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Play and autism

What is autism?

Autism is a lifelong developmental disability that affects the way people communicate and relate to people around them. Some people have accompanying learning difficulties but everyone with the condition shares a difficulty in understanding the world. People at the high-functioning end of the autistic spectrum are described as having Asperger syndrome.

All people with autism have impairments in social interaction, social communication and social imagination. This is known as the triad of impairments.

What is play?

Play is a diverse and complex behaviour that is viewed as central to the normal development of children (Jordan and Libby, 1997). However, it is very difficult to come to a concise definition of what is meant by play. Dictionaries vary in the definitions they offer. Most, however, seem to imply some kind of fun, a way of entertaining oneself. Garvey (1977) expands on this, listing play as having the following characteristics:

play is pleasurable and enjoyable
play has no goal imposed on it from the outside
play is spontaneous and voluntary
play involves some active engagement on the part of the player
play has certain systematic relations to what is not play. It can be contrasted to non-play.

Development of play

A child's play goes through a number of developmental stages (Boucher, 1999):

sensory motor play
exploratory and manipulative play
physical play including rough and tumble
social play
pretend (make-believe) play.

It is sometimes suggested that there are two types of pretend play. So, for example, Libby et al (1998) differentiate functional play (eg pushing a toy car along the carpet and making a brmmmm noise) from symbolic play, which involves treating an object or situation as if it is something else (eg pretending a banana is a telephone). In Libby et al's study, children with autism did not demonstrate significantly less functional play than children with Down syndrome or young children with typical development. They did, however, have difficulties in the production of symbolic play although there was evidence of some capacity to engage in symbolic play, albeit mainly object substitution. Not all researchers make the distinction between symbolic and functional play. Many use the term pretend play as an umbrella term.

Leslie (1987) asks three questions in order to distinguish sophisticated functional play from symbolic play:

Has one object been made to stand for another, different object (object substitution)? eg has the child pretended a shell was a cat?
Has a pretend property been attributed to an object or a situation? eg has the child pretended the dollys [clean] face is dirty?
Has the child invented an imaginary object? eg has the child pretended that a spoon is there when it is not?

Leslie felt that true pretence requires two levels of representation. In first-order representation, a child may use a toy as a substitute for the real thing, but not indulge in symbolic play, because s/he believes in the reality of the object (eg a toy cooker is believed to be a real cooker). Second-order representation involves the awareness that the pretend object is something different eg a pencil is used as a rocket (William, Reddy and Costell, 2001).

Why play?

Play allows children to learn and practise new skills in safe and supportive environments (Boucher, 1999). Sensory motor play teaches young infants about their own bodies and about objects in the immediate environment. Manipulative and exploratory play teaches the older infant about objects and their properties and about influencing the world around them. Physical play, including rough and tumble play, teaches toddlers and preschoolers gross motor skills and provides the experience of whole body interaction with both others and objects in their environment. Social play, from the earliest exchanges between caregiver and baby to the complex interaction between primary school children, for example, by playing doctors and nurses, teaches about social relationships and how to engage in them, as well as about the cultural norms of the society in which the child is growing up. Sherratt and Peter (2002) suggest that "make-believe play" can develop thought flexibility in children with autism.

Restal and Magill-Evans (1993), in their study of preschool children, state that play provides a medium through which children develop skills, experiment with roles, and interact with others. They found children with autism to be disadvantaged in their use of play for these purposes. Play also matters for children with autism because playing is the norm in early childhood and a lack of play skills can aggravate childrens social isolation and underline their difference from other children (Boucher, 1999). Boucher also emphasises that play should be fun. If improving the play skills of children with autism gives them a sense of mastery, and increases their pleasure and their motivation to play, that is a justifiable aim in itself. She goes on to say that we can also learn a great deal from watching a child at play and it gives the child with autism, who may have difficulty in expressing feelings and thoughts in words, chances to express themselves.

