Successful Internalization of a Chronic Biliary Cutaneous Fistula After Liver Transplantation : Deepithelializing the Fistula Tract Biliary cutaneous fistulas are uncommon sequelae after biliary surgery and can be a source of significant morbidity . We describe a liver recipient who developed a biliary cutaneous fistula secondary to hepatic artery thrombosis ; this subsequently drained for over 7 years . Through a novel approach , using the transabdominal fistula tract as a conduit , the fistula skin opening was deepithelialized and anastomosed to a jejunal loop , internally draining the tract . For over 7 years postoperatively , this internal drainage procedure has continued to function effectively . This approach may have value in internalizing longstanding biliary cutaneous fistulas in well-selected patients in whom there is no existing biliary ductal system or the existing system anatomically does not lend itself to restoration of functional internal drainage through conventional approaches . Introduction Biliary cutaneous fistulas are uncommon sequelae after biliary surgery and hepatic trauma . Persistent biliary fistulas can be associated with local skin morbidity , malabsorption of fat soluble vitamins , steatorrhea , impaired wound healing , and sepsis as a result of fistula tract obstruction .1 We describe a rare scenario in which a liver transplant recipient developed a biliary cutaneous fistula secondary to hepatic artery thrombosis . Through a novel approach , the fistula skin opening was deepithelialized and , using this transabdominal fistula tract as a conduit , anastomosed to a jejunal loop , thereby internally draining the fistula . This operative procedure , which has provided a successful long-term result , is discussed . Materials and Methods Case Report A 60-year-old man of Chaldean descent underwent orthotopic liver transplant for cirrhosis secondary to chronic alcohol use . His early postoperative course was complicated by hepatic artery thrombosis with necrosis of the extrahepatic biliary system . Because of sepsis and family issues , retransplantation was not a realistic option . Surprisingly , his graft remained viable with good metabolic function despite the absence of normal extrahepatic drainage . For 7 years subsequent to transplantation , his biliary drainage was managed with a U-tube connected to a bulb drain exiting the skin in the right subcostal region -LRB- Fig. 1 -RRB- . As a result , he suffered from severe malnutrition , pain , and skin breakdown . The persistent external drainage markedly affected his lifestyle , as the continuously draining bile required dressing changes over the exit site two to four times per day . The U-tube , frequently becoming obstructed with biliary sludge , required bimonthly replacement . Preoperative fistulogram -LRB- Fig. 2 -RRB- demonstrated the continuity of the cutaneous opening with a large channel through the mid portion of the liver , but with no evidence of a true ductal system . Figure 1 -LRB- a -RRB- Longstanding -LRB- 7-year-old -RRB- biliary cutaneous fistula draining through right upper quadrant scar . Functional U-tube in place with copious biliary drainage . -LRB- b -RRB- Close-up of U-tube exit site.Figure 2Preoperative fistulogram in which contrast was injected through the existing U-tube . The cutaneous opening at the upper left side of the frame is in continuity with the large contrast-filled channel that enters the substance of the liver . Note the complete absence of an extrahepatic biliary system . Surgical Procedure With the patient under general anesthesia , the abdominal cavity was entered through a right subcostal incision along the scar of the previous transplant incision . The incision was fashioned so as to preserve a 1 '' diameter button of full-thickness skin surrounding the opening to the fistula tract -LRB- Fig. 3 -RRB- . Extensive adhesions between the fascia , liver surface , and small intestine were carefully lysed . The fistula tract was dissected retrogradely from surrounding subcutaneous tissue and muscle , preserving a rectus fascial ring . This created a conduit that could be anastomosed to small intestine . Dissection of the tract was stopped proximally at the level of the liver surface to preserve its integrity and vascularity . The fistula opening was lowered into the abdominal cavity . A 60-cm long Roux-en-Y jejunal limb was constructed 50 cm distal to the ligament of Treitz using stapled technique . Figure 3 -LRB- a -RRB- At operation , the U-tube was prepped into the surgical field . -LRB- b -RRB- Dissection of the epithelialized chronic biliary cutaneous fistula tract . In entering the abdomen through the previous right subcostal incision , a 1 '' diameter button of full-thickness skin containing the fistula tract was preserved . A 4-mm-wide skin edge was sharply deepithelialized circumferentially around the dissected fistula opening . This conduit was then anastomosed to the Roux limb using two layers of running 4-0 Prolene suture -LRB- Fig. 4 -RRB- . The inner layer approximated the deepithelialized skin edge of the fistula tract to full-thickness jejunum . The outer layer approximated the conduit 's scar tissue and the preserved rectus fascial ring to seromuscular jejunum . An omental wrap was fashioned around the anastomosis . The anastomosis was performed over an 8-French feeding tube , which was exteriorized through a previous U-tube exit site and connected to a bile bag . Figure 4 -LRB- a -RRB- Anastomosis of Roux-en-Y jejunal limb to deepithelialized fistula tract . -LRB- b -RRB- Illustration depicting the anastomosis . The abdominal cavity was irrigated and closed in the standard fashion . The patient tolerated the 3-h procedure well . Blood loss was minimal . He was discharged on postoperative day 8 . Result This patient has now been followed for 7 years since the described procedure and is doing well without external drainage of bile . The condition of his periincisional skin improved dramatically shortly after the procedure . At this time his liver function tests and nutritional parameters are normal and his graft function remains adequate on a low dose immunosuppressive regimen . Discussion Chronic biliary cutaneous fistulas are challenging to manage from many standpoints : metabolic , nutritional , hygienic , and quality of life . The patient 's being a liver transplant recipient , added further complexity . First , malignant change was reported in chronic biliary cutaneous fistulas 2 ; this possibility is of real concern in light of this patient 's immunosuppressed state . Second , this patient had severe malabsorption and resulting difficulty in maintaining acceptable cyclosporin blood levels . Finally , the ongoing presence of his U-tube poses the threats of ascending cholangitis , hemobilia , intrahepatic biloma , and biliary-venous fistula , which are all well-documented complications that have been associated with U-tubes.3 The decision for operative intervention was made out of these concerns and for progressive difficulty in maintaining adequate external biliary drainage . Late retransplantation was considered ; however , the patient 's graft function had been excellent over the 7 years subsequent to his transplant , and the patient and his family refused to consider it . In both the posttraumatic and postbiliary surgery settings , existing literature advocates initial nonsurgical management of biliary cutaneous fistulas , as a significant number will close either spontaneously or with nonsurgical intervention .1,4,5 In the series by Zer , four of seven biliary fistulas sealed spontaneously .5 Endoscopic approaches to reducing intrabiliary pressure and thereby encouraging drainage along a path of least resistance include endobiliary stenting , sphincterotomy , and nasobiliary drainage .1,4 Finally , selective biliary embolization , percutaneous transhepatic catheter drainage , sclerosis with tetracycline , and oral nitrates were also described to promote closure .4,6 -- 9 Operative procedures for refractory biliary cutaneous fistula were dictated by the anatomic site of biliary tract disruption . Roux-en-Y hepaticojejunostomy , in which a jejunal loop is sutured directly to the liver capsule , was employed in the context of intrahepatic biliary injury after trauma .11,10,4 Reports in which an actual fistula tract is used as a conduit and sutured to a loop of small bowel , however , are rare . Smith described the anastomosis of a jejunal loop to a divided fistulous tract arising from the lateral surface of the liver in a patient with a penetrating injury to the upper abdomen .12 That same author described the internal drainage of a biliary cutaneous fistula secondary to blunt liver trauma into the gallbladder .12 In both cases the fistula tract was divided and then the proximal end of the divided tract was anastamosed to an intestinal loop over a tube . Deepithelialization of the skin opening and its direct usage in an anastomosis has not , to our knowledge , been previously described . Furthermore , this procedure is unique in that the internalization was done in the case of a functioning liver after hepatic artery thrombosis . The existing anatomy that had been established over 7 years of fistulous drainage dictated the type of procedure that was performed . In contrast to fistulas that arise after biliary tract surgery -LRB- for example , after cholecystectomy with common bile duct exploration -RRB- , there was no remnant of a previous biliary ductal system . The preoperative fistulogram revealed flow of contrast from the skin directly to the liver surface with no evidence of an extrahepatic ductal system . The fistula therefore provided the only source of biliary drainage for the entire liver . An alternative surgical option would have been hepaticojejunostomy , in which the jejunum would have been sutured to a fibrous ring at the origin of the fistula tract from the liver surface . This , however , would have required more extensive dissection with possible disruption of collateral vasculature to the previously ischemic liver and to the tract itself , as well as dissection of the transverse colon , which in part bordered the tract . At operation , the superficial portion of the fistula tract was well established and appeared well vascularized . The potentially harmful deep dissection necessary for a hepaticojejunostomy was therefore avoided . We emphasize the decision to have fashioned a tongue of omentum over the anastomosis . By nature , the tissue comprising a fistula tract is probably somewhat tenuous . This patient 's immunosuppressed and malnourished state compound the risk of anastomotic breakdown . We feel that the well-vascularized , adherent omental tongue was an important aspect of the operation in reinforcing the anastomosis . As of 7 years of follow-up , the patient has not developed signs of biliary obstruction . His immunosuppressant levels are easier to maintain and he does not have evidence of malabsorption . It is unlikely that he will develop cicatricial narrowing of the tract , as it had remained well epithelialized for the 7 years before this operation . There is a theoretical concern about formation of squamous cell carcinoma at the anastomotic site , which we continue to keep in mind during long-term follow-up . Conclusion In summary , through a novel approach this patient 's biliary cutaneous fistula was internalized , which has eliminated his associated skin morbidity and malabsorption . Furthermore , his well-functioning graft was salvaged , thus saving the cost of retransplantation and sparing an additional liver for another patient . Internalization of a long-standing biliary cutaneous fistula through deepithelializing the skin opening and using the tract as a conduit is technically feasible . We believe it to be a valid approach in the patient in whom there is no existing biliary ductal system or the existing system anatomically does not lend itself to restoration of functional internal biliary drainage by conventional approaches .

