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PlayinChildrenwithASD

Aplanforyourlearning...

What• Define play & the characteristics of play in children with ASD• Describe narrative play therapy

How

• Review what we know about play in the literature• View videos• Complete a small group activity related to selecting a play strategy to

support a child with ASD

Why

• Increase your understanding of play & its relationship to JA, language & theory of mind

• Apply your knowledge to the assessment and intervention of play in children with ASD

Take-homeMessage1. Play is the “recreation” of young children2. Children with autism need to be taught play skills 3. Play development is fluid4. Play evolves into recreation

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Whatis‘Play’?

• A context in which children learn and practice other skills (Boucher, 1990; Naber et al., 2008)

• Social & language skills (Boutot et al., 2005)

• Use of speech & communication (Fekonja et al., 2005)

•Motor skills• Literacy and math skills• Critical to children’s quality of life

CharacteristicsofPlay

• Pleasurable• Involves active engagement• Intrinsically motivated • Flexible

Playdevelopment...

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1.SolitaryPlay:playingalone

2.OnlookerPlay:watchesothersplay;doesnotjoinin.

3.ParallelPlay:sidebysidewithdifferenttoysoractivities

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4.AssociativePlay:playwithothersandsharestoys

5.CooperativePlay:playingtogetherinstructuredgames

6.SymbolicPlay:useofobjectstorepresentsomethingentirelydifferent.

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7.ImaginativePlay:dramaticandpretendplay

PlaydevelopmentisfluidSolitary “Play” Parallel “Play”

Associative “Play”

ConsideringtheDSM-5CharacteristicsforASD...

1. Deficits in social emotional reciprocity• Abnormal social approach• Failure of normal back and forth conversation• Reduced sharing of interests, emotions or affect• Failure to initiate or respond to social interaction

2. Deficits in nonverbal communicative behaviors• Poorly integrated verbal & nonverbal communication• Abnormalities in eye contact and body language• Deficits in understanding and use of gestures• Lack of facial expressions and nonverbal communication

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3. Deficits in developing, maintaining and understanding relationships

• Difficulties adjusting behavior to suit various social contexts• Difficulties in sharing imaginative play • Difficulties making friends• Absence of interest in peers

4. Restricted, repetitive patterns of behavior, interests, or activities

• Stereotyped or repetitive motor movements, use of objects, or speech

• Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior

• Highly restricted, fixated interest that are abnormal in intensity or focus

• Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment

ASDCharacteristics(DSM-5)

WhymightPlayDevelopmentbeimpactedbyASDcharacteristics?

Characteristics Example of impact

Minimally verbal Difficult to ask a child to play

PlayinchildrenwithASD...Development• ⇓ pretend play: frequency, complexity, novelty &

spontaneity (Baron-Cohen, 1987; Bernabei et al., 1999; Rutherford et al., 2007; Wing et al., 1977)

• ⇓ symbolic play: >routine & <spontaneous (Williams, 2003)

Variety• ⇑ Repetitive & stereotyped play (Mundy et al., 1986; Sigman & Ungerer, 1982)

• ⇓ Variety of object selection (Van Berkerlaer-Onnes, 2003)

• ⇓ Variety of play (Sigman & Ungerer, 1984; Williams et al., 2001)

• Problems generating play ideas ~ praxis (Jarrold et al., , 1996)

è Remains in older children who have less varied recreation (Hilton et al., 2009; Potvin et al., 2011)

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Nature of play• ⇓ time in functional play (Lewis & Boucher, 1988; Jarrold et al., 1996)

• ⇓ appropriate object use (Freeman et al., 1984)

• Prefer touch & taste more to visual exploration (Williams, 2003) or preoccupied in visual exploration of single object (Freeman et al., 1979)

PlayinchildrenwithASD...

RelationshipsbetweenPlay,Language,Cognition&ToM

• Joint attention predicts pretend play (Rutherford et al., 2007)

• Pretend play & ToM (Leslie, 1987; Rutherford et al., 2007)

• Language & symbolic play emerge concurrently (Gould, 1986; Spencer, 1996; Stanley & Konstantareas, 2007)

• Non-verbal cognitive ability & expressive language are related to symbolic play (Stanley & Konstantareas, 2007)

AssessingPlayDevelopmentWhattoconsiderwiththosewithASD???

• Does the child know how to play?• Does the child go for what is familiar &

only act upon objects in a familiar way?• Is play the child�s first choice for an

activity?• Does the child require a routine & comfort

with knowing what to do?

