play intervention and children with asd

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


“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


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


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


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


Development of pretend play 12 months to 5 years


Play scripts

Body

Within the home

Outside the home

Fantasy – characters from books, TV etc

Anything can happen


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


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


Social interaction

Imitate others

Observe others

Associative play

Cooperate and negotiate


Doll/teddy play

Place doll in correct position

Doll does things on their own

Doll has emotions

Doll has its own life


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


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



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

Narrative Story telling


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.


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.


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


Pretend play and the brain


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)


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)


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


Learn to Play program Stimulates the brain


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


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


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


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


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



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



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


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.


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)


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


Research Study 1


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


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.


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.


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


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”


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


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.


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


Development continued after the program


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


thankyou Question?


play intervention and children with asd

Documents