O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O


Brief Report : Normal Intestinal Permeability at Elevated Platelet Serotonin Levels in a Subgroup of Children with Pervasive Developmental Disorders in Curaçao -LRB- The Netherlands Antilles -RRB- This study investigated the relationship between platelet -LRB- PLT -RRB- serotonin -LRB- 5-HT -RRB- and intestinal permeability in children with pervasive developmental disorders -LRB- PDD -RRB- . Differential sugar absorption and PLT 5-HT were determined in 23 children with PDD . PLT 5-HT -LRB- 2.0 -- 7.1 nmol/109 PLT -RRB- was elevated in 4/23 patients . None exhibited elevated intestinal permeability -LRB- lactulose/mannitol ratio : 0.008 -- 0.035 mol/mol -RRB- . PLT 5-HT did not correlate with intestinal permeability or GI tract complaints . PLT 5-HT correlated with 24 h urinary 5-hydroxyindoleacetic acid -LRB- 5-HIAA ; p = .034 -RRB- . Also urinary 5-HIAA and urinary 5-HT were interrelated -LRB- p = .005 -RRB- . A link between hyperserotonemia and increased intestinal permeability remained unsupported . Increased PLT 5-HT in PDD is likely to derive from increased PLT exposure to 5-HT . Longitudinal studies , showing the -LRB- in -RRB- consistency of abnormal intestinal permeability and PLT 5-HT , may resolve present discrepancies in the literature . Introduction Autism has been linked to gastrointestinal -LRB- GI -RRB- disturbances -LRB- White 2003 -RRB- . It is , however , questionable whether GI anomalies in children with autism are specific -LRB- Erickson et al. , 2005 -RRB- . An increase of chronic diarrhea , constipation , abdominal bloating and food regurgitation has been found in some studies , but could not be confirmed in more recent studies -LRB- reviewed by Erickson et al. 2005 -RRB- . Increased GI permeability , as established through the differential sugar absorption test -LRB- SAT -RRB- , was demonstrated in 9/21 -LRB- 43 % -RRB- -LRB- D'Eufemia et al. , 1996 -RRB- and 19/26 -LRB- 76 % -RRB- -LRB- Horvath & Perman , 2002 -RRB- of patients diagnosed with autism . The SAT measures the integrity of the intestine by the ingestion of two indigestible saccharides that after GI uptake become fully excreted in urine . One of these -LRB- usually lactulose -RRB- passes the intestinal wall through paracellular transport -LRB- ` leakage ' -RRB- , while the other -LRB- usually mannitol -RRB- passes by paracellular and transcellular transport . The urinary lactulose/mannitol ratio is used as a measure of intestinal integrity and permeability -LRB- van Elburg et al. , 1995 -RRB- . In addition , a recent study found a high prevalence of congenital GI anomalies -LRB- adjusted odds ratio 5.1 , 95 % confidence interval 1.8 -- 14.1 -RRB- , notably pyloric stenosis , in autism , which may be linked to the high rate of GI dysfunction reported by their parents -LRB- Wier , Yoshida , Odouli , Grether , & Croen , 2006 -RRB- . The implication of the GI tract in autistic pathophysiology warrants more detailed investigation of the gut-brain axis -LRB- Erickson et al. , 2005 -RRB- . Especially the role of serotonin -LRB- 5-hydroxytryptamine ; 5-HT -RRB- , as a messenger within this axis -LRB- Gershon , 2005 -RRB- , deserves attention . Many different aspects of the 5-HT system in autism have already been studied -LRB- Burgess , Sweeten , McMahon , & Fujinami , 2006 ; Croonenberghs , Verkerk , Scharpe , Deboutte , & Maes , 2005 ; Janusonis , 2005 ; Mulder et al. , 2004 -RRB- . A recent report -LRB- Mulder et al. , 2004 -RRB- on platelet -LRB- PLT -RRB- 5-HT in PDD showed PLT hyperserotonemia in approximately 36 % of patients with autism and in 58 % of patients with PDD not otherwise specified -LRB- NOS -RRB- . Using mixture-modeling analysis Mulder et al. -LRB- 2004 -RRB- derived an empirical cut-off value that enabled dichotomization of patients with PDD into normo - and hyperserotonemic . Extensive behavioral assessments did , however , not show significant correlates with PLT 5-HT or hyperserotonemic status . A common -LRB- developmental -RRB- factor , causing both an autistic brain and deregulated 5-HT release from the GI tract , years after birth , may be involved in the etiology of PDD -LRB- Janusonis , 2005 -RRB- . The primary site of the hyperserotonemia in autism is likely to be located in the GI tract . Serotonin is a biogenic amine that derives from the essential amino acid tryptophan -LRB- Tryp -RRB- by hydroxylation and subsequent decarboxylation . The GI tract contains about 80 % of bodily 5-HT , which is unevenly distributed among the enterochromaffin cells -LRB- 90 -- 95 % -RRB- and neurons -LRB- 5 -- 10 % -RRB- -LRB- Houghton , Atkinson , Whitaker , Whorwell , & Rimmer , 2003 -RRB- . The main functions of 5-HT are in smooth muscle contraction , blood pressure regulation , and peripheral and central neurotransmission . Serotonin localized in the basolateral stores of enterochromaffin tissue is released upon neuronal , chemical or mechanical stimulation . Several 5-HT receptors control GI motility , sensation and secretion -LRB- Gershon , 2005 -RRB- . Following its release , 5-HT is removed from the interstitial space by 5-HT selective reuptake transporters -LRB- Gershon , 2005 -RRB- . However , part of the 5-HT enters the portal blood and systemic circulation where it is either rapidly taken up and accumulated by PLT , or metabolized by the liver , lung and kidneys into its major metabolite 5-hydroxyindoleacetic acid -LRB- 5-HIAA -RRB- -LRB- Houghton et al. , 2003 -RRB- . Platelets store and transport the majority -LRB- 99 % -RRB- of circulating 5-HT -LRB- Ortiz , Artigas , & Gelpi , 1988 -RRB- . Elevated PLT 5-HT levels observed in subgroups of patients with PDD , may be related to increased GI motility . This notion is supported by higher PLT 5-HT in patients with diarrhea predominant irritable bowel syndrome -LRB- d-IBS -RRB- , as compared with healthy controls -LRB- Houghton et al. , 2003 -RRB- , although this was not consistently found -LRB- Atkinson , Lockhart , Whorwell , Keevil , & Houghton , 2006 -RRB- . Patients with d-IBS have augmented GI motility , which is likely to cause increased exposure of their circulating PLT to 5-HT -LRB- Atkinson et al. , 2006 ; Gershon , 2005 ; Houghton et al. , 2003 -RRB- . Increased PLT 5-HT is also observed in patients with carcinoid tumors -LRB- Kema et al. , 2001 -RRB- . Carcinoid tumors derive from enterochromaffin cells and are characterized