The Effectiveness Of Using Play Based

Published Date: 02 Nov 2017

Introduction

Autism Spectrum Disorders (ASDs) consist of Autistic Disorder, Aspergers Disorder, and Pervasive Developmental Disorder- Not Otherwise Specified (PDD- NOS). They are located on a continuum of severity of disability (Schultz, 2005) and it is believed that these disorders share an underlying neurobiological origin (Adolph, Sears, & Piven, 2001; Bachevalier & Loveland, 2006; Schultz, 2005). A 2008 study conducted by the Centers for Disease Control estimates that 1 in 88 children has an ASD (U.S. Department of Health and Human Services, 2012). As the rate of ASD diagnoses in children increases, there becomes a greater need and importance to understand the causes of the disorder and a need for empirically validated forms of treatment. ASD, a congenital, lifelong, pervasive developmental disorder, is defined as a neurobiological disorder characterized by severe and sustained impairment in social interaction, language and communication deficits, and stereotyped repetitive behavior manifested prior to age 3 years (American Psychiatric Association, 2000). This disorder occurs across all racial, ethnic, and social backgrounds.

An interesting characteristic of ASD is that the disorder can look very different from case to case. While some people with ASD will never speak, others may develop normal language abilities. Also, some people with ASD seem indifferent to interacting with others, while some desire relationships and to show love to others. This author has experienced this variability first hand from her experience working with young children diagnosed with ASD. Mastrangelo (2009) outlined some of the other features often present in ASD which include deficits in imitation, gesturing, observational learning, joint attention, symbolic play, and understanding expression of emotion. There is variability in intellectual functioning and developmental profile. Aggressive or self-injurious behavior, restricted, repetitive, and stereotyped patterns of behavior, preoccupations with restricted range of interests, obsessive routine and rituals, and repetitive motor mannerisms may be present. Often there is great distress over changes in the environment, unusual responses to sensory stimuli, and difficulty with sleeping, eating, and toileting (Mastrangelo, 2009). Deficits in language in children with ASD make their interaction with others ineffective, often leading to poor social relationships. People with ASD have a difficult time initiating and responding to bids for interaction from both adults and peers (Murdock & Hobbs, 2011).

Because symptoms of ASD vary from child to child, different types of interventions are more effective for different children on the spectrum (Kasari, 2002). There is a variety of intervention approaches used to treat ASD. These interventions include applied behavior analysis (ABA), social communication, emotion regulation, transactional support model (SCERTS), DIR/floortime, TEACCH Autism program, relationship development intervention (RDI), special diets and vitamins, medication, Picture Exchange Communication System (PECS), sensory integration, speech, occupational, and music therapies, and special education (Peters-Scheffer, Didden, Korzilius, & Sturmey, 2011). While some of these approaches are supported by empirical research, there is not strong empirical support for the effectiveness of many of these approaches. Most often, early intervention behavioral treatment techniques are used with young children with ASD because it is supported by empirical research. The other approaches receiving support and interest from researchers have one thing in common- the use of play as a means of interacting with the child and reaching their goals. Current researchers are examining the benefits of using play therapy techniques in the treatment of children with ASD. Children with ASD struggle with motor planning, expressive and receptive communication, imitation, and fine and gross motor skills, all of which contribute to the difficulties they encounter when learning how to play (Mastrangelo, 2009). The lack of make-believe or social-imitative play is part of the criteria for diagnosing ASD (APA, 2000). Much can be learned about a child’s developmental status by observing and evaluating his or her play, as all children play at some level.

Defining Play

For centuries scholars have debated why children, and even adults, play. Why is something so frivolous universal to all cultures? Erik Erikson (1950) described play as a child’s occupation with toys being the tools. Virginia Axline, the creator of nondirective play therapy, believes play is one way we express who we are and is a way for people to communicate, especially between children (Kenny & Winick, 2000). Brown and Vaughan (2000) believe that "the ability to play is critical not only to being happy, but also to sustaining social relationships and being a creative, innovative person" (p.6). So, what is play? The definition of play has been greatly debated for centuries. At its basic level, play is a very primal activity- both preconscious and preverbal (Brown and Vaughan, 2000). It does not have a set purpose and it is voluntary. Most often, play is defined as an activity that someone participates in for enjoyment and recreation. We participate in it because it is fun and it makes us feel good. Smith and Pellegrini (2008) outline some other characteristics of play found to be true in all circumstances including being self-chosen and self-directed, meaning you choose to play and choose what actions to involve in play, with flexibility being an important part of those actions. Also, play is done for the enjoyment of the activity, the process being more important than having a goal or some other means to an end. Instead, play is done for the sake of playing. Finally, they found that play creates a positive affect and is enjoyed by those who participate.

