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Semin Speech Lang 2022; 43(04): 331-346
DOI: 10.1055/s-0042-1750348
Review Article

Playing to Pretend or “Pretending” to Play: Play in Children with Autism Spectrum Disorder

Carol Westby
1   Bilingual Multicultural Services in Albuquerque, Albuquerque, New Mexico
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Abstract

Children diagnosed with autism spectrum disorder (ASD) exhibit early delays and deficits in play. In infancy, they engage in unusual exploratory behaviors with toys. As toddlers, they are slow to develop functional play, and in preschool some children with ASD fail to develop symbolic play despite having the necessary cognitive and language skills. Furthermore, when children with ASD are engaged in play, they demonstrate less playfulness. This article reviews the literature on the characteristics of exploratory, functional, and symbolic/pretend play in children with ASD and possible reasons for their unusual patterns of play development. Increased quantity and quality of play are frequent therapeutic goals for children with ASD. If play interventions are to be successful, it is critical that speech-language pathologists have an adequate assessment of children's play skills. Several frameworks and tools appropriate for assessing play in typical children and children with ASD are described.

Keywords

autism spectrum disorder - theory of mind - functional play - symbolic play - naturalistic developmental behavior intervention


Publication History

Article published online:
27 July 2022

© 2022. Thieme. All rights reserved.