by high 5-HT production with diarrhea as a frequent symptom -LRB- Modlin , Kidd , Latich , Zikusoka , & Shapiro , 2005 -RRB- . Consequently , measurement of PLT 5-HT is used as a sensitive marker for the early diagnosis and the subsequent follow-up of patients with carcinoid tumors -LRB- Kema et al. , 2001 -RRB- . The aim of the present study was to investigate whether the subgroup of children with PDD having increased PLT 5-HT levels , is the same as the one exhibiting increased intestinal permeability as established by a SAT . Methods Patients Parents of patients with PDD -LRB- n = 31 -RRB- according to the DSM-IV TR -LRB- American Psychiatric Association , 1994 -RRB- were asked for the participation of their affected children via the local patient society and pediatricians . Oral and written informed consent were obtained . Information regarding comorbidity , medication , nutritional supplements and the prevalence of GI related complaints was obtained from medical records and with the aid of assisted questionnaires . The study was performed in Curaçao -LRB- The Netherlands Antilles -RRB- in the summer of 2004 . All collected urine and blood samples were transported in dry ice to the Netherlands for further analyses in the University Medical Center Groningen -LRB- UMCG -RRB- . The study was approved by the Medical Ethical Committee of the St. Elisabeth Hospital in Curaçao . Sugar Absorption Test The SAT was performed according to van Elburg et al. -LRB- 1995 -RRB- . Shortly , the patients ingested a sugar -LRB- lactulose , mannitol and sucrose -RRB- containing test fluid after an overnight fast . All urine voidings during the following 5 h were collected and pooled . Urinary sugars were analyzed by gas chromatography as previously described -LRB- Jansen , Muskiet , Schierbeek , Berger , & van der Slik , 1986 -RRB- . A urinary lactulose/mannitol -LRB- L/M -RRB- ratio above 0.090 was considered to be indicative for abnormal GI integrity/increased intestinal permeability -LRB- van Elburg et al. , 1995 -RRB- . Serotonin Assays For estimation of 5-HT turnover and exposure of PLT to 5-HT , we examined 24 h urinary excretion of 5-HIAA and total 5-HT -LRB- Kema et al. , 2001 -RRB- . For this , parents were asked to abstain their child completely from 5-HT containing foods -LRB- e.g. banana , pineapple , kiwi , walnuts -RRB- during collection and during the preceding 12 h . The volumes of the urine samples were measured before storing at − 20 °C . Urinary 5-HIAA and total 5-HT concentrations were determined as previously reported -LRB- Kema et al. , 2001 -RRB- . Urinary 5-HIAA values were evaluated with the use of age-dependent reference values -LRB- American Association for Clinical Chemistry , 2005 -RRB- . Non-fasting venous blood -LRB- for serum antibodies -RRB- and EDTA-anticoagulated blood -LRB- all other assays -RRB- were collected from children with PDD . EDTA-anticoagulated blood was placed on melting ice . Hematological indices were measured immediately after sampling . Within 1 h after collection a 1:1 mixture of K2EDTA and Na2S2O5 was added to PLT-rich plasma -LRB- PRP -RRB- to prevent oxidation of indoles . Plasma and serum were stored at − 80 °C . Simultaneous analysis of indoles -LSB- Tryp , 5-hydroxytryptophan -LRB- 5-HTP -RRB- , 5-HT and 5-HIAA -RSB- in PRP was performed as previously described -LRB- Kema et al. , 2001 -RRB- . PLT 5-HT data were compared with both a local cut-off value of 5.4 nmol/109 PLT -LRB- Meijer , Kema , Volmer , Willemse , & de Vries , 2000 -RRB- and an empiric cut-off value of 4.55 nmol/109 PLT -LRB- Mulder et al. , 2004 -RRB- . The local cut-off value represents the 97.5 th percentile of a reference group of healthy adults , that is employed in our laboratory for the diagnosis of carcinoid tumors . The empirical cut-off value represents the bottom of the valley of the PLT 5-HT bimodal distribution , as exhibited by patients with PDD . This value allows optimal classification into those who are normoserotonemic and hyperserotonemic . Platelet-rich-plasma Tryp data were evaluated with the use of age-dependent reference values -LRB- American Association for Clinical Chemistry , 2005 -RRB- . Exclusion of Celiac Disease Serum IgA anti-endomysium titers and HLA genotype were assessed to rule-out celiac disease , which is an established cause of increased GI permeability -LRB- van Elburg , Uil , Mulder , & Heymans , 1993 -RRB- . Statistics All data were analyzed using the Statistical Product and Service Solutions package , version 11.5 -LRB- SPSS Inc. . Chicago -RRB- . Data were tested for normality using the Shapiro -- Wilk W test . Group comparisons -LRB- normo - and hyperserotonemic -RRB- were performed with the Mann -- Whitney U test -LRB- non-parametric -RRB- . Spearman -LRB- non-parametric -RRB- tests were used to evaluate correlations at α = 0.05 , to minimize type-II errors . Results Patients We enrolled the first 24 -LRB- 77 % -RRB- of the 31 patients with PDD whose parents agreed to participate . Patient characteristics are reported in Table 1 . The parents reported 13/23 -LRB- 57 % -RRB- of their affected children to have one or more GI symptoms . Table 1Characteristics of patients with pervasive developmental disorders in Curaçao tested for platelet serotonin and intestinal permeabilityParameterGender -LRB- male/female -RRB- 18 -LRB- 75 % -RRB- / 6 -LRB- 25 % -RRB- Age -LRB- years -RRB- 9.9 -LRB- ± 3.9 -RRB- DSM-IV TR diagnoses 299.00 -LRB- autistic disorder -RRB- 8 -LRB- 33 % -RRB- 299.80 -LRB- PDD-NOS -RRB- 16 -LRB- 67 % -RRB- Ethnicity Caucasian8 -LRB- 33 % -RRB- African -- American13 -LRB- 54 % -RRB- Other3 -LRB- 13 % -RRB- Comorbidity Epilepsy5 -LRB- 22 % -RRB- Allergy2 -LRB- 9 % -RRB- Asthma1 -LRB- 4 % -RRB- Intestinal yeast infection1 -LRB- 4 % -RRB- Medication for comorbidity9 -LRB- 38 % -RRB- Nutritional supplements -LRB- vitamins/ω3-oils -RRB- 9 -LRB- 38 % -RRB- / 2 -LRB- 4 % -RRB- Diet -LRB- gluten and casein free -RRB- a2 -LRB- 9 % -RRB- Physical complaints related to GI tracta13 -LRB- 57 % -RRB- Nausea0 -LRB- 0 % -RRB- Vomiting1 -LRB- 4 % -RRB- Diarrhea4 -LRB- 17 % -RRB- Constipation4 -LRB- 17 % -RRB- Bloating and gaseousness8 -LRB- 35 % -RRB- an = 23 . PDD-NOS pervasive developmental disorder -- not otherwise specifiedData represent number -LRB- percentage -RRB- or mean -LRB- ± SD -RRB- for 24 patients , unless otherwise specified Because of cleanliness problems , no urine samples were obtained