. \1';... fl\m lIlT). is _\;'."ist:lJ1t Director. Cknll)~tioJl;lI 1'he)';II))' Dep,lrtmem, Health S~'ien(es CemrC'. H20 Shnbmok Strcct, \Vinnipq!" fvfanitoba, R:3A lR9. The J-Imerican.lournal «/Occupalionat Therapy P lay has an important role in children's development. Reilly (1974) prorosed that the product of play is skill and that play assists children in mastering clevelopmental tasks These tasks include the development of habits necessary to assume complex roles in society (Neville, Kielhofner, & Royeen, 1985) . Play also offers children the opportunity [0 gain a sense of control over theil" environment (NeVille et 0,1.,1985) ,md to develop interests in aCtivities that are pleasing to them (Kielhafner, 1980). Autism is a developmental disorder. Children with auti,sm are a heterogeneous group with three central areas of dysfunction (Kaplan & Sadock, 1991). First, the child's ahilitv to panake in social interactions is qualitativelv impaired. Second, the chilel's ability to communicate and to engage in imaginative activity is also impaired. finallv, the child's activities and interests are severely restricted. The:>e areas of impairment manifest themselves in several behavioral characteristics that often include abnormalities in plav beh3vior. One puqx)se of this stud v lVas to comrarc the play of children with autism with the rial' of children without d)'sfunction in their homes This information may increase umJcrst:mding of the devc!ormenwl deficits and deviancies that 3re a:>sociated with autism and how they influence pia\' heh:1Vior This information also has pracriGIl implications. A.nah'sis of plav behaviors can help to determine areas of developmental dela\' or deviancy that Gill he addressed through treatment programs that use pJa\' as a therapeutic medium. The second rurpose ofthis sllId\' was to examine the relationships between children's rla\' performance and their communication, sociaL ami mowr ahilities. Undel'standing these relarion-:>Ilips may proVide conceptual information that can gUide treamenr Jxograms that usc l)lay to develop adaptive ahilities. Pre\'ious research h,lS pnwided .stl"Ong evidence of differences het\\een the plav of children \\lith autism ami that of children without c!l·.sf'unniun. This resC:1rch h<.1s focuseel on the diffcl"ences in rial' hehavior in three major areas social pia\', imaginative play, and variety of play. Several researchers have found differences in thc .soci:1I 1' 1<.1)' of childl-en with 'lutism. McH'lle (J983) found that chi](lren with autism spent a gl'earcr amount of time in sulit:lIY 1)1a\' than their no1' 111<11 Iv developing peers. Lord (1984) sUJllmari/cd several studies in which initi,ltions ancl t'esponses to interaction during plav tendecl to be low for children with autism. Mund\', Sigman, Ungerer, and SherJll,Hl (1987) f'ound that children with autism were less likel\' to initiate joint arrcntion with their play partner than were children \\ljth mental ret<lrdarion or children without dvsfunetion. Dewe)', Lord, and i\'!Jgill (1988) Clinicians and researchers have also reported an absence of imaginative activity during the play of children with autism. The cognitive deficits of many children with ~utigm m~y p~rti~lly ~ccount for thig ~bgence To control for the effect of mental age on play, Sigman and Ungerer (1984) used cognitive abilities to match children with autism, ranging in chronological age from 39 to 74 months, with children with mental retardation and children without dysfunction. The children with autism spent equal amounts of time in manipulation, relational play (putting two objects together), and functional play (using realistic objects in a way that reflects their intended use). In contrast, children without dysfunction and children with mental retardation both spent more time in functional play than in either manipulation or relational play. The children with autism were able to participate in mature forms of play, but did not use these abilities to the same extent as the other two groups of children. There may be qualitative differences in the play of children with autism that result from factors other than cognition. One factor that could account for some of these qualitative differences in pretend play relates to the social impairments of children with autism (Wing, 1988). For children without dysfunction in preschool settings, there is a positive relationship between cognitively complex and socially complex levels of play (Rubin, Watson, & Jambor, 1978) . Pretend play, a cognitively complex form of play, includes social qualities when children assume the roles of other people. To assume such roles, children must understand that other people have perspectives different from their own. This ability to attribute different intentions and beliefs to others is called theory of mind (Premack & Woodruff, 1978). Baron-Cohen, Leslie, and Frith (1985) showed that many children with autism lack the capacity to understand other people's perspectives. The lack of pretend play observed in many children with autism may result from cognitive impairments that relate to social understanding. The restricted and repetitive nature of play is another characteristic of children with