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  • References

  • 1 Russ SW. Play in Child Development and Psychotherapy: Toward Empirically Supported Practice. Routledge; 2003
    CrossrefGoogle Scholar
  • 2 Singer JL, Singer DG. Preschoolers' imaginative play as precursor of narrative consciousness. Imagin Cogn Pers 2005; 25 (02) 97-117
    CrossrefPubMedGoogle Scholar
  • 3 Berk LE, Mann TD, Ogan AT. Make-believe play: wellspring for development of self-regulation. In: Singer DG, Golinkoff RM, Hirsh-Pasek K. eds. Play=Learning: How Play Motivates and Enhances Children's Cognitive and Social-Emotional Growth. New York: Oxford University Press; 2006: 74-100
    Google Scholar
  • 4 Hirsh-Pasek K, Golinkoff RM, Berk LE, Singer GE. A Mandate for Playful Learning in the Preschool: Presenting the Evidence. New York: Oxford University Press; 2009
    Google Scholar
  • 5 Hughes FP. Children, Play, and Development. Los Angeles: SAGE Publications; 2021
    Google Scholar
  • 6 Kanner L. The specificity of early infantile autism. Z Kinderpsychiatr 1958; 25 (1-2): 108-113
    PubMedGoogle Scholar
  • 7 Thiemann-Bourque K, Johnson LK, Brady NC. Similarities in functional play and differences in symbolic play of children with autism spectrum disorder. Am J Intellect Dev Disabil 2019; 124 (01) 77-91
    CrossrefPubMedGoogle Scholar
  • 8 Leslie AM. Pretense and representation: the origins of “theory of mind.”. Psychol Rev 1987; 94 (04) 412-426
    Google Scholar
  • 9 Sigman M, Ungerer JA. Cognitive and language skills in autistic, mentally retarded, and normal children. Dev Psychol 1984; 20 (02) 293-302
    CrossrefPubMedGoogle Scholar
  • 10 Thompson BN, Goldstein TR. Disentangling pretend play measurement: defining the essential elements and developmental progression of pretense. Dev Rev 2019; 52: 24-41
    CrossrefPubMedGoogle Scholar
  • 11 Parten MB. Social participation among pre-school children. J Abnorm Soc Psychol 1932; 27 (03) 243-269
    CrossrefPubMedGoogle Scholar
  • 12 Guralnick MJ, Hammond MA. Sequential analysis of the social play of young children with mild developmental delays. J Early Interv 1999; 22 (03) 243-256
    CrossrefPubMedGoogle Scholar
  • 13 Wintre MG. Changes in social play behavior as a function of preschool programs. J Educ Res 1989; 82 (05) 294-301
    CrossrefPubMedGoogle Scholar
  • 14 Xu Y. Children's social play sequence: Parten's classic theory revisited. Early Child Dev Care 2010; 180 (04) 489-498
    CrossrefPubMedGoogle Scholar
  • 15 Skard G, Bundy AC. Test of Playfulness. Play in Occupational Therapy for Children. Elsevier; 2008. :71–93
    Google Scholar
  • 16 Naber FB, Bakermans-Kranenburg MJ, van Ijzendoorn MH. et al. Play behavior and attachment in toddlers with autism. J Autism Dev Disord 2008; 38 (05) 857-866
    CrossrefPubMedGoogle Scholar
  • 17 Williams E. A comparative review of early forms of object-directed play and parent-infant play in typical infants and young children with autism. Autism 2003; 7 (04) 361-377
    CrossrefPubMedGoogle Scholar
  • 18 Ozonoff S, Macari S, Young GS, Goldring S, Thompson M, Rogers SJ. Atypical object exploration at 12 months of age is associated with autism in a prospective sample. Autism 2008; 12 (05) 457-472
    CrossrefPubMedGoogle Scholar
  • 19 Kaur M, Srinivasan SM, Bhat AN. Atypical object exploration in infants at-risk for autism during the first year of lifer. Front Psychol 2015; 6: 798
    CrossrefPubMedGoogle Scholar
  • 20 Miller M, Sun S, Iosif AM. et al. Repetitive behavior with objects in infants developing autism predicts diagnosis and later social behavior as early as 9 months. J Abnorm Psychol 2021; 130 (06) 665-675
    CrossrefPubMedGoogle Scholar
  • 21 Sidhu J, Barlas N, Lifter K. On the meanings of functional play: a review and clarification of definitions. Top Early Child Spec Educ 2020; doi: 0271121420951859
    PubMedGoogle Scholar
  • 22 Lifter K, Bloom L. Object knowledge and the emergence of language. Infant Behav Dev 1989; 12 (04) 395-423
    CrossrefPubMedGoogle Scholar
  • 23 Papaeliou C, Sakellaki K, Papoulidi A. The relation between functional play and other forms of cooperation and word learning in ASD. Int Arch Commun Disord 2019; (02) 1-12
    PubMedGoogle Scholar
  • 24 Williams E, Reddy V, Costall A. Taking a closer look at functional play in children with autism. J Autism Dev Disord 2001; 31 (01) 67-77
    CrossrefPubMedGoogle Scholar
  • 25 Christensen L, Hutman T, Rozga A. et al. Play and developmental outcomes in infant siblings of children with autism. J Autism Dev Disord 2010; 40 (08) 946-957
    CrossrefPubMedGoogle Scholar
  • 26 Fanning PAJ, Sparaci L, Dissanayake C, Hocking DR, Vivanti G. Functional play in young children with autism and Williams syndrome: a cross-syndrome comparison. Child Neuropsychol 2021; 27 (01) 125-149