from one patient , while from another we only received urine for SAT . Blood sampling from yet another patient was problematic . Consequently , our study comprised urine for SAT from 23/24 patients , 24 h urine from 22/24 patients and blood samples from 23/24 patients . Table 2 shows the indices related to 5-HT turnover and intestinal permeability of these patients . Table 2Indices of serotonin -LRB- 5-HT -RRB- turnover and intestinal permeability in patients with pervasive developmental disorders in CuraçaoParameterReference values < RV ≥ RVPLT 5-HT -LRB- nmol/109 PLT -RRB- a3 .4 -LRB- 2.0 -- 7.1 -RRB- < 4.55 b6 -LRB- 26 % -RRB- < 5.4 c4 -LRB- 17 % -RRB- Tryp -LRB- μmol/l -RRB- a50 .0 -LRB- ± 10.9 -RRB- 2 -- 18y : 0 -- 79d0 -LRB- 0 % -RRB- 0 -LRB- 0 % -RRB- 2y : 35 -- 73d -RCB- 6y : 37 -- 76d3 -LRB- 13 % -RRB- 0 -LRB- 0 % -RRB- 16y : 54 -- 93d5-HIAA -LRB- μmol/24 h -RRB- e8 .4 -LRB- 3.9 -- 36.4 -RRB- 3 -- 8y : 2.1 -- 29.3 d -RCB- 9 -- 12y : 5.2 -- 32.9 d1 -LRB- 5 % -RRB- 1 -LRB- 5 % -RRB- 13 -- 17 : 4.7 -- 34.0 d > 18y : 5.2 -- 36.6d5-HT -LRB- nmol/24 h -RRB- e305 -LRB- ± 92 -RRB- Lactulose -LRB- mmol/5 h -RRB- f0 .024 -LRB- ± 0.11 -RRB- Mannitol -LRB- mmol/5 h -RRB- f1 .32 -LRB- ± 0.59 -RRB- L/M ratio -LRB- mol/mol -RRB- f0 .019 -LRB- ± 0.007 -RRB- < 0.090 g23 -LRB- 100 % -RRB- 0 -LRB- 0 % -RRB- aPlatelet-rich plasma , n = 23bEmpiric cut-off derived from Mulder et al. -LRB- 2004 -RRB- cUpper reference value derived from apparently healthy adults Meijer et al. -LRB- 2000 -RRB- dFrom reference American Association for Clinical Chemistry -LRB- 2005 -RRB- eAbout 24 h urine , n = 22fAbout 5 h urine from sugar absorption test , n = 23gFrom reference van Elburg et al. -LRB- 1995 -RRB- Data represent number -LRB- percentage -RRB- , median -LRB- range -RRB- or mean -LRB- ± SD -RRB- . RV ; reference value ; PLT , platelet ; Tryp , tryptophan ; 5-HIAA , 5-hydroxyindoleacetic acid ; L/M , lactulose/mannitol Sugar Absorption Test Intestinal permeability , reflected by the L/M ratio -LSB- median -LRB- range -RRB- 0.017 mol/mol -LRB- 0.008 -- 0.035 -RRB- -RSB- , indicated that none of the patients had increased intestinal permeability -LRB- i.e. L/M ratio ≥ 0.090 -RRB- . Serotonin Assays PLT 5-HT -LSB- median -LRB- range -RRB- : 3.4 -LRB- 2.0 -- 7.1 -RRB- nmol/109 PLT -RSB- was elevated in 4 -LRB- range : 5.7 -- 7.1 nmol/109 PLT -RRB- and 6 -LSB- range 4.6 -- 7.1 nmol/109 PLT -RSB- patients if compared to the local cut-off value -LRB- -LRB- Meijer et al. , 2000 -RRB- ; < 5.4 nmol/109 PLT -RRB- or the empirical cut-off value -LRB- -LRB- Mulder et al. , 2004 -RRB- ; < 4.55 nmol/109 PLT -RRB- , respectively . The sole patient exhibiting detectable levels of plasma 5-HIAA -LRB- 26.0 μmol/l -RRB- , also exhibited increased PLT 5-HT -LRB- 6.4 nmol/109 PLT -RRB- . However , this patient did not exhibit increased urinary total 5-HT or 5-HIAA excretions . Urinary excretion of 5-HIAA was within normal range . Exclusion of Celiac Disease None of the patients were positive for serum IgA anti endomysium and 8/23 -LRB- 35 % -RRB- patients had a genotype positive for either HLA-DQ2 -LRB- n = 5 -RRB- or HLA-DQ8 -LRB- n = 3 -RRB- . Based on the results of serology , none of the patients seemed to have celiac disease , although we did not perform further tests to exclude this . Statistics There was no correlation between PLT 5-HT and L/M ratio -LRB- p = .663 ; r = − .098 -RRB- . Patients exhibiting GI tract complaints did not have higher PLT 5-HT , higher L/M ratios , or higher 5-HIAA and total 5-HT 24 h urinary excretions -LRB- p > .4 -RRB- . Platelet 5-HT correlated with 24 h urinary 5-HIAA excretion -LRB- p = .034 ; r = .465 -RRB- . Also the 24 h excretion rates of 5-HIAA and total 5-HT showed a positive correlation -LRB- p = .005 ; r = .580 -RRB- . Discussion In this study of children with PDD we did not observe a relation between PLT 5-HT and intestinal permeability , as derived from the urinary L/M ratio . The number of children with PDD exhibiting increased PLT 5-HT was lower compared with reports of others . For instance , the recent study of Mulder et al. -LRB- 2004 -RRB- showed 23/81 -LRB- 28 % -RRB- of Dutch children with PDD to exhibit increased PLT 5-HT , using the same analytical method and a cut-off value of 5.4 nmol/109 PLT . Also our data on intestinal permeability contrast with previous reports -LRB- D'Eufemia et al. , 1996 ; Horvath et al. , 2002 -RRB- showing that 43 -- 76 % of children with autism have increased intestinal permeability , as established by a SAT . A weakness of the current study is its small size and the lack of a local age - and gender matched control group . We have , on the other hand , no indications for deviant reference values for PLT 5-HT or L/M ratios in Curaçao , as compared with The Netherlands . Age and gender do not appear to affect PLT 5-HT -LRB- Mulder et al. , 2004 -RRB- , but it must be noted that PLT 5-HT reaches highest levels during childhood and gradually decreases during adulthood -LRB- Flachaire et al. , 1990 -RRB- . Dependent on the cut-off values employed , we nevertheless found 4 and 6 patients with increased PLT 5-HT . Neither of these patients had abnormal intestinal permeability or L/M ratios residing in the upper range of normality . However , the positive correlation between PLT 5-HT levels and 24 h urine 5-HIAA , and also the relation between urinary 5-HIAA and urinary 5-HT , suggest that , also in PDD , exposure of PLT to 5-HT determines PLT 5-HT and its consistently found increase in a subgroup . It is possible that increased PLT 5-HT and GI permeability are not consistent features of children with PDD in time . Long term , e.g. monthly , monitoring of a well defined patient and control group may shed more light on this potential source of variance as a cause of the conflicting results found by several investigators . Differences in the activity of the 5-HT transporter based on genetic polymorphisms are unlikely , since these seem to have minor effects , if any , on PLT 5-HT levels -LRB- Mulder , 2006 -RRB- . In conclusion , the finding of a subgroup of children with PDD exhibiting hyperserotonemia was replicated . None of the children exhibited increased intestinal permeability , while PLT 5-HT was unrelated to both intestinal permeability and GI symptoms . Additional studies are needed to elucidate the etiology of increased PLT 5-HT in PDD and to establish its relation with intestinal pathology , if any .