autism. Children with autism spend considerable time in play behaviors (Baron-Cohen, 1987; Lewis & Boucher, 1988; Ungerer & Sigman, 1981). Their choices for play materials and play activities, however, are different in variety and type from those of children without dysfunction matched on cognitive measures. Wing (1988) suggested that restrictions in variety of play may be positively associated with the severity of cognitive impairment and may result, in part, from an unusual attachment to preferred objects. It is still not understood what properties influence these children's preference for certain objects or activities. The inherent structure in an activity may influence the toy preferences of children with autism. Dewey et al. (1988) found that children with autism preferred structured games and constructive activities over imaginative activities in contrast to children without dysfunction and children with behavior disorders who preferred imaginative activities. In contrast, children without dysfunction and children with behavior disorders preferred imaginativ~ ad;v;t;~$. Structure also may increase the cognitive complexity of autistic children's play. Gould (1986) found that the pretend play of a group of children who were socially impaired, including children with autism, was more complex during administration of a standardized play test than during observations in natural environments. Other studies have found that the play behavior of children with autism increases when other people proVide modeling and reinforcement (Tryon & Keane, 1986) , instruction, guidance, modeling, and reinforcement (Meyer et ai., 1987), prompting, reinforcement and self-management procedures (Stahmer & Schreibman, 1992), and imitation (Tiegerman & Primavera, 1981). In summary, previous research has suggested three areas of play in which children with autism may be different from their normally developing peers. The strongest evidence exists for differences in the social aspects of play. Differences in the imaginative aspects of play may not be evident if the child's cognitive ability is considered and the social aspects of play are controlled. Finally, children with autism may play with fewer types of toys than their normally developing peers. In the present study, our objective was to build on previous research in two ways. First, we examined the individual components of play, including social, imaginative, and motor play in the context of other components rather than in isolation. Second, we evaluated children's play in their homes, not in clinics or preschools. The home environment is familiar to children and can optimize their play behavior. Method Eight boys and one girl with autism between the ages of 3 and 6 years and nine children with normal development participated in the study. Children with mental ages of less than 18 months or with IQs of less than 30 were excluded from the study, as were those with severe physical handicaps. This ensured that all children had the cognitive ability to participate in many forms of play behavior and the mobility to make choices about their play experiences. Each child's parent had to speak and understand English to complete the Vineland Adaptive Behavior Scales (\lABS) (Sparrow, Balla, & Cicchetti, 1984) interview. Children were matched for gender, age, and socioeconomic status. Children were matched for gender because boys and girls have different preferences for play materials and activities by approximately 2 years of age (Rubin, Fein, & Vandenberg, 1983) . One was tested with the Coloured Progressive Matrices (Raven, 1965), and one with the Leiter International Performance Scale (Arthur, 1952). The mental ages of the children with normal development were assumed to equal their chronological age. Children whose parents expressed concern during questioning about their development or who scored more than one standard deviation higher or lower than the appropriate standard score mean on the VABS were excluded from the study (n = 3). This ensured that the children without d~lsfunction were neither advanced nor delaved for their chronological age. Children were matched for parental socioeconomic status because this factor may influence the social and cognitjve complexit)1 of children's play (Rubin, 1977: Smilansky, 1968) Parental socioeconomic staws (SES) was determined from parental reports of occupation based on Blishen, Carroll, and Moore's (1987) socioeconomic index for Canadian occupations. Scores were dichotomized into two levels (higher and lower) using the median scores for men and women. If both parents were employed, the score of the parent with the highest SES level was used. Seven matched pairs were in the higher SES level and twO matched pairs were in the lower SES level. Children with autism were recruited through a clinical psvchologist. They were diagnosed acconling to criteria from rhe Diagnostic and Statislical j1;'!c1l1ualfor ,'vlental Disorders, third edition (DSM !!!