    CrossrefPubMedGoogle Scholar
  • 27 Sparaci L, Northrup JB, Capirci O, Iverson JM. From using tools to using language in infant siblings of children with autism. J Autism Dev Disord 2018; 48 (07) 2319-2334
    CrossrefPubMedGoogle Scholar
  • 28 Lam YG. Symbolic play in children with autism. In: Patel VB. et al, eds. Comprehensive Guide to Autism. New York: Springer; 2014: 551-567
    Google Scholar
  • 29 Wing L, Gould J. Severe impairments of social interaction and associated abnormalities in children: epidemiology and classification. J Autism Dev Disord 1979; 9 (01) 11-29
    CrossrefPubMedGoogle Scholar
  • 30 Charman T, Swettenham J, Baron-Cohen S, Cox A, Baird G, Drew A. Infants with autism: an investigation of empathy, pretend play, joint attention, and imitation. Dev Psychol 1997; 33 (05) 781-789
    CrossrefPubMedGoogle Scholar
  • 31 Jarrold C. A review of research into pretend play in autism. Autism 2003; 7 (04) 379-390
    CrossrefPubMedGoogle Scholar
  • 32 Riguet CB, Taylor ND, Benaroya S, Klein LS. Symbolic play in autistic, Down's, and normal children of equivalent mental age. J Autism Dev Disord 1981; 11 (04) 439-448
    CrossrefPubMedGoogle Scholar
  • 33 Ungerer JA, Sigman M. Symbolic play and language comprehension in autistic children. J Am Acad Child Psychiatry 1981; 20 (02) 318-337
    CrossrefPubMedGoogle Scholar
  • 34 Jarrold C, Boucher J, Smith PK. Generativity deficits in pretend play in autism. Br J Dev Psychol 1996; 14 (03) 275-300
    CrossrefPubMedGoogle Scholar
  • 35 Lewis V, Boucher J. Generativity in the play of young people with autism. J Autism Dev Disord 1995; 25 (02) 105-121
    CrossrefPubMedGoogle Scholar
  • 36 Charman T, Baron-Cohen S. Brief report: prompted pretend play in autism. J Autism Dev Disord 1997; 27 (03) 325-332
    CrossrefPubMedGoogle Scholar
  • 37 Rutherford MD, Young GS, Hepburn S, Rogers SJ. A longitudinal study of pretend play in autism. J Autism Dev Disord 2007; 37 (06) 1024-1039
    CrossrefPubMedGoogle Scholar
  • 38 Kasari C, Chang Y-C, Patterson S. Pretending to play or playing to pretend: the case of autism. Am J Play 2013; 6 (01) 124-135
    PubMedGoogle Scholar
  • 39 Benson JD, Nicka MN, Stern P. How does a child with sensory processing problems play?. Internet J Allied Health Sci Pract 2006; 4 (04) 4
    PubMedGoogle Scholar
  • 40 Wolfberg P, Bottema-Beutel K, DeWitt M. Including children with autism in social and imaginary play with typical peers: Integrated Play Groups Model. Am J Play 2012; 5 (01) 55-80
    PubMedGoogle Scholar
  • 41 Chan P-C, Chen C-T, Feng H, Lee Y-C, Chen K-L. Theory of mind deficit is associated with pretend play performance, but not playfulness, in children with autism spectrum disorder. Hong Kong J Occup Ther 2016; 28 (01) 43-52
    CrossrefPubMedGoogle Scholar
  • 42 Chen K-L, Chen C-T, Lin C-H, Huang C-Y, Lee Y-C. Prediction of playfulness by pretend play, severity of autism behaviors, and verbal comprehension in children with autism spectrum disorder. Neuropsychiatr Dis Treat 2019; 15: 3177-3186
    CrossrefPubMedGoogle Scholar
  • 43 Hobson RP, Lee A, Hobson JA. Qualities of symbolic play among children with autism: a social-developmental perspective. J Autism Dev Disord 2009; 39 (01) 12-22
    CrossrefPubMedGoogle Scholar
  • 44 Lee YC, Chan PC, Lin SK. et al. Correlation patterns between pretend play and playfulness in children with autism spectrum disorder, developmental delay, and typical development. Res Autism Spectr Disord 2016; 24: 29-38
    CrossrefPubMedGoogle Scholar
  • 45 Román-Oyola R, Figueroa-Feliciano V, Torres-Martínez Y. et al. Play, playfulness, and self-efficacy: Parental experiences with children on the autism spectrum. Occup Ther Int 2018; 2018: 4636780
    CrossrefPubMedGoogle Scholar
  • 46 Jarrold C, Conn C. The development of pretend play in autism. The Oxford Handbook of the Development of Play. Oxford Handbooks; 2011
    Google Scholar
  • 47 Baron-Cohen S. Mindblindness: An Essay on Autism and Theory of Mind. MIT Press; 1997
    Google Scholar
  • 48 Dore RA, Smith ED, Lillard AS. How is theory of mind useful? Perhaps to enable social pretend play. Front Psychol 2015; 6: 1559
    PubMedGoogle Scholar
  • 49 Bigham S. Impaired competence for pretense in children with autism: exploring potential cognitive predictors. J Autism Dev Disord 2010; 40 (01) 30-38
    CrossrefPubMedGoogle Scholar
  • 50 Russell JE. Autism as an Executive Disorder. Oxford University Press; 1997
    Google Scholar
  • 51 Faja S, Dawson G, Sullivan K, Meltzoff AN, Estes A, Bernier R. Executive function predicts the development of play skills for verbal preschoolers with autism spectrum disorders. Autism Res 2016; 9 (12) 1274-1284