O O O O O B O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O O B O O O O O B O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O O O O B O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

pervasive platelets serotonin gastrointestinal permeability


Play Behavior and Attachment in Toddlers with Autism Play helps to develop social skills . Children with autism show deviances in their play behavior that may be associated with delays in their social development . In this study , we investigated manipulative , functional and symbolic play behavior of toddlers with and without autism -LRB- mean age : 26.45 , SD 5.63 -RRB- . The results showed that the quality of interaction between the child and the caregiver was related to the development of play behavior . In particular , security of attachment was related to better play behavior . When the developmental level of the child is taken into account , the attachment relationship of the child with the caregiver at this young age is a better predictor of the level of play behavior than the child 's disorder . Introduction Play is important in the development of a child because it allows children to learn and practice new skills in safe and supportive conditions -LRB- Boucher 1999 -RRB- . In play children have the opportunity to develop not only motor skills but also cognitive and social skills -LRB- e.g. Pellegrini and Smith 1998 -RRB- . Play shows developmental steps ; cognitive development is reflected in , in order , manipulative , functional and symbolic or representational play . First children handle toys in oral and manipulative ways by feeling , licking , sniffing , turning them around , throwing them away , etc. . This manipulation creates opportunities to learn about different objects , relations , and about ways to interact and influence the direct environment -LRB- Gibson 1988 ; Piaget 1962 ; Ruff 1984 ; Williams 2003 -RRB- . Functional play develops at approximately 14 months of age -LRB- Bretherton 1984 -RRB- , and is defined by Ungerer and Sigman -LRB- 1981 -RRB- as ` the appropriate use of an object or the conventional association of two or more objects , such as a spoon to feed the doll , or placing a teacup on a saucer ' . The child assigns a function to an object that it contains in daily life , even when an object is miniaturized . Around 24 months of age , symbolic play emerges , although it is difficult to define the point at which play becomes truly ` symbolic ' -LRB- Jarrold et al. 1993 -RRB- . Symbolic play is considered a higher level of play , because it involves pretence , whereas pretence is not necessarily present in functional play . The social part in play development starts with the step from the child 's playing by itself to noticing the play of others . This social aspect develops further by participating in the play of others , which creates the opportunity to deal with ` interference ' of others and to develop cooperation skills . Play forms also the context for learning about trust , negotiation and compromise , and with these skills the child has the opportunity to form and maintain friendships -LRB- Jordan 2003 -RRB- . The quality of the relationship with the parent may have an impact on motivational aspects of play behavior as well as on the quality of play . A secure relationship with a trusted attachment figure optimizes the opportunity for the child to explore the environment under safe and supportive conditions -LRB- Ainsworth 1978 ; Bowlby 1982 -RRB- . Indeed it has been found that children with secure attachment relationships display more sophisticated , complex and diverse play during interaction with their mother and during solitary play -LRB- e.g. , Bornstein et al. 1996 ; Fiese 1990 ; Haight and Miller 1992 ; O'Connell and Bretherton 1984 ; Slade 1987 ; Tamis-LeMonda et al. 2002 -RRB- . Play Behavior and Autism One of the core deficits in autism is a severe deficit in social behavior . In children with Pervasive Developmental Disorders -LRB- PDD -RRB- this is demonstrated in play behavior at various levels . Deviations in play behavior can be detected in the first year of life -LRB- Ungerer and Sigman 1981 ; Van Berckelaer-Onnes 2003 -RRB- and continue through all phases of play development . The first phase of play development , which involves exploratory/manipulative behavior of objects , is in children with autism characterized by a number of unusual features . They tend to restrict their play to a limited selection of objects -LRB- Van Berckelaer-Onnes 2003 -RRB- , or even an isolated part of an object -LRB- Freeman et al. 1979 -RRB- . They prefer proximal senses of touch and taste above visual exploration -LRB- Williams 2003 -RRB- and can become intensely preoccupied for long periods of time with non-variable visual examination of just one object -LRB- Freeman et al. 1979 -RRB- , or non-play -LRB- Ruff 1984 -RRB- , which impairs further development of play -LRB- Van Berckelaer-Onnes 2003 -RRB- . Although several studies reported children with autism to produce the same number of functional acts under spontaneous as well as structured conditions -LRB- e.g. Baron-Cohen 1987 ; Van Berckelaer-Onnes 1994 ; Charman 1997 ; Lewis and Boucher 1988 ; Libby et al. 1998 ; Williams et al. 2001 -RRB- , it has also been found that children with autism spend significantly less time playing functionally than controls -LRB- Lewis and Boucher 1988 ; Jarrold et al. 1996 ; Sigman and Ungerer 1984 -RRB- , show lower levels of appropriate object use -LRB- Freeman et al. 1984 -RRB- , less variety in their functional play -LRB- Sigman and Ungerer 1984 -RRB- , more repetition -LRB- Atlas 1990 ; Williams et al. 2001 -RRB- and fewer functional acts -LRB- e.g. Mundy et al. 1990 ; Sigman and Ungerer 1984 ; Ungerer and Sigman 1981 -RRB- . Children with autism spectrum disorders -LRB- ASD -RRB- may experience particularly difficulties in symbolic play . When symbolic play is performed , their play behavior may be more like ` learned routine ' rather than spontaneous play -LRB- Williams et al. 2001 -RRB- . The lack of this particular type of play in the behavioral repertoire of children with autism does however not necessarily imply a specific impairment in their symbolic abilities . It might reflect a more general cognitive or social deficit associated with autism impinging on the whole range of play development -LRB- Jarrold et al. 1993 -RRB- . This Study Play behavior in children with autism has been studied before , under various circumstances and on different levels . However , most studies involved subjects older than 42 months of age . The control groups in these studies were mainly subjects matched on mental age -LRB- MA -RRB- , which created substantial differences in chronological age . In this study we investigated play behavior of children with and without ASD , but also of atypically and typically developing controls under the age of 36 months . Several domains of play behavior were analyzed to investigate differences in play behavior between clinical and non-clinical children , and between clinical children with and without ASD . Observing play behavior at this young age provides the opportunity to detect whether the basic play skills of children with ASD are disturbed , or whether the differences appear at a later age when higher levels of play are expected to be shown . We expected the ASD children to lag behind in their level of play behavior already from their first years of life . Play behavior in children with ASD was also examined in relation to attachment quality . We expected that ASD children with secure attachment relationships would be more playfully engaged and socially involved compared to insecurely attached children with the same disorder . Furthermore , as disorganized attachment is the most insecure type of attachment , it was expected that disorganized children would show more delay in ` social ' play behavior compared to children without disorganized attachment . Method Diagnostic Assessments This study was part of a study on early screening for autism . For further details regarding recruiting see Dietz et al. -LRB- 2006 -RRB- , and Swinkels et al. -LRB- 2006 -RRB- . The children were recruited between the age of 14 and 36 months , based on social developmental delay , but final psychiatric diagnosis was obtained at 42 months . Psychiatric examinations included a series of six visits that were scheduled within a period of 5 weeks . At each weekly visit , the social and communicative behavior of the child was observed in a small group of young children and their parents . The assessments included a standardized parental interview , developmental history , and the Vineland Social-Emotional Early Childhood