Functions of play. Researchers have found play to be a crucial part of development for children and it has a variety of purposes. Even animals need play to learn how to socialize. Researchers have found that if social mammals miss out on play, they do not have the ability to tell who is a friend or an enemy, they miss social signals, and tend to either be aggressive or retreat when social situations arise (Brown and Vaughan, 2000). Most children do not need instruction on how to play. Instead, they find something they enjoy and they do it. Through play, children begin to explore their world, learn how the world works, and how to interact with others (Brown & Vaughan, 2000).

Babies begin by holding toys and using their mouths to explore objects. As they get older, children learn to imitate the world around them. When a child plays, they are able to learn, practice new skills, and explore their surroundings in a safe and supportive environment (Boucher, 1999; Walberg & Craig-Unkefer, 2010). The safe environment allows children to try new things without worrying about their physical or emotional well-being. Because of this, they are able to learn new skills and experience new situations without being at risk. As they develop these skills and learn to play they are also developing language, social interaction, and literacy skills (Walberg & Craig-Unkefer, 2010; Nelson, McDonnell, Johnson, Crompton, & Nelson, 2007), as well as sensory processing systems and social and emotional interactions (Machalicek, Sigafoos, & Regester, 2009). Hess (2006) noted, "play supports the exploration of social roles where the child learns to negotiate, compromise, and become aware of and understand the mental states of others". Play is way for children to express themselves and can be an avenue for sharing thoughts and feelings they may not be able to verbalize yet with words (Boucher, 1999). If a child does not develop normal play behaviors, it can have damaging effects throughout their life.

Types of play. There are a variety of types of play and it is important to understand what each type teaches a child. In 1951, Jean Piaget wrote about the various ordered stages of play that develop during the first four years of a child’s life (Casby, 2003). According to Piaget, there are three types of play: practice play, symbolic play, and games with rules. From age 2-18 months an infant will engage in practice play, when sensorimotor activities are the basis for activity. During this time, children learn about cause and effect as they are trying out different objects, mostly by grasping, mouthing, or banging them. From 18 months- 4 years old, symbolic play is central to development. The transition from practice to symbolic play occurs during the mental operations stage and the preoperational period. Piaget believed the infants play gradually shifts to more controlled and planned actions. Toddlers will begin to use objects as they were designed to be used and imitate real-life activities. By age 2, symbolic functioning appears as the child begins to use substitutes for objects and by age 3, the child should be able to combine symbolic play schemes (Casby, 2003).

Other researchers have continued to examine the stages and types of play that emerge during typical child development as well as their functions. The first type of play to emerge is sensorimotor-exploratory play. Sensorimotor play is important for infants to explore their body and learn about their surroundings (Boucher, 1999; Nelson et. al., 2007). As infants move into more manipulative and exploratory play and interact with the world around them, they learn about everyday objects, cause and effect, problem solving techniques, and develop fine motor skills (Casby, 2003; Boucher, 1999).

Nonfunctional play develops next, as infants begin to use more than one object at a time and stack, bump, touch, and push these objects together (Casby, 2003). Nonfunctional play prepares the child for functional play. Functional play is defined as the child’s ability to use an object appropriately or use two or more objects together in the way they are intended, such as using a bottle to feed a doll or placing a train on the tracks (Williams, Reddy, & Costall, 2001; Casby, 2003).

