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Play intervention and Children with ASD
Prof. Karen Stagnitti
Deakin University
Amaze Conference
2014
Karen Stagnitti (c) July 2014
Today’s presentation
Play is a powerful intervention
Why children with ASD would benefit
Pretend play
Pretend play and children with ASD
Learn to Play program
Research and case studies
Karen Stagnitti (c) July 2014
“To be truly competent in the world
children must be able to do more than repeat a string of facts…they must understand more than laws governing the physical world….To exist successfully within the world requires an understanding of people…”
Westby, 1991, p. 131
Karen Stagnitti (c) July 2014
Understanding people
Is gained through a child playing
Children observe and imitate others
Reproduce what they see in their play
Experiment with social situations, emotions
Self-initiate their own play = organising their brain (Ayres, 1972) and deeper learning
Extend beyond the literal = problem solving
Flexibility
Cooperating and negotiating with others in play
Play is safe, non-threatening
Children do their own risk assessments within play
Karen Stagnitti (c) July 2014
Why children with ASD would benefit
Difficulties in play is a characteristic of children with ASD
Play – pretend play – involves social competence, flexible thinking, symbols and stories, and social-emotional regulation
Understanding a child’s pretend play gives valuable information about how a child engages within their world
Mostly play ability is not directly addressed in many interventions
Building self-initiated play ability is EMPOWERING for a child
Karen Stagnitti (c) July 2014
Pretend play
Understanding a pretend scenario requires children to:
Go beyond the literal Understand the imposed meaning Interact meaningfully with others in social
interaction To ‘see’ the ‘invisible’ Understand context of a situation Self-initiate
Karen Stagnitti (c) July 2014
Play scripts
Body
Within the home
Outside the home
Fantasy – characters from books, TV etc
Anything can happen
Karen Stagnitti (c) July 2014
Sequences of play actions
Repetitive and illogical
Simple, logical sequential actions
Late 3 years – play strategy
Play over 2-3 days
Play over 2-3 weeks
Karen Stagnitti (c) July 2014
Object substitution
Manipulate objects
Use a physically similar looking object for intended object
Use same object for 2 or more representations
Use body and imaginary objects
Use any object – doesn’t look anything like the represented
Karen Stagnitti (c) July 2014
Social interaction
Imitate others
Observe others
Associative play
Cooperate and negotiate
Karen Stagnitti (c) July 2014
Doll/teddy play
Place doll in correct position
Doll does things on their own
Doll has emotions
Doll has its own life
Karen Stagnitti (c) July 2014
Role play
Imitate others
Observe others
Imitate a characteristic of someone
Short periods of time in role
Several roles within a play scene
Same role within the play scene
Karen Stagnitti (c) July 2014
Embeds other types of play
Pretend play – as understood here – embeds other types of play
Children can impose pretend play on other play skills, such as gross motor play or fine motor play
Karen Stagnitti (c) July 2014
Karen Stagnitti (c) July 2014
Play scripts Sequences of play action
Object substitution Social Role Play Doll/Teddy
Body 1 pretend action Functional use of objects
Imitates a pretend action
Carries out actions previously seen
1 action
in home 2-3 similar actions. illogical
similar looking object Imitates object substitution
As above Child sits doll in chair
in and out of the home
simple, logical actions
1 object = 2 functions Child asks for objects needed in play
imitates others The doll can do things
personally experienced but less frequent life events
Detailed logical actions.
1 object = many uses Parallel play. Short Doll wakes up, an abstract doll
Themes include TV, books, computer games etc.
Child uses multiple logical play actions
uses blocks to build a wall.
Associative play Role play is fluid a doll’s house.
As Above a play strategy Child uses body parts and imaginary objects
As above As above Doll is a character – good, bad, naughty
Sub-plots occur in play
a planned storyline use an object with a distinct function
Cooperative, negotiate
several roles own character
anything at all. sequences are pre-planned organised, logical and have sub-plots. Complex storylines
language As Above same role Doll live its own life
Symbolic play
Construction play
Socio-dramatic Or Dramatic play
Role play
Thematic Fantastic play
Pretend play develops before narrative ability begins
2 years – Children can tell a story about themselves. They tell stories before they can read.
2-3 years – Children attempt fictional storytelling
3 years – Children begin to develop narrative ability
3 – 5 years – Children move from description of objects and events, to temporal sequencing of actions relevant to solving a problem
Preschoolers can tell stories and their storytelling can be enhanced.
School age – Majority of children possess a basic repertoire of narrative abilities.
3rd grade – Children tell complete stories
11 or 12 years of age – children reach a peak in their ability to tell oral narratives. The average child has mastered story grammar.