Scales -LRB- Sparrow et al. 1997 -RRB- ; the Autism Diagnostic Interview -- Revised -LRB- ADI -- R ; Lord et al. 1994 -RRB- ; standardized behavior observation -LRB- Autism Diagnostic Observation Schedule ADOS-G ; DiLavore et al. 2000 -RRB- , and pediatric examination and medical work-up . On the basis of all available information , and on the basis of clinical judgment , a diagnosis was given by an experienced child psychiatrist . The inter-rater reliability for two diagnostic categories ; ASD or other than ASD was calculated . Agreement among three child psychiatrists -LRB- HvE , JB , ED -RRB- was reached in 92 % of 38 cases . Agreement corrected for chance was 0.74 -LRB- Cohen 's Kappa -RRB- . Agreement for all diagnostic categories was reached in 79 % of 38 cases . Agreement corrected for chance was 0.67 -LRB- Cohen 's Kappa -RRB- . Diagnostic discrepancies were resolved at a consensus meeting . If appropriate , children and their parents were offered `` care as usual '' . The cognitive level of the child was measured with the Mullen Scales of Early Learning -LRB- Mullen 1995 -RRB- . Diagnostic Groups Forty-one clinical children participated in this study . At the age of 42 months they were classified with AD -LRB- n = 12 ; mean age 30.25 months -LRB- SD 4.81 -RRB- and developmental level 51.17 -LRB- SD 4.06 -RRB- -RRB- , PDD-NOS -LRB- n = 11 ; mean age 27.73 months -LRB- SD 7.42 -RRB- and developmental level 71.36 -LRB- SD 15.98 -RRB- -RRB- , MR -LRB- n = 10 ; mean age 26.50 months -LRB- SD 5.38 -RRB- and developmental level 55.10 -LRB- SD 4.09 -RRB- -RRB- or LD -LRB- n = 8 ; mean age 27.75 months -LRB- SD 5.68 -RRB- and developmental level 83.63 -LRB- SD 8.48 -RRB- -RRB- . No difference in age was detected between the clinical groups , but developmental level was significantly different , F -LRB- 3 , 40 -RRB- = 23.44 , p < .01 . Besides the clinical diagnosis , the groups of children were also divided into the group ASD , including children with AD and PDD-NOS -LRB- n = 23 , mean age 29.04 months -LRB- SD = 6.18 -RRB- and a mean developmental level 60.83 -LRB- SD = 15.19 -RRB- -RRB- . The other group -LRB- non-ASD -RRB- contained children with the developmental disorders MR and LD -LRB- n = 18 , mean age 27.06 months -LRB- SD = 5.38 -RRB- , developmental level 67.78 -LRB- SD = 15.85 -RRB- -RRB- . No differences in age and developmental level were detected between clinical children with and without ASD . We included two control groups . One control group contained children who were referred to the hospital due to doubt about the development -LRB- AC -LRB- Atypical Controls -RRB- , n = 16 -RRB- . Clinical investigation , however , showed that these children were free from clinical diagnoses . The other control group recruited through well-baby clinics contained typically developing children -LRB- NC -LRB- normal controls -RRB- , n = 16 -RRB- . Based on parental reports and observations of the psychologists , these children were free from any child psychiatric disorder . The group of children with atypical development was younger -LRB- AC ; M = 20.50 , SD = 3.03 -RRB- compared to the typical developing control group -LRB- NC ; M = 28.00 , SD = 1.75 -RRB- , t = − 8.57 , p < .01 . Although the children in the atypical control group were not showing severe developmental delays , their overall developmental level was lower -LRB- AC ; M = 85.00 , SD = 10.46 -RRB- compared to the typically developing control group -LRB- NC ; M = 98.44 , SD = 12.18 -RRB- t = − 3.35 , p < .01 . However , no significant differences were detected in the play behavior of the both control groups . Descriptive characteristics of the children are presented in Table 1 . Table 1Characteristics of the various diagnostic groupsADPDDNOSMRLDACNCM -LRB- SD -RRB- M -LRB- SD -RRB- M -LRB- SD -RRB- M -LRB- SD -RRB- M -LRB- SD -RRB- M -LRB- SD -RRB- Total12111081616Boy/Girl8/48 / 38/28/013 / 36/10Age30 .25 -LRB- 4.81 -RRB- 27.73 -LRB- 7.42 -RRB- 26.50 -LRB- 5.38 -RRB- 27.75 -LRB- 5.68 -RRB- 20.50 -LRB- 3.03 -RRB- 28.00 -LRB- 1.75 -RRB- Dev . level51 .17 -LRB- 4.06 -RRB- 71.36 -LRB- 15.98 -RRB- 55.10 -LRB- 4.09 -RRB- 83.63 -LRB- 8.48 -RRB- 85.00 -LRB- 10.46 -RRB- 98.44 -LRB- 12.18 -RRB- Aut . Symp .36.25 -LRB- 5.99 -RRB- 21.55 -LRB- 14.19 -RRB- 23.30 -LRB- 9.86 -RRB- 7.38 -LRB- 2.97 -RRB- 11.13 -LRB- 6.85 -RRB- Security of Attachment − 1.96 -LRB- 3.03 -RRB- 1.06 -LRB- 3.34 -RRB- − 1.28 -LRB- 3.57 -RRB- 2.19 -LRB- 2.52 -RRB- 1.54 -LRB- 2.32 -RRB- 2.17 -LRB- 1.86 -RRB- Disorg . of Attachment5 .17 -LRB- 2.95 -RRB- 2.82 -LRB- 2.64 -RRB- 4.00 -LRB- 3.04 -RRB- 2.00 -LRB- 2.33 -RRB- 2.40 -LRB- 2.41 -RRB- 1.50 -LRB- 1.10 -RRB- Attachment classification Insecure-avoidant212000 Secure3627613 Insecure-ambivalent022023 Disorganized723120 Measures Strange Situation Procedure Ainsworth -LRB- Ainsworth et al. 1978 -RRB- developed the SSP to observe the attachment behavior of the child towards the mother in a standardized and stressful laboratory setting . The SSP was coded by two trained observers -LRB- SS & MBK -RRB- , who were blind for the diagnoses of the children . Agreement for the four attachment classifications -LRB- n = 28 -RRB- corrected for chance was .74 -LRB- Cohen 's Kappa -RRB- . Besides the attachment classifications , we also used the simplified Richters et al. -LRB- 1988 -RRB- algorithm to compute continuous scores for attachment security -LRB- Van IJzendoorn and Kroonenberg 1990 -RRB- on the basis of the interactive SSP scale scores for proximity seeking , contact maintaining , resistance and avoidance . Disorganization was coded using the Main and Solomon -LRB- 1990 -RRB- 9-point rating scale for disorganized/disoriented attachment . Play Behavior Play behavior was observed according to protocol . The child and the mother were left in the room for ten minutes . The mother was instructed not to stimulate the child to play but to join when the child asked for cooperation in this free play situation . All children received the same set of toys . Videotapes were coded by means of ` The Observer ' -LRB- Noldus 1991 -RRB- using an ethogram developed to analyze the play behavior of 2-year-old children , who can not speak or speak very little . The behaviors mouthing , manipulative play , exploration , functional play , representational play 1 and 2 , container play , grouping and stacking 1 and 2 were defined by Largo and Howard -LRB- 1979 -RRB- . Doll directed play and relational play were derived from Williams et al. -LRB- 2001 -RRB- . Fenson et al. -LRB- 1976 -RRB- provided descriptions of the behaviors symbolic acts and banging . From Leslie 's -LRB- 1987 -RRB- definitions of symbolic play , only subject substitution was used . The various play behaviors were categorized in manipulative , functional or symbolic play , and these variables were used in the analyses . The amount of time that a child spent actually playing was calculated as the percentage of time the child played of the total time of the play session . The amounts of time the child performed manipulative , functional and/or symbolic play , were calculated as percentages of the time spent playing . When the child did not play , it would typically show other behaviors such as sitting passively . Reliability among the three coders for play behavior was based on 50 % of the videotapes . Agreement was reached in 92 % of 38 cases . Mean agreement corrected for chance was 0.74 -LRB- Cohen 's Kappa -RRB- . The variable ` level of play ' was calculated based on the three different levels of play behavior ; manipulative , functional and symbolic play . Durations of the three kinds of play behavior were included in the calculation with the following formula : -LRB- -LRB- 1 x duration of manipulative play -RRB- + -LRB- 2 x duration of functional play -RRB- + -LRB- 3 x duration of symbolic play -RRB- -RRB- / total duration of play . Differential weights were thus assigned to the social and cognitive levels of play . The variable ` change toys ' was based on the frequency per minute the child initiated play with another toy . The preference of toys was measured by calculating which toys were preferred most during play . Correlations between play behavior , child characteristics and attachment related variables are presented in Table 2 . Table 2Correlations between play , characteristics of children and attachment related variablesAge Developmental levelAttachment security Attachment disorganizationManipulative playFunctional playSymbolic playLevel of playDuration of playNumber of autistic characteristics .23 − .66 ** − .47 ** − .41 ** .28 * − .20 − .19 − .23 − .08 Age in months -- − .21.01 − .00 − .02.06.03.08.07 Developmental level -- .43 ** − .44 ** − .33 ** .30 * .21.35 ** .19 Attachment security -- − .49 ** − .00.08.09.14.14 Attachment disorganization -- .05 − .23 − .09 − .30 * − .30 * Manipulative play -- − .59 * − .15 − .38 ** .08 Functional play -- − .20.78 ** .66 ** Symbolic play -- .37 ** .10 Level of play -- .87 *** Correlation is significant at the .05 level ** Correlation is significant at the .01 level Analyses Play Behavior and Clinical Diagnoses No gender differences were found for the variables ` duration of play ' , ` manipulative ' , ` functional ' and ` symbolic ' play , the ` overall level of play ' and ` change toys ' . Analyses started with an overall analysis -LRB- ANOVA -RRB- for all groups , taking differences in developmental level and age into account . Next , differences between the clinical groups with and without ASD were analysed . Preference for toys was investigated using ANOVA for the whole sample , taking differences in developmental level and age into account , and for clinical children with and without ASD . Contribution of Attachment To examine whether security of attachment and attachment disorganization contributed to differences in play behavior and preference for toys , analyses with attachment were performed overall , in clinical children and in the group of children with ASD . Play behaviors and preference of toys of children with and without secure attachment , and children with and without disorganized attachment were analyzed . Results Duration of Play Behavior No differences were detected for duration of play time after controlling for difference in age and developmental level -LRB- F -LRB- 5 , 72 -RRB- = 1.87 , p = .11 -RRB- . Also , no differences were detected between clinical children with and without ASD -LRB- t = − 1.09 , p = .29 -RRB- . Mean values for the play variables are presented in Table 3 . Table 3Duration , level and type of play , and change of toys of the various diagnostic groupsDuration of play -LRB- % time -RRB- Level of playChanging toys -LRB- freq/min -RRB- nM -LRB- SD -RRB- M -LRB- SD -RRB- M -LRB- SD -RRB- AD 1257.32 -LRB- 22.24 -RRB- 15.66 -LRB- 7.29 -RRB- .04 -LRB- .01 -RRB- PDDNOS 1168.19 -LRB- 12.61 -RRB- 20.00 -LRB- 5.05 -RRB- .05 -LRB- .02 -RRB- MR 1070.20 -LRB- 10.73 -RRB- 18.47 -LRB- 5.03 -RRB- .05 -LRB- .02 -RRB- LD 866.38 -LRB- 22.45 -RRB- 20.96 -LRB- 8.74 -RRB- .04 -LRB- .02 -RRB- AC 1669.50 -LRB- 15.03 -RRB- 21.47 -LRB- 5.89 -RRB- .05 -LRB- .02 -RRB- NC 1677.19 -LRB- 15.67 -RRB- 24.00 -LRB- 5.34 -RRB- .05 -LRB- .02 -RRB- Manipulative playFunctional playSymbolic playnM -LRB- SD -RRB- M -LRB- SD -RRB- M -LRB- SD -RRB- AD 1222.86 -LRB- 20.68 -RRB- 32.28 -LRB- 20.62 -RRB- 2.19 -LRB- 7.35 -RRB- PDDNOS 1124.90 -LRB- 18.32 -RRB- 34.74 -LRB- 19.55 -RRB- 8.54 -LRB- 12.43 -RRB- MR 1032.38 -LRB- 18.65 -RRB- 35.01 -LRB- 21.32 -RRB- 2.81 -LRB- 5.08 -RRB- LD 817.91 -LRB- 10.05 -RRB- 37.53 -LRB- 26.57 -RRB- 10.93 -LRB- 10.99 -RRB- AC 1614.66 -LRB- 9.33 -RRB- 50.36 -LRB- 20.48 -RRB- 4.49 -LRB- 7.45 -RRB- NC 1615.62 -LRB- 14.95 -RRB- 56.33 -LRB- 21.61 -RRB- 5.25 -LRB- 7.55 -RRB- Manipulative , Functional and Symbolic Play Overall analysis showed no differences for percentage of time actually spent on manipulative -LRB- F -LRB- 5 , 72 -RRB- = 1.00 , p = .43 -RRB- , functional -LRB- F -LRB- 5 , 72 -RRB- = 2.08 , p = .08 -RRB- , or symbolic play -LRB- F -LRB- 5 , 72 -RRB- = 1.32 , p = .27 -RRB- when differences in age and developmental level were taken into account . Mean values of the percentage of time for the three different forms of play are presented in Table 3 . Neither were differences detected for manipulative play between clinical children with and without ASD -LRB- t = − .38 , p = .71 -RRB- , for functional play between clinical children with and without ASD -LRB- t = − .39 , p = .70 -RRB- , and for symbolic play between clinical children with and without ASD -LRB- t = − .39 , p = .70 -RRB- , when differences in age and developmental level were taken into account . Mean values of the percentage of time for the three different forms of play for clinical children with and without ASD are presented in Table 4 . Table 4Play behaviors of children with and without ASDDuration of play -LRB- % time -RRB- Level of playChanging toys -LRB- freq/min -RRB- nM -LRB- SD -RRB- M -LRB- SD -RRB- M -LRB- SD -RRB- ASD 2362.52 -LRB- 18.72 -RRB- 17.74 -LRB- 6.56 -RRB- .04 -LRB- .02 -RRB- Non-ASD 1868.50 -LRB- 16.50 -RRB- 19.58 -LRB- 6.82 -RRB- .04 -LRB- .02 -RRB- Manipulative play -LRB- % time -RRB- Functional play -LRB- % time -RRB- Symbolic play -LRB- % time -RRB- nM -LRB- SD -RRB- M -LRB- SD -RRB- M -LRB- SD -RRB- ASD 2323.84 -LRB- 19.17 -RRB- 33.46 -LRB- 19.96 -RRB- 5.23 -LRB- 10.38 -RRB- Non-ASD 1825.95 -LRB- 16.75 -RRB- 36.13 -LRB- 23.09 -RRB- 6.42 -LRB- 8.98 -RRB- Level of Play Level of play , taking differences in developmental level and age into account , did not show any differences between the different groups -LRB- F -LRB- 5 , 72 -RRB- = 1.20 , p = .32 -RRB- . Mean values of the level of play are presented in Table 3 . Moreover , no differences were detected between clinical children with and without ASD either -LRB- t = − .87 , p = .39 -RRB- , see Table 4 . Preference for Toys and Change of toys Analyses were performed for the duration of play that the children were involved with the toys ` car ' , ` doll ' , ` puzzle ' , ` daily utensils ' , bricks ' , ` book ' and ` ball ' , to analyze whether there were any differences in preference for toys . Again , differences in age and developmental level were taken into account . An overall difference was found for playing with ` daily utensils ' F -LRB- 5 , 72 -RRB- = 2.53 , p = .04 . Children with AD spent significant less time playing with daily utensils . Overall differences were also found for reading a book , F -LRB- 5 , 72 -RRB- = 2.61 , p = .03 and playing with a puzzle F -LRB- 5 , 72 -RRB- = 3.11 , p = .01 . No differences were detected between children with and without ASD for the time spent playing with daily utensils and playing with a puzzle . However , children with ASD spent significantly less time -LRB- M = 2.12 , SD = 4.60 -RRB- reading a book compared to clinical children without ASD -LRB- M = 13.11 , SD = 17.62 -RRB- , t = − 2.88 , p < .01 . No differences were detected for changing toys in the overall group , taking differences in age and developmental level into account F -LRB- 5 , 72 -RRB- = .47 , p = .80 . Mean values of the frequency of changing toys are presented in Table 3 . There were also no differences between the clinical children with and without ASD -LRB- t = .37 , p = .72 -RRB- , see Table 4 . Quality of Attachment and Play Children with a secure attachment showed higher levels of play -LRB- M = 21.74 , SD = 6.32 -RRB- compared to children without secure attachment -LRB- M = 18.24 , SD = 6.61 -RRB- , t = − 2.18 , p = .03 . However , because of the higher percentages of secure attachment in children without a clinical disorder , the difference was also tested in the group of children with clinical diagnoses . In the clinical group children with secure attachment -LRB- M = 20.88 , SD = 7.02 -RRB- showed significantly higher levels of play than children without a secure attachment relationship -LRB- M = 16.35 , SD = 5.73 -RRB- as well , t = − 2.20 , p = .04 . Children with ASD who were securely attached spent more time playing symbolic play compared to children with ASD without a secure attachment -LRB- t = − 2.37 , p = .03 -RRB- . Level of play was also higher in children with ASD with a secure attachment relationship compared to children with ASD without a secure attachment relationship -LRB- t = − 3.27 , p < .01 -RRB- -LRB- Fig. 1 -RRB- . Moreover , children with ASD with a secure attachment relationship spent more time actually playing compared to children with ASD without a secure attachment relationship -LRB- t = − 2.74 , p = .01 -RRB- . The differences within the group of children with ASD with and without secure attachment relationships remained significant after taking differences in age and developmental level into account ; for symbolic play F -LRB- 1 , 23 -RRB- = 4.47 , p = .05 , for level of play F -LRB- 1 , 23 -RRB- = 8.88 , p < .01 , and for duration of play F -LRB- 1 , 23 -RRB- = 7.19 , p = .01 , see Table 5 . Fig. 1Secure and disorganized attachment and mean level of play in children with ASDTable 5Play behaviors of children with ASD with and without secure and disorganized attachmentDuration of play -LRB- % time -RRB- Level of playChanging toys -LRB- freq/min -RRB- nM -LRB- SD -RRB- M -LRB- SD -RRB- M -LRB- SD -RRB- ASD-nonB 1454.99 -LRB- 20.16 -RRB- a * 14.78 -LRB- 5.65 -RRB- a * .04 -LRB- .02 -RRB- ASD-B 974.22 -LRB- 7.09 -RRB- a * 22.33 -LRB- 5.25 -RRB- a * .05 -LRB- .02 -RRB- ASD-nonD 1470.74 -LRB- 12.46 -RRB- b * 20.24 -LRB- 5.38 -RRB- b * .05 -LRB- .02 -RRB- ASD-D 949.73 -LRB- 20.22 -RRB- b * 13.84 -LRB- 6.58 -RRB- b * .04 -LRB- .01 -RRB- Manipulative playFunctional playSymbolic playnM -LRB- SD -RRB- M -LRB- SD -RRB- M -LRB- SD -RRB- ASD-nonB 1422.77 -LRB- 18.59 -RRB- 30.74 -LRB- 19.82 -RRB- 1.48 -LRB- 4.40 -RRB- a ** ASD-B 925.50 -LRB- 21.08 -RRB- 37.67 -LRB- 19.87 -RRB- 11.05 -LRB- 14.22 -RRB- a ** ASD-nonD 1427.40 -LRB- 21.07 -RRB- 35.98 -LRB- 16.78 -RRB- 7.36 -LRB- 12.31 -RRB- ASD-D 918.30 -LRB- 15.25 -RRB- 29.53 -LRB- 24.09 -RRB- 1.90 -LRB- 5.44 -RRB- aASD-B versus ASD non-BbASD-D versus ASD non-D * p < .05 , ** p < .01 Disorganized Attachment Relationship and Play Children with a disorganized attachment classification showed lower levels of play -LRB- M = 16.39 , SD = 6.83 -RRB- than children without a disorganized attachment classification -LRB- M = 21.32 , SD = 6.20 -RRB- , t = 2.51 , p = .02 . Within the clinical group no difference was shown for level of play of children with and without disorganized attachment . However , children without a disorganized attachment relationship spent more time playing -LRB- M = 69.29 , SD = 15.67 -RRB- compared to children with a disorganized attachment classification -LRB- M = 55.50 , SD = 19.28 -RRB- t = 2.25 , p = .04 . Children with ASD with disorganized attachment showed lower levels of playing than children with ASD without disorganized attachment -LRB- t = 2.44 , p = .03 -RRB- , see Fig. 1 . This difference remained significant after taking differences in age and developmental level into account , F -LRB- 1 , 23 -RRB- = 5.29 , p = .03 . Moreover , children with ASD without disorganized attachment spent more time playing compared to children with ASD with disorganized attachment -LRB- t = 11.94 , p = .02 -RRB- . Again , the difference remained significant after taking differences in age and developmental level into account , F -LRB- 1 , 23 -RRB- = 9.40 , p < .01 -LRB- see Table 5 -RRB- . Children with and without secure or disorganized attachment relationships did not differ on preference for toys . Discussion Our findings highlight the importance of attachment in the development of play of children with autism and other developmental disorders . Attachment quality explained play behavior regardless of the clinical status of the children . Taking developmental level of the child into account , we found that children with a secure attachment relationship spent more time playing . They also showed a higher level of play and more symbolic play behavior . Children with a disorganized attachment relationship spent less time playing , and within the group of children with ASD disorganized attachment was related to lower levels of play . Our earliest understanding about the world and our own actions may have a social rather that a cognitive origin -LRB- Hobson 2002 ; Jordan 2003 ; Vygotsky 1978 -RRB- . Social deficits belong to the core deficits of children with autism . Nevertheless , children with autism are able to develop a secure attachment relationship with the primary caregiver -LRB- Naber et al. 2007 ; Rutgers et al. 2004 -RRB- , which contributes to better play outcomes in children with autism . We indeed found that children with secure attachment relationships showed more exploration and higher levels of play , whereas children with disorganized attachment showed less exploration , even after controlling for developmental level . Especially in children with autism the quality of attachment relationship was associated with the development of ` social ' play . Unexpectedly , for duration of play , level of play or changing toys no differences were detected between children with and without ASD , or even between children with and without a developmental disorder , after controlling for developmental level . Nevertheless , similar to Williams et al. -LRB- 2001 -RRB- , we found that children with autism preferred toys that were based on ` simpler ' play behavior . Children with autism did not prefer daily utensils or books to play with . Several explanations may account for the absence of a difference in most play variables . First , we used a free play situation with the mother . Although the parents were instructed only to follow the child leads and not to structure the setting , the presence of the parent may have motivated the child to continue playing . Second , the lower levels of play behavior typical for this young age period may still be within the reach of children with autism . At a later age , when the children are expected to show symbolic play behavior at higher levels , differences in the amount or quality of symbolic play may emerge . Third , play behavior in children with autism may show delays compared to other children -LRB- Beyer and Gammeltoft 2000 ; Howlin 1986 ; Lord 1984 ; Lord and Magill 1989 ; Wolfberg 1999 -RRB- , but as Jarrold -LRB- 2003 -RRB- pointed out , the absence of pretend/symbolic play in children with autism may result from assessing individuals who are -LRB- mentally -RRB- too young to be expected to show pretend/symbolic play . In the current young age group few children showed much symbolic play , and no difference emerged . Fourth , we used ethological measures to observe play behavior in an objective manner , but the context and coherence or patterning of the behavior was not taken into account . A more holistic approach with global ratings of play behavior may uncover differences between children with and without autism . Limitations of the Study Although studies of play behavior are required at an early age to get more insight into its development , the young age of the children is also a limitation because symbolic play was not yet in reach of many subjects in the current study . However , retrospective parental reports and screening studies mention differences in play behavior already at this young age . Longitudinal studies are needed to follow the development of these children 's play across time to see whether differences in play behavior arise at a later stage , and to examine whether the effects of a positive attachment relationship are lasting . Conclusions and Future Research As pointed out in a review of Jarrold et al. -LRB- 1993 -RRB- , studies that indicate a lack of symbolic play behavior in children with autism can not be seen as convincing proof of the inability of the child to produce this type of play , because MA matched controls would be needed . In our study , we matched the clinical groups both on chronological and on MA . Due to this matching we were able to compare play behavior of children with and without autism . We found no differences in play between children with and without ASD . This may be due to the mental and chronological age of the toddlers included in our study ; the lower levels of play behavior typical for this age period may still be within the reach of children with autism . At a later age , children with autism may start to lag behind which might be shown in delayed and infrequent occurrence of symbolic play . We hope to follow-up the current sample to test this interpretation . What we did find were striking differences between children with and without secure or disorganized attachment relationships . The quality of the parent-child relationship appears to contribute substantially to the development of play in young children regardless of their autistic symptoms . Intervention studies based on play behavior have shown to positively contribute to the development of play in children with ASD during the intervention period . However , no long-term effects have been documented . Our findings show the importance of attachment and suggest that interventions focusing on the improvement of play behavior of children with autism should also focus on enhancing the quality of the attachment relationship . The early intervention study with PDD children by Mahoney and Perales -LRB- 2005 -RRB- explored this approach in stimulating cognitive , communicative and socio-emotional functioning . Attachment-based video-feedback intervention has been proven to be effective in typically developing children -LRB- Bakermans-Kranenburg et al. 2003 ; Juffer et al. 2007 -RRB- and this approach might not only in the short run but also long-term lead to improvement of quality of attachment as well as level of play behavior in children with autism .

B I O B O O O B O O O O O O O O O B O O O O B I O O O O O O O O O O O O O O O O O O O O O O B I O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O B O O O O B I O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O B O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O B I O O O B O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O B I O O O B O

attachment
autism
developmental disorder
play behavior