Once a child has figured out how to play with toys functionally, they are prepared for symbolic play. Symbolic play, also known as pretend play, teaches children the use of symbols, social roles, and imagination (Boucher, 1999). Casby (2003) found that symbolic play includes decontextualization, decentration, and symbolization skills. Decontextualization refers to the ability to perform actions in a time and space different from normal, for example, pretending to sleep when it is not nap time or nighttime. Decentration involves the child being able to think outside of their normal self and take on the role of another. For example, they might pretend to be "mommy" and feed the doll a bottle or pretend to drink coffee. Symbolization consists of using something to stand for something else, like using a block for a car for example (Casby, 2003).

Other important types of play include social play and physical play. Social play, playing with others, is important for learning the skills necessary for friendship, communication, cooperation, and for learning about the cultural norms of the society (Brown & Vaughan, 2000). This type of play leads to a sense of belonging. Active, physical play is important for developing gross motor skills and learning about the body’s abilities and limitations (Boucher, 1999). It also promotes exploration and learning, flexibility, adaptability, and resilience (Brown & Vaughan, 2000).

Play is an essential part of being a child. It helps children push their own limits and master new skills, which feels good! Most children move through the stages of play development naturally, increasing their play skills and abilities at each step along the way. However, for children with ASD, this is not the case. These stages never develop or only partially occur (Mastrangelo, 2009).

Development of Play in ASD

Play deficits are a core feature in the diagnosis of ASD. Because these children typically have very little functional language, lack flexibility, and are not socially motivated they do not have the understanding to develop normal play skills (Thomas & Smith, 2003). When children with ASD play, it is often repetitive, sensory seeking, very concrete, and without imagination (Thomas & Smith, 2010). Many prefer to play alone (Walberg & Craig-Unkefer, 2010; Thomas & Smith, 2003; Boucher, 1999). When they play, children with ASD tend to use sensorimotor play, the earliest form of play in typically developing children (Boucher, 1999). This type of play is not functional. These children have a habit of manipulating objects in ways they were not intended to be used, for example, lining up toys, spinning the wheels, flapping them, or holding the toy in front of their face for an extended amount of time (Walberg & Craig-Unkefer, 2010; Thomas & Smith, 2003). They do not tend to move forward to imitating or engaging with others, exploring, or make believe play. This may be due to children with ASD lacking the knowledge of categories and the concept that toys have a function (Walberg & Craig-Unkefer, 2010).

In a study comparing play behaviors of children with autism to children with Down Syndrome and typically developing children, Williams, Reddy, and Costall (2001) reported that the children with ASD mostly engaged in simple acts involving single objects in functional play. These children would repeat the same actions with these objects instead of coming up with new actions and schemes. They also spend less time in functional play.

This author has seen and experienced the repetitive patterns and isolation that children with ASD often get stuck in. The children have preferred toys in the therapy room, and if left to their own will, they will easily get stuck in patterns that are neither functional nor therapeutic. For instance, one boy will take out an ice cream cone play set, and instead of putting the various colored ice cream pieces on the cone and pretending to eat, he will line them up on the floor and get extremely frustrated when one is moved or taken away. He will even move them to a different part of the room to be away from everyone else. Even when children have developed more advanced play skills, such as building a marble tower or putting together a puzzle, they rarely bring others into the activity with them the way typically developing children will.

Children with ASD also struggle with pretend play skills. This is due to their inability to understand hypothetical ideas. They are stuck in reality. They may even see pretend play as meaningless because it is not real (Hess, 2006). One study, reviewed by Hobson, Lee, and Hobson (2009), found that all 20-month-old developmentally delayed infants were able to show some kind of representational play, using object substitution, but none of the children with autism were able to, even after adult prompts and modeling. They found that even when children with autism get older and may be able to use some pretend play actions and object substitution, their play continues to be limited and stereotyped. Hobson, Lee, & Hobson’s (2009) study discovered that even if a child with ASD engages in symbolic play, they tend to be "less generative, less emotionally expressive, and less motivated and engaged in symbolizing (p.19)" and that while they may be able to metarepresent they lack creativity, investment, and fun in pretend play (Hobson, Lee, & Hobson, 2009).

Brain development. The development of ASD is known to neurobiological, but exactly where the problem is coming from is still unknown. There are many different theories as to which parts of the brain important for learning play skills are deficient in children with ASD. The theories tend to fall into three categories: metarepresentational (or theory of mind), executive functioning, and intersubjectivity theories (Brown & Whiten, 2000; Mastrangelo, 2009).