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• Elicit varied play through prompting & modeling in multiple context• Unstructured situations• Independent play• Peer play• Home, school & community

• Complete a Play Preference Inventory (Wolfberg, 1995)• Child�s play preferences• Peers’ play preferences

• Use a Play Observation Diary (Van Hoorn, et al., 1993)• Record spontaneous & guided play• Identify the learning & social contexts for play

ObservingPlay

AssessingPlay

• In your videotaped observations, look for . . . (Howlin et al., 1999)• Sensory motor play (simple toy manipulation)• Emerging functional play (conventional use without pretense)• Established functional play (more than 3 tx in 10 minutes)• Emerging pretend play (object substitution, attribution of pretend properties

& use of imaginary objects/events)• Established pretend play (demonstrates 3 or more examples)

• Westby Symbolic Play Scale Checklist (1980, 1988)• Transdisciplinary Play-Based Assessment (Linder, 1993, 2008)• Infant-Preschool Play Assessment Scale (I-PAS) (Flagler)

SampleofWestbySymbolicPlayScaleActivity Explanation Language Observed Play Observed Other Comments

Place desirable toy under a scarf or blanket; if no response; partially hide the object’

Place desirable object away from child and see how child retrieves it

Have a pull string toy available for child to pull

Bangs toys appropriately

Mouths toys

___No true language or may

have words that are associated

with actions (e.g., _________)

Exhibits the following

communicative functions:

____Request

____Command

STAGE I (9-12 months)

___Awareness that objects

exist when not seen; finds toys

hidden under scarf

___Means-end behavior;

crawls or walks to get what he

wants; pulls string toys

___Does not mouth or bang all

toys—some used appropriately

Watch what the child does with available toys; note how she explore the toys

Look at trial & error

What motor schemes are noted

Hands wind-up toy or some other toy to get the adult’s help

___Context dependent single

words (e.g., uses ‘car’ when

riding in a car but not when

sees a car; words come & go

Exhibits the following

communicative functions:

___Request ___Personal

___Command

___Interactional

___Protesting ___Greeting

___Label ___Response

STAGE II (13-17 months)

__Purposeful exploration of

toys; discovers operation of

toys through trial & error; uses

variety of motoric schemas

__Hands toy to adult if unable

to operate

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Infant-PreschoolPlayAssessmentScale(I-PAS,Flagler)

• Criterion reference• Teachers, clinicians & other clinicians can systematically observe

children at play• Developmentally sequenced from birth to 5• Examines play in contexts where you can observe the following:• Communication• Cognition• Sensorimotor• Fine motor• Social-emotional

TransdisciplinaryPlay-basedAssessmentandIntervention

StrategiestoSupportPlayDevelopmentinASD

Watch and make a list of the strategies mentioned: https://www.youtube.com/watch?v=X0nlSluF33w

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Time Delay to Teach Social Play Skills (Liber et al., 2008)

GOALS• Appropriate play with toys• Initiation with peers• Requesting peer assistance

SOCIAL PLAY INTERACTIONS • Use peer�s name• Turn shoulders or face towards peers• Make a statement, request or ask a question of peer

Strategies to Support Play Development

What’s Time Delay?

§National Professional Development Center (http://autismpdc.fpg.unc.edu/)

§Evidence-Based Practices§Autism Internet Modules (FREE!!!)(http://www.autisminternetmodules.org/mod_intro.php?mod_id=49)

Visual scripts in inclusive playgroups (Ganz & Flores, 2008, 2010)

• Choose theme, prepare setting and materials• Choose social & language learning objectives for child• Base script on child�s reading, language abilities & attention• Teach script one-on-one to child• Develop peer instruction cards & teach them to typically

developing peers• Implement script during playgroups, provides frequent

opportunity to practice social skillsWhat are Visual Scripts?(http://autismpdc.fpg.unc.edu/sites/autismpdc.fpg.unc.edu/files/Scripting_factsheet.pdf/)

Research Evidence for Structured Play Groups(http://autismpdc.fpg.unc.edu/sites/autismpdc.fpg.unc.edu/files/Structured_Play_Groups_factsheet.pdf)

Strategies to Support Play Development

• Virtual reality to facilitate pretend play (Herrera et al, 2008)

http://autismpdc.fpg.unc.edu/sites/autismpdc.fpg.unc.edu/files/Technology_Aided_Instruction_factsheet.pdf

• Picture Me Playing (Murdock & Hobbs, 2011)

• Social Stories to improve game play skills (Quirmbachat al., 2009)

• Interpersonal Synchrony “intervention” (Landa et al., 2010)

• Peer-mediated intervention (Petursdottir et al., 2007)