Karen Stagnitti (c) July 2014
Development Of Narrative
Pretend Play and Narrative Development
Understanding narrative intrinsically relates to a child’s ability to forward think or ‘predict’ what will happen. That is, children understand what the character’s plans are and what is going to happen.
Problem solving in the narrative gives
children exposure to divergent problem solving skills.
Karen Stagnitti (c) July 2014
Social interaction
Social interaction is significantly related to elaborate pretend play
Social disruption is negatively related to symbolic play – particularly object substitution
Social disconnection is negatively related to elaborate symbolic play
Karen Stagnitti (c) July 2014
Pretend play – overlaps with TOMM (Whitehead et al., 2009)
Medial prefrontal cortex (ToMM, mentalising, emotion)
Temporo-parietal junction
Inferior frontal gyrus
Posterior superior temporal sulcus (ToMM, emotional gestures)
Anterior medial prefrontal cortex
Temporal poles (ToMM, emotional gestures)
Amygala
Right posterior superior temporal sulcus
Ventrolateral prefrontal areas (narrative)
Orbitomedial prefrontal cortex (narrative)
Posterior cingulate (role play, narrative)
Inferior parietal and dorsolaterial frontal (role play, narrative)
Karen Stagnitti (c) July 2014
Pretend play – overlaps with narrative (Whitehead et al., 2009)
Medial prefrontal cortex (ToMM, mentalising, emotion)
Temporo-parietal junction
Inferior frontal gyrus
Posterior superior temporal sulcus (ToMM, emotional gestures)
Anterior medial prefrontal cortex
Temporal poles (ToMM, emotional gestures)
Amygala
Right posterior superior temporal sulcus
Ventrolateral prefrontal areas (narrative)
Orbitomedial prefrontal cortex (narrative)
Posterior cingulate (role play, narrative)
Inferior parietal and dorsolaterial frontal (role play, narrative)
Karen Stagnitti (c) July 2014
Children with ASD - play deficits
Children do not change easily from one activity to another – they lack flexibility and adaptability.
Doll play usually not played with in a representational way
Play action sequences are poor or limited Linked to poor narrative Object substitutions may be present but usually
only associated with 1 action ‘chunking templates’ may be observed child may or may not imitate experimentation with objects may be the main
form of play Repetition of play actions Seeing only the literal meaning Do not understand the play of their peers
Karen Stagnitti (c) July 2014
Learn to Play program
“Learn to Play”
Program designed to increase the spontaneous initiation of pretend play
Developmentally based program
Suitable for children from 12-18 months developmental age
Successful if children have focused attention, meaningful 1 word, or gesture at 18 months level or higher
It is a DYNAMIC INTERACTIVE PROGRAM
Karen Stagnitti (c) July 2014
Learn to Play with children with ASD
begin with structure
start on the child’s pretend play developmental level
shift the child’s attention by interrupting and/or challenging the play (eg, you move their parked car)
use protodeclarative pointing (i.e., the toy is over there and you point as you say it)
use emotions associated with the play e.g., scared, happy, tired, sad, surprised
focus on developing logical, sequential sequences of play actions
only use play scripts that the child has had some life experience of
you will need to repeat play scenes but also
use a variety of play scenes from the same developmental level
remove structure as the child begins to initiate play
Karen Stagnitti (c) July 2014
Child’s developmental level of pretend play
Play themes
Sequences of action
Object substitution
Social
Role play
Doll/Teddy
Establish the child’s developmental play age
Karen Stagnitti (c) July 2014
Child’s developmental level of pretend play
Choose developmentally appropriate play activities
Repeat Play activity
Variety of activities Amount of toys
& objects
Use emotions Have fun
General Overview of Model
Allow opportunity for child to
initiate
Challenge child Karen Stagnitti (c) July 2014
Level 1: 18mths-2.5 years
Karen Stagnitti (c) July 2014
Developmental level across 6 developmental skills
Repeat x 3
Variety on same level
“More play ideas”
5 activities per 1 hour session Limited amount
of toys & Objects
Challenge When child
Is ready
Emphasis on • engaging the child • encouraging the child to imitate
To begin
Karen Stagnitti (c) July 2014
Developmental level across 6 developmental skills
Repeat x 2
Variety on same level
“More play ideas”
3 activities per 1 hour session Expand amount
of toys & Objects
Challenge Challenge
Extend sequences
When children begin to add one action to the play
Karen Stagnitti (c) July 2014
Developmental level across 6 developmental skills
Variety of play themes And
Ability to add 1 activity per 1 hour session
Expand amount of toys & Objects
Challenge with problems to narrative
Extend sequences
Expand
Learn to Play
You give power to the child
You have an idea of where to start and introduce a play idea
You watch the reaction of the child
You are usually on the floor not a table
You supply the exact toys /materials you need
You only add or change the play direction if it instigated by the child.