Hess (2006) suggests the main reasons why children with ASD have a difficult time participating in pretend play is that they do not engage in reciprocal interaction, they are not able to see how other people interpret an action (have a theory of mind), and they are not able to use imagination. Mastrangelo (2009) agreed that children with ASD lack a theory of mind and therefore struggle with metarepresentation, the ability to see things from a different perspective. For instance, a child with ASD may not be able to understand why someone might use a banana as a telephone because they just see a banana. They are not able to hold two mental representations at the same time- the real-world roles and pretend roles of an object at the same time. Hobson, Lee, and Hobson (2009) believe that in ASD "impairments in this ability to identify with others’ attitudes is said to explain the children’s limitations in perspective taking and restricted awareness of themselves as bearers of mental states- and therefore their limited capacity to generate and introduce the kinds of pretend meanings that are essential to play (p. 13)". Theory of mind researchers have demonstrated that children with ASD have problems understanding knowledge, empathy, deception, humor and teasing, language, and belief/false belief (Brown & Whiten, 2000). These problems could contribute to the lack of joint attention, social understanding, and reciprocal interactions found in ASD that make social play so difficult (Mastrangelo, 2009).

Another hypothesis of why children with ASD have a difficult time learning play behaviors given by Williams, Reddy, and Costall (2001) is that they believe ASD to be an executive disorder. An executive disorder means that people with ASD have a difficult time with forward planning and flexibility, that is coming up with alternative behaviors or that their repetitive behaviors interfere with their ability to come up with new actions. They are not able to metarepresent, due to an impairment in the decoupling mechanism. According to Williams, Reddy, and Costall (2001), this mechanism helps the child to see an object as something else, but also know that it is not true. Metarepresentation is required for symbolic play and the development of a theory of mind. The theory of mind hypothesis may be able to explain the core social, language, and imaginative deficits in the disorder as well as problems with joint attention, communication, imitation, and pretend play (Mastrangelo, 2009).

A third hypothesis argued by Rogers and Pennington (1991) is the intersubjectivity theory. This theory combines the first two theories (metarepresentational and executive functioning) and includes a third factor- a deficit in imitation. This theory is formed on the basis that infants and children learn about the behavior, subjective experiences, and mental states of other people by imitating them, using social mirroring, and affect sharing. The problem with all three of these theories is that none of them are true for all children with ASD. The disorder can vary greatly from child to child, and not all deficits are specific just to ASD.

Implications. If a child with ASD does not learn to play, they risk becoming even more socially isolated as they continue to grow and develop because they do not know how to play with their peers. Their lack of joint attention skills and ability to share enjoyment with others in activities as well as their ability to initiate and sustain play behaviors may make it difficult for children with ASD to be integrated into a classroom with typically developing peers (Mastrangelo, 2009; Nelson, McDonnell, Johnston, Crompton, & Nelson, 2007). If these children can learn and master new play skills, they might be more motivated to play functionally and even have fun doing it. Because play deficits are a core feature of ASD, a considerable amount of intervention research has focused on teaching play skills to children with ASD.

Play Therapy in Treating ASD Symptoms

Researchers have proven the importance and benefits of play in typically developing children. Because play is a natural way for children to communicate and think about the world around them, it seems that play therapy would be the best mode of treatment when working with children so they can act out experiences they might not be able to express verbally (Kenny, 2000). Researchers have found play therapy to be an effective treatment method for many children. This includes those who have been abused or neglected (Crenshaw & Hardy, 2007; Griffith, 1999), children with divorced parents (Lowenstein, 2006), and children with aggressive and behavioral problems (Davenport & Bourgeois, 2008). It has also been found to be effective with children diagnosed with Attention-Deficit/ Hyperactivity Disorder (Ray, Schottelkorb, & Mei-Hsiang, 2007), Obsessive-Compulsive Disorder (Myrick & Green, 2012), children with medical problems (Hendon & Bohon, 2007), and most recently children diagnosed with ASD (Simeone-Russell, 2011; Kenny, 2000; Thomas & Smith, 2003; Josefi & Ryan, 2004).