Strategies to Support Play Development

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Integrated Play Groups (Wolfberg, 1995; Zercher et al., 2001)

FEATURES• Well designed play spaces• Play materials with interactive potential• Consistent schedule & routine• Focus on competence• Guided participation• Developmentally appropriate peer partners• Immersion in natural settings

Strategies to Support Play Development

StrategiestoSupportPlayDevelopment

INTEGRATED PLAYGROUPS• At least 5 children, 2 with ASD & 3-5 TD• Meet 2+ times a week for 30-60 minutes• Adult interventionist is play facilitator• Interventionist monitors play initiations &

scaffolds interactions• Can support the play of older elementary

children (Schuler & Wolfberg, 2000; Wolfberg, 1995)

Whataretheparentsdoingtosupportasocialplayroutine?

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Howisthefamilyfacilitatingtoyplaywiththeir3yearold?

WhatstrategiesistheClinicianusingtosupportthischild’splay?

WhatstrategiesistheClinicianusingtosupportthischild’splay?

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WhatstrategiesistheClinicianusingtosupportthischild’splay?

WhatstrategiesistheClinicianusingtosupportthischild’splay?

WhatstrategiesistheClinicianusingtosupportthischild’splay?

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Howistheclinicianincreasingflexibilityinplay?

NarrativePlayforChildrenwithASD(Densmore,2000)

NarrativePlayTherapy

• Teaches joint attention• Children follow a

sequence of symbolic play with peers• Occurs in natural settings • Language supported in

social contexts(Densmore, 2000)

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NarrativePlayTherapy• Introduce a story in small

sequential steps, using circles of communication• Model the language to

tell the story, share objects in play & experience play events with peers

NarrativePlayTherapy• GOAL 1=>Develop joint

attention• LEVEL 1

Peer partner learns to comment to child with ASDEXAMPLE:Prompt peer to say �Look!�& point to rising balloon

NarrativePlayTherapy• GOAL 1=>Develop joint

attention• LEVEL 2

Teach child with ASD to look at peer partner & to commentEXAMPLE:Prompt comments like �Cool!� or �Awesome!�

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NarrativePlayTherapy• GOAL 1=>Develop joint

attention• LEVEL 3

Ask children to take turns holding an object & prompt children to ask & answer questions of one anotherEXAMPLES:�Can I hold it?� �Should we let it go?� �Will it fly away?�

NarrativePlayTherapy• GOAL 1=>Develop joint

attention• LEVEL 4

Encourage children to initiate a back & forth exchange by modeling comments during their play using emotional expressionEXAMPLES:�Catch it, here it comes� or �Look out it�s going to fly away�

NarrativePlayTherapy• GOAL 1=>Develop joint

attention• LEVEL 5

Have children play independently & observe attempts at JA; praise the children for their actions & keep data on comments & gaze toward peerEXAMPLE:�I like the way you are looking at your friend.�

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NarrativePlayTherapy• GOAL 1=>Develop joint

attention• LEVEL 6

Prompt peer partner to move objects toward child with ASD & to verbally prompt & gesture to get the child with ASD to respond; use questions to > time engaged in commenting

EXAMPLES:�Do you want to hold it?� �Are you going to let it go?

NarrativePlayTherapy• GOAL 2=>Develop a sense of

story• LEVEL 7

Prompt child with ASD & peer partner to create a story around object of play

EXAMPLES:�Where do you think the balloon will go?� �Is it carrying a secret message?

NarrativePlayTherapy• GOAL 2=>Develop a sense of story• LEVEL 8

Introduce simple language; rephrase children�s comments to help develop the story; allow children to name characters

EXAMPLES:�David is riding the hot air balloon and lands in Alaska. He is so cold he decides to come home.�

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NarrativePlayTherapy• GOAL 2=>Develop a sense of story• LEVEL 9

Put narrative on the computer; have children add photos to create a book; take pictures of children acting out their story & add to the book

NarrativePlayTherapy• GOAL 2=>Develop a sense of story• LEVEL 10

Make videotape of play partners creating their story; allow children to watch the video & share this with the parents

NarrativePlayTherapy• GOAL 2=>Develop a sense of story• LEVELS 11 & 12

Identify other locations for supporting play with peers, narrating actions, modeling comments, rephrasing verbalizations & cuing the children to look at one another & their objects of play as well as making comments to create a story

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NarrativePlayTherapy

EFFECTIVENESS & VALUE• Some positive case study

reports (Densmore, 2000)

• Support for incorporating favorite themes in social play with sibs & peers (Baker, 2000, Baker et al., 1998)