How play differs in autism

The DSM-IV (American Psychiatric Association, 1994) diagnostic criteria for autistic disorder includes a lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level as one of the indicators of autism. CHAT (Baron-Cohen et al, 2000, the CHecklist for Autism in Toddlers, is a screening questionnaire which was devised with the assumption that those children who are not exhibiting joint attention and pretend play behaviours by the age of 18 months could be at risk for later receiving a diagnosis of autism. It asks several questions about play, one of which is 'Does your child ever pretend, for example, to make a cup of tea using a toy cup, or pretend other things?' The GP/health visitor will also observe the child to see if they can complete this task. Failure to do so, together with failure at other questions/tasks, indicates that the child is in the autism spectrum risk group.

A child with autism will rarely be perceived as the playing child (Beyer and Gammeltoft, 2000) and their play can be impaired at all developmental stages. Most research, however, has concentrated on pretence, especially symbolic play.

Research has shown that for young children with autism, sensory motor play dominates beyond the verbal mental age, at which it normally declines in infants without autism (Jordan and Libby, 1997). Further, having missed out the early experiences of manipulation and combination enjoyed by children without autism, toys and objects are used in an inflexible way. For example, a child with autism may be preoccupied with spinning the wheels on a toy car, rather than playing a racing or driving game. Roeyers and van Berckelaer-Onnes (1994) describe children with autism as missing the curiosity of typically developing children. They conclude that their play behaviour is often limited to simple manipulation, the quality of their play is lower than that of non-autistic children of comparable mental age and (spontaneous) symbolic play is usually absent or impaired.

Some children with autism do not give any indication that they want to play with other children, preferring to play by themselves; other children would like to but they can have great difficulty in indicating this wish. Teresa, Freddy and Jared take part in integrated playgroups. All have difficulty in getting the other children to play with them. Teresa, wanting Sook to play with her, is not explicit enough when she says, 'Play in doll house, Sook?' Freddy fails in his attempts to get the other children to play with him, firstly by hiding, then by imitating them and finally by playing the bad boy and disrupting their games (Wolfberg, 1999).

A child may well be playing, even though we do not perceive it. Indeed, the child spinning the wheels on a toy car may still meet the characteristics of play as described by Garvey (1997). Further, research has shown that children with autism may not be totally unable to engage in pretend play, particularly if play is highly structured or if prompts are used to stimulate pretence (eg Jarrold, Boucher and Smith, 1996). On the basis of their findings, Jarrold, Boucher and Smith suggest that children with autism have problems in generating pretend play, rather than in the mechanics of pretence itself. Similarly, Stahmer (1999) writes that although children with autism show a lack of spontaneous play in free settings, this is not the result of a complete inability to play, but may be due at least in part to the fact that they find play difficult, so they experience repeated task failure. This in turn can lead to frustration and a pervasive lack of motivation to play.

Often, when symbolic play does appear to occur in the child with autism, it is copied from the television or something similar. Repeatedly re-enacting a clip from Toy story or another video is an example of this: whilst the child's play may appear original and imaginary, it actually is not. Play in children with autism can also be very repetitive. Wolfberg (1999) tells of Teresa, who became attached to a particular doll. Every day she would perform the same ritual with the doll, bathing it and washing and combing its hair. Another child, Freddy, played the same chasing game everyday. At first, he would only play the game with his classmate Jared, but eventually began to initiate chasing games spontaneously with other children. He did, however, need the assistance of an adult to guide each step along the way. Sherratt (1999) showed that this imitated behaviour may provide a stimulus that can enable children with autism to generate spontaneous pretence.

Jarrold, Boucher and Smith (1996) found that not only are children with autism impaired in their production of spontaneous pretend play, but that they also spend significantly less of their time compared with controls in functional play (eg making a doll walk). They argue that the finding that children with autism show impaired levels of functional play is a problem for Leslie's metarepresentational account (Leslie, 1987) because functional play does not require metarepresentational abilities, but is nevertheless impaired. Similarly, Williams, Reddy and Costell (2001) found that in contrast to matched controls (children with Down syndrome and typically developing children), children with autism did not normally engage in elaborated functional play (eg stirring a spoon in a pot). Instead their play consisted of simple functional play (eg placing a spoon in a pot but not stirring it). The control groups divided their time equally between these two types of play. Children with autism also produced fewer different acts and spent less of their play time in functional play that was new, when compared with the control groups.

