




178(5) 461-465





1205-1211






29ndash43




15(5) 579-99








157ndash166










Mosby



























doi 101111j1440-1630200500487x




16 245ndash260













52(2) 150-157









172(5) 431-438

























76



















Children 24(4) 344-363








56 470ndash474




Disorders 11(4) 427-438



























361-377




Disorders 29(5) 367-378




67-77















64(1) 17-22


























243-252









LLC





Autism doi 1011771362361311416380










338




















Elsevier




178(5) 461-465





1205-1211






29ndash43




15(5) 579-99








157ndash166










Mosby



























doi 101111j1440-1630200500487x




16 245ndash260













52(2) 150-157









172(5) 431-438

























76



















Children 24(4) 344-363








56 470ndash474




Disorders 11(4) 427-438



























361-377




Disorders 29(5) 367-378




67-77















64(1) 17-22






29ndash43




15(5) 579-99








157ndash166










Mosby



























doi 101111j1440-1630200500487x




16 245ndash260













52(2) 150-157









172(5) 431-438

























76



















Children 24(4) 344-363








56 470ndash474




Disorders 11(4) 427-438



























361-377




Disorders 29(5) 367-378




67-77















64(1) 17-22





















76



















Children 24(4) 344-363








56 470ndash474




Disorders 11(4) 427-438



























361-377




Disorders 29(5) 367-378




67-77















64(1) 17-22















64(1) 17-22

Documents

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