    CrossrefPubMedGoogle Scholar
  • 52 Frith U. Autism: Explaining the Enigma. Blackwell Publishing; 2003
    Google Scholar
  • 53 Jordan R. Social play and autistic spectrum disorders: a perspective on theory, implications and educational approaches. Autism 2003; 7 (04) 347-360
    CrossrefPubMedGoogle Scholar
  • 54 Baron-Cohen S. Autism, hypersystemizing, and truth. Q J Exp Psychol (Hove) 2008; 61 (01) 64-75
    Google Scholar
  • 55 Sigman M, Ruskin E, Arbeile S. et al. Continuity and change in the social competence of children with autism, Down syndrome, and developmental delays. Monogr Soc Res Child Dev 1999; 64 (01) 1-114
    PubMedGoogle Scholar
  • 56 Lovaas OI. Behavioral treatment and normal educational and intellectual functioning in young autistic children. J Consult Clin Psychol 1987; 55 (01) 3-9
    CrossrefPubMedGoogle Scholar
  • 57 McEachin JJ, Smith T, Lovaas OI. Long-term outcome for children with autism who received early intensive behavioral treatment. Am J Ment Retard 1993; 97 (04) 359-372 , discussion 373–391
    PubMedGoogle Scholar
  • 58 Gresham FM, MacMillan DL. Autistic recovery? An analysis and critique of the empirical evidence on the Early Intervention Project. Behav Disord 1997; 22 (04) 185-201
    CrossrefPubMedGoogle Scholar
  • 59 Smith T, Lovaas OI. The UCLA young autism project: a reply to Gresham and MacMillan. Behav Disord 1997; 22 (04) 202-218
    CrossrefPubMedGoogle Scholar
  • 60 Schreibman L, Dawson G, Stahmer AC. et al. Naturalistic developmental behavioral interventions: Empirically validated treatments for autism spectrum disorder. J Autism Dev Disord 2015; 45 (08) 2411-2428
    CrossrefPubMedGoogle Scholar
  • 61 Greenspan SI, Wieder S. Engaging Autism: Using the Floortime Approach to Help Children Relate, Communicate, and Think. Da Capo Lifelong Books; 2006
    Google Scholar
  • 62 Gutstein SE, Burgess AF, Montfort K. Evaluation of the relationship development intervention program. Autism 2007; 11 (05) 397-411
    CrossrefPubMedGoogle Scholar
  • 63 Sussman F, Lewis RB. More Than Words: A Guide to Helping Parents Promote Communication and Social Skills in Children with Autism Spectrum Disorder. Hanen Centre Toronto; 1999
    Google Scholar
  • 64 Prelock PA, McCauley RJ. Treatment of Autism Spectrum Disorders. Baltimore, MD: Brooks Publishing; 2012
    Google Scholar
  • 65 Kasari C, Freeman S, Paparella T. Joint attention and symbolic play in young children with autism: a randomized controlled intervention study. J Child Psychol Psychiatry 2006; 47 (06) 611-620
    CrossrefPubMedGoogle Scholar
  • 66 Rogers SJ, Dawson G. Early Start Denver Model for Young Children with Autism: Promoting Language, Learning, and Engagement. Guilford Publications; 2020
    Google Scholar
  • 67 Sandbank M, Bottema-Beutel K, Crowley S. et al. Project AIM: autism intervention meta-analysis for studies of young children. Psychol Bull 2020; 146 (01) 1-29
    CrossrefPubMedGoogle Scholar
  • 68 Sandbank M, Bottema-Beutel K, Woynaroski T. Intervention recommendations for children with autism in light of a changing evidence base. JAMA Pediatr 2021; 175 (04) 341-342
    CrossrefPubMedGoogle Scholar
  • 69 Zosh JN, Hopkins EJ, Jensen H. et al. Learning through Play: A Review of the Evidence. Billund, Denmark: LEGO Fonden; 2017
    Google Scholar
  • 70 Stagnitti K. The Child Initiated Pretend Play Assessment (ChIPPA)[kit]. West Brunswick, Victoria, Australia: Co-ordinates Publications; 2007
    Google Scholar
  • 71 Lewis V, Boucher J. The Test of Pretend play: ToPP. Psychological Corporation; 1997
    Google Scholar
  • 72 Lewis V, Boucher J, Lupton L, Watson S. Relationships between symbolic play, functional play, verbal and non-verbal ability in young children. Int J Lang Commun Disord 2000; 35 (01) 117-127
    CrossrefPubMedGoogle Scholar
  • 73 Westby CE. Children's Play: Reflections of Social Competence. Thieme Medical Publishers; 1988. :1–14
    Google Scholar
  • 74 Westby C, Wilson D. Using pretend play to promote foundations for text comprehension. Top Lang Disord 2017; 37 (03) 282-301
    CrossrefPubMedGoogle Scholar
  • 75 Hendrix R, Palmer K, Tarshis N, Winner M. We Thinkers! Volume 2: Social Problem Solvers. Social Thinking Publishing; 2016
    Google Scholar
  • 76 Kasari C, Gulsrud AC, Shire SY, Strawbridge C. The JASPER Model for Children with Autism: Promoting Joint Attention, Symbolic Play, Engagement, and Regulation. Guilford Publications; 2021
    Google Scholar
  • 77 Luckett T, Bundy A, Roberts J. Do behavioural approaches teach children with autism to play or are they pretending?. Autism 2007; 11 (04) 365-388
    CrossrefPubMedGoogle Scholar