-R) (American Psychiatric Ass(\ciation, 1987) bv two experts a clinical psychologiSt who had extensive expertise in the field of autism and either anorher psvchologist or a psychiatrist. The children with normal developmcnt were chosen from groups whose parents had responded to request.s for volunteers froiD day care and church groups. All 18 mothers of the children in the final sample gave signed consent to participate. The mean mental age. chronological age, and maternal education of both group,s of chilcit-en are shown in Table 1 . No/e. n = 9 for both groups. The American Journal oj Occupational The'-apy Preschool Play Scale. We used the Preschool Play Scale (PPS) (Bledsoe & Shepherd, 1982; Knox, 1974) to measure play performance in a developmental framework, The scale has four dimensions: space management, material management, imitation, and participation. Childhood plav behaViors in I-year time I'eriods from birth to 6 years are combined into categories and described within these dimensions, The child is observed in a free play siru,ujon and rated according to the highest age level attained in each category, The mean of the category scores provides a climension score. The total score is calculated bv taking the mean of the dimension scores The PPS was modified in four ways. The music and books categories were eliminated from the imitation dimension and lerritmy and exploralion were eliminated from the space management dimension because of the limited number of observations that have been made in these categories in previous srudies (Bledsoe & Shepherd, 1982; Harrison & Kielhofner, 1986). Bundy (1989) omitted these categories when using the PPS to compare the plav of children with sensorv integrative dysfunction with that of children without (jysfunction. We made changes in the partici pation dimension because we did not observe the child's plav with peers in this study. The tl'pe catcgorv was eliminated, and the items in the language categorv that specifv communication to peers were changed to specifv adults. Finall)l, all categories of the imitation dimension were combined, because many items in thc different categories were similar and created dependencies in scoring separate categories, Procedures for the use of the PPS were pilot-tested with four preschool children. Interrater reliability was established between the investigatOr and a second experienced pediatric occupational therapist through use of videotapes of the children in the pilot test until point-bypoint agreement was 89% and the intraclass correlation coefficient was .77. During the study, these vicleOtapes were ~core(1 bv the investigator after observations of nine Downloaded from http://ajot.aota.org on 03/19/2019 Terms of use: http://AOTA.org/terms children as reliability criteria to help prevent observer drift. Interrater reliabilities for the PPS total and dimension scores were determined with randomly selected videotapes of two children with autism and two children with normal development who participated in the study. Intraclass correlation coefficients (ICCs) for the two independent raters were as follows: total score = 0.96; participation = 0.84; imitation = 1.00; space management = 0.50; material management = 0.94. AJI ICCs were within acceptable ranges except the space management dimension. On this dimension, the raters scored three out of four children identically and differed by one age level for the fourth child. Types ofplay materials. The total number of categories of materials played with by a child during the observation period was used as a measure of variety in the child's interest in play materials. The categories were adapted from Johnson and Ershler (1985) and were as follows: 1. Dramatic play materials included small vehicles, house play materials, dolls, dress up clothes, and toys representing farms, stores, fire halls and villages. building pieces (e.g., Lego pieces), puzzles, and modeling clay. ed a climbing apparatus, tricycles, scooters, balls, tops, rattles, and kaleidoscopes. Other toys included all objects that are commonly considered to be a child's toy or game but could not be classified elsewhere. intended for use as a child's toy (e.g., household objects and rocks). Interrater reliability was calculated for the total observation time and for an unstructured play period with Videotapes of four children. An ICC could not be determined for the number of play materials used during the total observation time because of the lack of variance in one rater's scores. Point-by-point agreement was .75. The ICC for the unstructured play period was .75. Vineland Adaptive Behavior Scales. The VABS is a standardized, norm-referenced evaluation of adaptive behavior of persons from birth to 18 years, 11 months of age. It is a useful tool for assessing the adaptive abilities of children with autism (Volkmar et aI., 1987; Watson & Marcus, 1988) . The survey form has the four behavior domains of communication, daily living skills, socialization, and motor skills. Age-equivalent scores are calculated for the adaptive behavior composite and each domain. Reliability and validity studies are described in the administration manual (Sparrow et aI., 1984) . Children were videotaped during free play in their homes in a room chosen by their parent. During the first 15 min, parents responded to their children when approached, but were instructed to intervene only to prevent injury to person or property. Immediately after