In sum, the play of children with autism can, therefore, be seen as impoverished. As Sherratt (1999) postulates, the difficulty that children with autism experience in pretend play arises from difficulties they have in both the fluid organisation of thought processes and in communicating these thoughts to others. Further, disturbance of play in autism may lead directly to disturbance in all aspects of development (Jordan and Libby, 1997) although it could be that an inflexibility of thought processes causes an impairment in play and also an impaired development of other skills (Sherratt, 2001a). Sherratt and Peter (2002) suggest that teaching children with autism to play may increase a fluidity of thought and reduce conceptual fragmentation. In particular, if play is taught to young children it may assist them in reducing repetitive and rigid behavioural patterns and encourage communication development.

Why play differs in autism

Roeyers and van Berckelaer-Onnes (1994) offer three explanations as to why children with autism are impaired in their play. The first concerns difficulty with lower play levels. This refers to the notion that, in order to engage in functional and social play, a child has to pass through earlier phases of simple manipulation (eg mouthing, waving) and relational play (eg stacking using one object as a container to hold another) in an approximately normal manner. Children with autism have limited experience in these two categories because of their lack of curiosity and need to explore. Instead they often engage in stereotyped, persistent behaviour and self-stimulatory use of the proximal senses (sucking, licking, handling).

The second hypothesis is the cognitive theory. This concerns an impairment in the child's representational thought, the ability to form and manipulate symbols. Leslie's (1979) metarepresentational theory is an example of this.

The final suggestion is conative theory. This suggests that the elicited play of children with autism is less impaired than their spontaneous play. It negates the cognitive theory, suggesting instead that children with autism can pretend play, but do not do so spontaneously, perhaps because of repeated failures, as suggested by Stahmer (1999).

Why teach children with autism how to play?

Wolfberg (1999), in her review of the intervention literature, discovered that play (particularly with peers) has had a relatively small role in the education and treatment of children with autism. Of the interventions she could find, none was comprehensive and they did not appear to operate within a coherent conceptual framework of how play naturally occurs and interacts with social and symbolic development in children with autism. Consequently, such interventions may not tap a child's full potential for play. Sherratt (1999) also expresses concern that teaching children with autism how to play has been relatively neglected in both the literature and practice.

The development of symbolic pretend play seems to have much to offer in the remediation of the core difficulties that are experienced by children with autism (Sherratt, 1999). This is because symbolic pretend play offers a rich and meaningful environment for the manipulation of symbolic representations, which is something these children find particularly difficult. Sherratt and Peter (2002) have suggested that this may result in learning and changes to the brain. Symbolic pretend play also allows the children to develop flexibility of thought. Further, it offers them opportunities to engage within mutually satisfying social play, which can be used as a vehicle for developing the social skills that they so often lack. These opportunities are created by a shared understanding of pleasure experienced in play episodes (Sherratt and Peter, 2002). It also prevents secondary disabilities by enabling participation in social and cultural events (Jordan and Libby, 1997).

For anyone looking to teach symbolic pretend play to children with autism, Sherratt (1999; 2001b) stresses the importance of the following conditions, the first three of which are the key conditions:

Structure: this helps the child to understand the sequence of skills, activities or ideas that are necessary towards the attainment of an agreed goal. For example, a story such as Red riding-hood has a clear structure with stereotyped characters, repetitive phrasing and an effective hook line - the excitement of discovering that Grandma is in fact a wolf.
Effect: there needs to be an inherent pleasure in play or it ceases to be play. Children with autism may enjoy slapstick or programmes like Mr Bean.
Interests: the child must have an interest in the manipulation of materials to make the play experience personally meaningful. Using a subject that has an inherent meaning for the child (such as a favourite video sequence) is more likely to stimulate engagement and pretence. There is a clear difference between encouraging repetitiveness and using interests creatively.
Non-representational materials: eg boxes with or without lids, pieces of cloth, ribbons, string, plasticine, balloons and sticks. Representational materials (eg a soft toy animal) should be used in balance with non-representational materials.
Continuity: there should be some expectation of the process in teaching pretend play to enable the children to switch into pretence.
Social play: this may involve learning new skills from a more able player, gaining a desired object from someone else or sharing a sense of enjoyment from the actions of the other person.
Appropriate language: language and instructions should be kept simple and to the minimum. This allows the child to focus on the acts of pretence.