You are not ‘secure’ in total control, although you are monitoring all the time where the play is going
Karen Stagnitti (c) July 2014
General Principles
Start on the child’s level
Repeat play activity (Minimum 3 times >++)
If child not coping either, lower developmental level or remove some of the toys
Allow opportunity for the child to initiate ideas in the play scene.
Work on several skills at once.
Allow for challenge in the activities by introducing an activity from a higher developmental level.
Karen Stagnitti (c) July 2014
Neurplastic principles
1. focussed attention
2. starting simple = where the child’s development is
3. repetition with variation
4. pretend play, language and social skills ‘fire together’
5. use of symbols = higher abstract thought
6. play is relevant to a child’s daily life = meaningful
7. You play with your child (seeking)
8. Child-initiated
(neuroplastic principles from Diodge, 2010)
Karen Stagnitti (c) July 2014
Power of Learn to Play
Generalise to home and early childhood settings
HAPPY
Increase in language
Increase in social turn-taking
7 sessions
2 years of sessions
Karen Stagnitti (c) July 2014
2006
Multiple case study design
4 children diagnosed with ASD
Offered fortnightly sessions for 3 months
Resulted in 6-7 sessions
Honours student – Siobhan Merchant
Karen Stagnitti (c) July 2014
Papers
Analysed for Important Markers in Pretend Play
Stagnitti, K. & Casey, S. (2011). The Learn to Play program con bambinis con autismo: practical considerations and evidence. Autismo Oggi, 20, 8-13. (in Italian)
Analysed for Process of Learn to Play
Stagnitti, K. (2009). The Learn to Play program. In K. Stagnitti & R. Cooper (eds). Play as therapy: assessment and therapeutic interventions. Jessica Kingsley Publishers: London.
Karen Stagnitti (c) July 2014
Major findings
3 of the 4 children reached “Freedom in Play” in 7 sessions.
Freedom in Play = able to attach emotion and character to the dolls showing attention to detail being flexible in play increasing control of the play seeing the potential for the play materials Increased use of language.
None of the ‘Freedom in Play’ attributes were noted in the first session. Initially, EI workers were pessimistic about any improvements.
Karen Stagnitti (c) July 2014
Pretend play markers
Representation Pretend play related behaviours
Freedom in Play
Attributing a property
Reference to an absent object
Initiate one action
Asking for objects for play
Attention to detail
Initiating a sequence of actions
Object substitution
Attributed an emotion to themselves
Attributed emotions and character to a
doll
Increasing ability to decentre
Understood potential for use of the play
materials
Social play – turn taking
Following emotional engagement child increased control
of the play
Increased language utterances
Flexible in play
Changes seen in EI settings
Pretend Play Ability
Karen Stagnitti (c) July 2014
Parent program
Parents reported increase in play knowledge
Parents reported increase in valuing play
Parents reported “of all the therapy…yours is the most effective because I see the change at home”
Karen Stagnitti (c) July 2014
Benefits of Learn to Play
After 3 months increase in:
child’s language
child’s ability to play independently
time engaged in self-initiated play
child’s use of symbols in play
child’s ability to interact with others
child’s ability to initiate play ideas
greater flexibility in coping with new play ideas
Karen Stagnitti (c) July 2014
Specialist school
1 group with a play program (Learn to Play)
1 group comparison (no play)
O’Connor, C. & Stagnitti, K. (2011). Play, Behaviour, Language and Social Skills: The Comparison of a Play and a Non-Play Intervention within a Specialist School Setting. Research in Developmental Disabilities, 32, 1205-1211.
Karen Stagnitti (c) July 2014
Bill
Began with only 1 action (feed doll a doll using a spoon), no symbols in play. Elaborate symbolic play ability 2.5%
Finished responding to dolls as if real, sequences up to 15 minutes, use of symbols in play, enjoyment playing
Elaborate symbolic play 40%. Spontaneous object substitution = 3.
Writing books over Christmas 2010
Karen Stagnitti (c) July 2014
Ned
6 year old boy
ID and autism
Language but no pretend play
First session: working hard to engage him
By 8 weeks in, mother reported his ability to self-initiate play at home.
After program finished on pretend play level at 2.5 years. Play at home with his sister for 2 hours at a time. Language improved.
4 years later he has come back – play skills remained on level but didn’t move
He is beginning to increase in focus and follow through
Karen Stagnitti (c) July 2014