Deficits in play skills can contribute to further social and communication delays (Machalicek, Sigafoos, & Regester, 2009). Therefore, play should be an important part of early intervention. Play therapy can facilitate social, emotional, and linguistic development as well as improve independence and play behaviors (Josefi & Ryan, 2004) and children with ASD can learn to express themselves, be creative, and think abstractly (Murdock & Hobbs, 2011).

Play-based interventions being used with children with ASD vary greatly based on what types of children they should be used with, their purpose and goals, the methods used to reach those goals, and the theories they are based on (Boucher, 1999). Play interventions currently being used in the treatment of ASD symptoms include modeling, mirroring, play routines, play scripts, action songs, and parallel play (Thomas & Smith, 2003). Some teach the functional use of toys, while others are working towards greater play skills such as social interaction and symbolic play. Some methods are adult led and activity focused, while others are more interested in the child-directed approach.

O. Ivar Lovaas, the creator of Applied Behavioral Analysis (ABA), focused his treatment of ASD on cognitive and language impairments (Mastrangelo, 2009). He used a highly organized and structured program to focus on the acquisition of cognitive and language skills to increase IQ and academic achievement and getting rid of behavioral symptoms. However, his approach disregards the social and emotional development of the clients. Josefi and Ryan (2004) found that non-directive play therapy was successful in increasing joint attention, autonomy, and social and symbolic play, all areas that research shows are not affected by behavioral therapy. However, they also found that behavioral therapy is effective in treating the behavioral symptoms of ASD (i.e. ritualistic/ repetitive behaviors) and helps develop basic skills for school success. In their study, Josefi and Ryan found that play therapy did not reduce behavioral symptoms. This research has led to more play based interventions being paired with ABA techniques to help improve all symptoms of the disorder (Mastrangelo, 2009).

One common behavioral strategy for teaching play skills is the use of prompts and contingent reinforcement (Lang et al., 2009). Adults use the least intrusive prompt to get the child to do the desired behavior. When the behavior is done correctly, the child is rewarded with anything from a preferred food to verbal praise. Lang et al. found that even when external reinforcement was phased out, the children continued to use the play behaviors, suggesting that the play had become internally reinforcing on its own. Bernard-Opitz, Ing, and Kong (2004) compared behavioral and play interventions and found that both had positive effects on the children involved. This included improvements in play, attention, compliance, and communication.

In their study of a communication intervention for children with ASD, Walberg and Craig-Unkefer (2010) found that while it may be difficult for children with ASD to play functionally on their own, they can be taught social and play skills. This can be done through peer-mediated sessions, with typical developing peer models, adult models, the use of video modeling, and script fading techniques. Thomas and Smith (2003) discovered that using a play intervention called Tabletop Identiplay resulted in children increasing the amount of time that they play and their use of functional play during free-play time, as well as their ability to use the script sequence used in the intervention during play.

Lang et al. (2009) noted one way that many interventions teach functional and symbolic play skills is through the use of modeling. In this approach, the child watches another person perform the desired task and then they copy this task. For instance, an adult or peer can model how to eat pretend food and then the child can try. This intervention has the ability to teach complex skills such as conversational speech and perspective taking. However, in their review of interventions, Lang et al. found that some researchers do not agree with the modeling approach, claiming it is not really play because the child does not spontaneously play or they are rewarded for copying the model instead of being intrinsically motivated. This brings back the dilemma of defining play. The results from the Lang et al. study reveal there are a few reasons why it may be ok for the child’s play to be imitative. First, the imitative play skills may replace stereotypic or repetitive behaviors. Second, this type of play will allow for more dialogue and reciprocal interaction with an adult because the adult can understand what the child is playing out. Finally, if a child learns to play with toys appropriately, they will not stand out from their typically developing peers in a classroom setting, allowing for more chances to interact with their peers (Lang et al., 2009). In a longitudinal study, Kasari, Gulsrud, Freeman, Paparella, and Hellemann (2012) reported that children who received symbolic play as the basis of their treatment had lasting improvements in language skills and acquisition.