Roeyers and van Berckelaer-Onnes (1994) recommend stimulating lower play levels in children with autism, eg the simple handling and combining of objects, an experience they have missed during their first two years of life. Also, although a child might take part in a play training programme, such as the one devised by Roeyers and van Berckelaer-Onnes, the child also needs to be stimulated in the daily life situation to enable them to generalise their new learned skills.

There are a variety of ways in which attempts have been made to teach pretend play. Some have used behavioural techniques and, although these have met with some success, it has been questioned whether the children are just developing learned behaviours. Further, such approaches do not meet Garvey's criteria of being pleasurable and enjoyable: children may perform pretend play just to receive a reward.

Another method of eliciting pretend play that has been studied is the use of photographs, video or digital camera photographs connected to a computer, the aim being to make pretend play explicit. They have, however, been met with limited success (Jordan and Libby, 1997). More successfully, they may be used as part of the work of speech and language therapists, eg to help the child develop social scripts for pretend play sequences. For more experienced children, more than one child can play, so that the children have to wait their turn and fit their actions to those of others.

Stahmer (1999) looked at the use of pivotal response training (PRT) as a means of increasing play in children with autism. PRT is a training technique used to increase motivation. Techniques include clear instructions and questions, interspersion of maintenance tasks (interspersing tasks within a childs competence with new tasks), child's choice of toys, direct reinforcement, reinforcement of goal-directed attempts and turn taking. It is important that the new play skills to be taught are developmentally appropriate. Types of play that can be taught include manipulative play, functional play, symbolic play and sociodramatic play. Residual difficulties included a continued lack of interaction during play with peers and very low levels of initiations to peers or adults.

As Jordan and Libby (1997) conclude, teaching spontaneous play skills to children with autism, or developing existing play skills, is not easy; if it were so, it would not be a recognised core problem of autism. Retting (1994), also expresses concern as to whether or not attempts to facilitate play in children with autism have any lasting effects on their behaviour. Play, however, can and should be a valuable part of the school curriculum for pupils with autism, facilitating all aspects of development (Jordan and Libby, 1997).

Ideas for toys and leisure activities

As with all children, children with autism have a wide range of likes and dislikes. Shields (1999) has compiled a lists of toys that have been demonstrated as being popular with young children with autism. They include toys which are visually interesting (eg bubbles, shape and colour matching or sorting toys, jigsaws, Jack-in-the-box, lego, videos especially Thomas the Tank Engine, Pingu and Disney); books, especially those with flaps or items to touch, puzzle books, word books etc.; physical activity toys eg swing, slide, trampoline, rocking horse, ride-on toys, climbing frame, football etc.; games to play with other people eg tapes of singing and dancing games, picture lotto, snap, Connect 4, snakes and ladders, ludo, chess; and computer software early years programmes, characters (eg Thomas the Tank Engine, Pingu, Disney), software to develop vocabulary, factual software.

Play therapy

The purpose of play therapy for the child runs parallel to psychotherapy for the adult. It is to help children understand their behaviour and, if necessary, make changes. Waterhouse (2000) originally felt that play therapy would not benefit children with autism and certainly, traditional psychoanalytic play therapy, relying heavily on interpretation and transference, would not seem be appropriate to the child with autism. However, Waterhouse came to realise that the writing of adults with autism casts a different light on this. They suggested that communication could be achieved through symbols of various kinds, a form of communication that can be utilised by play therapists. Waterhouse stresses the need for the therapist to be fully aware of the problems created by autism if pitfalls, such as misinterpretation of play resulting in further confusion, are to be avoided. A survey of literature revealed that little research exists on the use of play therapy with children with autism (Mittledorf, Hendricks and Landreth, 2001). They go on to say that it is also difficult to evaluate the effectiveness of traditional play therapy because it is almost exclusively in case study form.

Following the realisation that autism is a developmental disorder, psychodynamic play therapy came to be seen by many as inappropriate. However, Broomfield (2000) argues that it is appropriate for helping some children with high-functioning autism. He presents a case study of Tim, a boy with high functioning autism, whom he first saw at age eleven and continued to see throughout his adolescence. Much of the therapy, certainly during his earlier adolescent years, involved acting out game shows and other television programmes. As time developed, the play changed from ritualistic play to play that showed much spontaneity, humour and feeling. This enabled him to play and talk about things in the real world. He came to realise that he just wanted to be normal and then, although he had considerable difficulties and needed special help, "that doesn't mean I can't live a good life". His therapy took off from there and Tim enrolled as a student.