the first observation period, the investigator asked the child and parent to sit together. The investigator showed the child several toys that she had brought with her. The toys represented the types of objects that elicit different levels of cognitive play: a small vehicle, a doll with clothes, colored blocks, a 4-piece puzzle, a lO-piece puzzle, a ball, a kaleidoscope, and a plastic container. Parents had the option of playing with their child during the second IS-min observation period. Thus, two different conditions were created. In the first condition, play was unstructured. In the second condition, structure was proVided by making specific toys and the child's parent available to the child. The second condition provided consistency in availability of play materials as well as a play partner so that the social elements of play could be observed. A set protocol was followed and modified slightly at times to respond to uncontrolled variables in the environment (e.g., the presence of a younger sibling at the time of the Videotaping). Efforts were made to limit the sibling's involvement in the subject's play. This situation occurred for two children with autism and for one child with normal development. Final play scores were calculated from the child's best performance rated during the two IS-min observation periods. This resulted in a total of 30 min of observation. Due to situational and technical difficulties, one autistic child and one normally developing child were scored on the basis of 29 min of observation. The investigator was blind to the mental ages of the children with autism and, as much as possible, to the chronological ages of the children without dysfunction. She was unaware of the matches between most of the children until the completion of the study. Most parents were interviewed with the VABS after the PPS observations were completed. Five children with autism had VABS scores from assessments that were completed by a clinical psychologist within the previous 2 to 4 months (M = 3 months). These scores were used instead of requiring the child's parent to repeat the interview. We analyzed the data with the SPSS-X statistical package (SPSS, 1988) on a mainframe computer system. The alpha level \-vas set at .05. To compensate for the increased chance of Type I errors when doing multiple I-tests, a procedure suggested by Ryan (1959) was followed. The alpha level of .05 was divided by the number of I-tests performed (five) resulting in a new alpha level of .01.  Results The group with autism had significantly lower PPS total scores (IV/ = 33.57 months; SD = 6.55) than the group with normal development (/VI = 42.53 months; SD = 6.11), I (16) = -3.00, P =008 (one-tailed). To determine whether the groups differed on any of the four PPS dimension scores that comprise the tOtal score, a Hotelling's Twas calculated with a multivariate analysis of variance procedure. This analysis yielded an exact F (4,13) of 3.30, p = .045 (see Table 2 ). Subsequent univariate Roy-Bargman stepdown F tests were also calculated to determine the contribution of each dimension to the variance while controlling for dependency between scores. The participation dimension was entered intO the equation first because this dimension was expected to show the greatest difference between groups. We also expected imitation and space management dimensions to contribute significantly to the differences. The material management dimension was entered last because no difference between groups was anticipated. Participation was the only dimension that contributed significantly to the differences bet\veen groups (see Table 3 ). Significant correlations among the four dimension scores could account for the lack of significant contributions to differences between groups by the dimensions that were entered into the equation after the participation dimension. Pearson correlations were used to determine whether there were significant associations between the four dimension scores. The dimension scores were not significantly correlated for either group. We used a I-test to calculate the number of play material categories used by each group. The mean total number of categories was identical for the two groups (N/ = 4.00). The group with autism had significantly lower VABS total scores (M = 2914 months; SD = 8.36) than the normally developing group (IV! = 5447 months; SD = 1145), t (16) = -5.36,p = .000). To determine the associations among PPS scores, VABS scores, and the mental or chronological age variable, Pearson correlations were calculated. PPS total scores were significantly correlated with VABS total scores for both the group with autism (r = .698,p = .037) and the group with normal development
Research suggests that since children with autism find it difficult to play with other children as well as participate in pretend play, it is particularly difficult for them to learn about social interaction REF .
Play and Preschool Children With Autism
The American journal of occupational therapy : official publication of the American Occupational Therapy Association
The American journal of occupational therapy : official publication of the American Occupational Therapy Association
Medicine