Another way to help children learn play skills similar to modeling is to use an adult partner who can provide scaffolding to teach the child appropriate play routines which they can then build off of in pretend play. In Hess’ (2006) study, she used guided role play techniques and stories to engage a 10-year-old boy with autism to play. The child’s ability to stay with the story-line and interact with the adult partner increased and non-role-play vocalizations were reduced after six weeks.

Josefi and Ryan (2004) suggest that non-directive play therapy should be the focus of treatment because children with autism are able to form a therapeutic relationship with a play therapist as well as show attachment behaviors. From this author’s experience, this was true for most of the children in the day treatment program. For example, one client sought out particular therapists for nose squishes and hugs, while another client would choose to sit on only one particular therapist’s lap or want to walk with that therapist because he felt comfortable with them.

Another play therapy technique with a focus on attachment, Theraplay, was reviewed by Simeone-Russell (2011). Theraplay was developed by Dr. Ann Jernberg and colleagues to help improve attachment relationship formation between children with ASD and their caregivers. In Theraplay, the child should develop a therapeutic attachment to the therapist. From this attachment, the child can learn to develop healthy attachments that allow them to explore the world and grow. This therapy provides opportunities for the child to feel safe and secure, to interact and build relationships with others, to develop a sense of self-esteem, and opportunities to try new things and experience success. When these elements come together, the children have been known to increase interactive behaviors and develop healthy, positive relationships (Simeone-Russell, 2011).

Further Research and Recommendations

Effective interventions for the treatment of ASD symptoms share some common themes, despite differing greatly in theory and techniques used. These similarities include using structured behavioral and educational approaches, teaching parents how to include elements of the intervention in the home, and having the child begin treatment before age five (Ozonoff & Cathcart, 1998). Early intervention services have been found to be successful in increasing a child’s functioning. However, it is still unclear as to what contributes to the success, as treatment approaches, service intensity, and family and child characteristics all play varying roles (Kasari, 2002). Also, questions remain about dose, intensity, mode of delivery, age of implementation, and setting for intervention. It is still unsure what the best combination for treatment options is in order to have optimal results. There are so many varying interventions available for helping children with ASD and parents are often left to the difficult task of sorting through and determining the best treatment for their individual child. In order to help parents with this task, it is important that treatment modalities be compared to one another to ensure each child can get the best treatment possible. Other questions that need further research include the amount of training therapists need in order to conduct therapy, how involved the parents or primary caregivers should be in the treatment process, and whether one-on-one or group settings are most ideal.

Most of the research studies including the use of play examined here are of single case or small group studies. While this provides a good source of information and a place to begin hypotheses, much more extensive research needs to be conducted in order to fully understand the costs and benefits of different treatment theories and techniques. It would be beneficial to look at more treatment options that combine ABA techniques with play therapy techniques, as it seems to be the best option for reaching all areas of a person’s life that is impacted by ASD.

Conclusion

Play is a complex part of life that occurs naturally for most children. It teaches them social, emotional, and cognitive skills necessary for success in their adult life, for interacting with others, and for learning and understanding their world. For children who lack the ability to play, they risk not developing the skills necessary for success in the home, school, and community. Therefore, understanding the development of play is important in early intervention. It is an area that can easily be observed in infants, toddlers, and young children. It can play a role in diagnosis and the treatment of a variety of developmental disabilities, including ASD. Treatment modalities that include the use of play therapy techniques and that teach children appropriate play schools are vitally important to the overall treatment of ASD. However, play therapy techniques may not be helpful for all children diagnosed with ASD. It would be important to look at the cognitive abilities of a child to ensure they are able to participate in the play activities. Also, physical abilities would be an important factor to consider as well. With the help of further research, the use of play therapy techniques in early intervention of ASD should become empirically supported. The biggest difficulty will be to figure out which play approach is best for which type of child with ASD, because a one-size-fits- all approach will not work for every child. When children with ASD are allowed opportunities to play, they are able to obtain skills necessary for communication, reciprocity, and sensory processing (Mastrangelo, 2009). The more opportunities for play that therapists and caretakers give children with ASD, the closer they are to helping the child develop appropriate skills.

Questions:

-Should I keep using ASD each time I mention the disorder or can I substitute "autism spectrum", or just "on the spectrum" at times?

-Are there any major holes or things that should be given more attention?

-Anything that is not cited that you think should be?