Conclusion

Whilst the child with autism may not be perceived as the playing child, research has shown that children with autism are not totally impaired in play. Their play, does however, differ in quality from their peers without autism. They also experience difficulty in playing with other children.

Although the play of a child with autism is known to be different, there has been little research on teaching children how to play. However, it is suggested that the acquisition of play skills has much to offer the child with autism. Little, too, has been written on play therapy with children with autism and the benefits this may have for more able children's development.

References

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders 4th edition, Washington, DC: American Psychiatric Association

Baron-Cohen, S. et al (2000). Early identification of autism: the Checklist for Autism in Toddlers (CHAT). Journal of the Royal Society of Medicine, 93 , pp. 521-525

Beyer, J. and Gammeltoft, L. (2000). Autism and play. London: Jessica Kingsley Publishers

Boucher, J. (1999). Editorial: interventions with children with autism methods based on play. Child Language Teaching and Therapy, 1999, 15 (1), pp. 1-5

Broomfield, R. (2000). It's the tortoise race: long term psychodynamic psychotherapy with a high-functioning autistic adolescent. Psychoanalytic Inquiry, 20 (5), pp. 732-745

Garvey, C. (1977). Play. London: Fontana

Jarrold, C., Boucher, J., and Smith, P. (1996). Generativity deficits in pretend play in autism. British Journal of Developmental Psychology, 14 , pp. 275-300

Jordan, R. and Libby, S. (1997). Developing and using play in the curriculum. In S. Powell and R. Jordan (eds) Autism and Learning: a guide to good practice. London: David Fulton Publishers
Available from the NAS Information Centre

Leslie, A. M. (1987). Pretense and representation: the origins of theory of mind. Psychological Review, 94 (4), pp. 412-426

Libby et al (1998). Spontaneous play in children with autism: a reappraisal. Journal of Autism and Developmental Disorders, 28 (6), pp. 487-497
Available from the NAS Information Centre

Mittledorf, W., Hendricks, S., and Landreth, G. L. (2001). Play therapy with autistic children. In: G. L. Landreth (ed.) Innovations in play therapy. New York: Routledge

Restall, G. and Magill-Evans, J. (1994). Play and preschool children with autism. The American Journal of Occupational Therapy, 48 (2), pp. 113-120

Retting, M. A. (1994). Play behaviors of young children with autism: characteristics and interventions. Focus on Autistic Behavior, 9 (5), pp.1-6

Richman, S. (2001). Raising a child with autism: a guide to Applied Behavior Analysis for parents. London: Jessica Kingsley Publishers

Roeyers, H. and van Berckelaer-Onnes, I. A. (1994). Play in autistic children. Communication and Cognition, 27 (3), pp. 349-360

Sherratt, D. (1999). The importance of play. Good Autism Practice, September, pp 23-31
Available from the NAS Information Centre

Sherratt, D. (2001a). Personal correspondence.

Sherratt, D. (2001b). Play, performance, symbols and affect. In J. Richer and S. Coates (eds) Autism: the search for coherence. London: Jessica Kingsley Publishers
Available from the NAS Information Centre

Sherratt, D. and Peter, M. (2002). Developing play and drama in children with autistic spectrum disorders. London: David Fulton

Shields, J. (1999). Ideas for toys and leisure. In The autistic spectrum - a handbook 1999. London: The National Autistic Society
Available from the NAS Information Centre

Stahmer, A. C. (1999). Using pivotal response training to facilitate appropriate play in children with autistic spectrum disorders, Child Language Teaching and Therapy, 15 (1), pp. 29-40

Waterhouse, S. (2000). A positive approach to autism. London: Jessica Kingsley Publishers

Williams, E., Reddy, V., and Costall, A. (2001). Taking a closer look at functional play in children with autism, Journal of Autism and Developmental Disorders, 31 (1), pp. 67-77
Available from the NAS Information Centre

Wolfberg, P. J. (1999). Play and imagination in children with autism. New York: Teachers College Press