Play intervention and
Children with ASD
Prof. Karen Stagnitti
Deakin University
Amaze Conference
2014
Karen Stagnitti (c) July 2014
 Play is a powerful intervention
 Why children with ASD would benefit
Today’s
presentation
 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
 Is gained through a child playing
 Children observe and imitate others
 Reproduce what they see in their play
 Experiment with social situations, emotions
Understanding
people
 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
 Difficulties in play is a characteristic of children with
ASD
Why children
with ASD
would
benefit
 Play – pretend play – involves social competence,
flexible thinking, symbols and stories, and socialemotional 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
 Understanding a pretend scenario requires children
to:
Pretend play
 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
Development of
pretend play
12 months to 5 years
Karen Stagnitti (c) July 2014
 Body
 Within the home
Play scripts
 Outside the home
 Fantasy – characters from books, TV etc
 Anything can happen
Karen Stagnitti (c) July 2014
 Repetitive and illogical
Sequences of
play actions
 Simple, logical sequential actions
 Late 3 years – play strategy
 Play over 2-3 days
 Play over 2-3 weeks
Karen Stagnitti (c) July 2014
 Manipulate objects
Object
substitution
 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
 Imitate others
Social
interaction
 Observe others
 Associative play
 Cooperate and negotiate
Karen Stagnitti (c) July 2014
 Place doll in correct position
Doll/teddy
play
 Doll does things on their own
 Doll has emotions
 Doll has its own life
Karen Stagnitti (c) July 2014
 Imitate others
 Observe others
 Imitate a characteristic of someone
Role play
 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
Play scripts
Thematic
Fantastic
play
Sequences of play
action
Object substitution
Social
Role Play
Body
1 pretend action
Functional use of
objects
Imitates a
pretend action
in home
2-3 similar actions.
illogical
similar looking object
Imitates object
substitution
in and out of the
home
simple, logical
actions
1 object = 2 functions
imitates others
Child asks for
objects needed in
play
The doll can do
things
personally
Detailed logical
experienced but less actions.
frequent life events
1 object = many uses
Parallel play.
Short
Doll wakes up,
an abstract doll
Themes include TV, Child uses multiple
books, computer
logical play actions
games etc.
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 prelanguage
planned organised,
logical and have subplots. Complex
storylines
As Above
same role
Doll live its own
life
Karen Stagnitti (c) July 2014
Carries out
actions
previously seen
As above
Doll/Teddy
1 action
Child sits doll in
chair
Symbolic
play
Construction
play
Socio-dramatic
Or
Dramatic play
Role play
Karen Stagnitti (c) July 2014
Karen Stagnitti (c) July 2014
Karen Stagnitti (c) July 2014
Narrative
Story telling
Karen Stagnitti (c) July 2014
 Pretend play develops before narrative ability
begins
Development
Of
Narrative
 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
Pretend
Play and
Narrative
Developm
ent
 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 and
the brain
Karen Stagnitti (c) July 2014
 Medial prefrontal cortex (ToMM, mentalising,
emotion)
 Temporo-parietal junction
 Inferior frontal gyrus
Pretend play
– overlaps
with TOMM
(Whitehead et al., 2009)
 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
 Medial prefrontal cortex (ToMM, mentalising,
emotion)
 Temporo-parietal junction
 Inferior frontal gyrus
Pretend play
– overlaps
with
narrative
(Whitehead et al., 2009)
 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
Stimulates the brain
Karen Stagnitti (c) July 2014
 “Learn to Play”
 Program designed to increase the spontaneous
initiation of pretend play
Learn to Play
program
 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
 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)
Learn to
Play with
children
with ASD
 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
Establish the child’s developmental play age
Sequences
of action
Object
substitution
Social
Role play
Play themes
Child’s developmental
level of pretend play
Karen Stagnitti (c) July 2014
Doll/Teddy
General Overview of Model
Child’s developmental level
of pretend play
Choose developmentally
appropriate play activities
Use emotions
Have fun
Repeat
Play activity
Variety
of activities
Amount of toys
& objects
Allow opportunity
for child to
initiate
Challenge child
Karen Stagnitti (c) July 2014
To begin
Level 1:
Repeat x 3
18mths-2.5
years
Emphasis on
• engaging the
child
• encouraging
the child
to imitate
Variety on same
level
“More play ideas”
5 activities per Limited amount
1 hour session of toys & Objects
Developmental level across 6
developmental skills
Karen Stagnitti (c) July 2014
Challenge
When child
Is ready
When children begin to add one action to the play
Repeat x 2
Extend
sequences
Variety on same
level
“More play ideas”
3 activities per
1 hour session
Expand amount
of toys & Objects
Developmental level across 6
developmental skills
Challenge
Challenge
Karen Stagnitti (c) July 2014
Variety of play themes
And
Ability to add
Challenge
with problems
to narrative
Extend
sequences
1 activity per
1 hour session
Developmental level across 6
developmental skills
Karen Stagnitti (c) July 2014
Expand amount
of toys & Objects
Expand
 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
Learn to Play
 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
 Start on the child’s level
 Repeat play activity (Minimum 3 times
>++)
General
Principles
 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
 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’
Neurplastic
principles
 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
 Generalise to home and early childhood settings
 HAPPY
Power of
Learn to Play
 Increase in language
 Increase in social turn-taking
 7 sessions
 2 years of sessions
Karen Stagnitti (c) July 2014
Research
Study 1
Karen Stagnitti (c) July 2014
 Multiple case study design
 4 children diagnosed with ASD
2006
 Offered fortnightly sessions for 3 months
 Resulted in 6-7 sessions
 Honours student – Siobhan Merchant
Karen Stagnitti (c) July 2014
 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, 813. (in Italian)
Papers
 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
 3 of the 4 children reached “Freedom in
Play” in 7 sessions.
 Freedom in Play =
Major
findings






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
Ability
Pretend play
markers
Attributing a
property
Reference to an
absent object
Representation
Object substitution
Attributed an emotion
to themselves
Pretend play related
behaviours
Social play –
turn taking
Initiate one action
Attributed emotions
and character to a
doll
Asking for
objects for play
Following emotional
engagement child
increased control
of the play
Increasing ability
to decentre
Attention to
detail
Increased language
utterances
Understood potential
for use of the play
materials
Flexible in play
Initiating a sequence
of actions
Freedom in Play
Karen Stagnitti (c) July 2014
Changes seen
in EI settings
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
After 3 months increase in:
 child’s language
 child’s ability to play independently
Benefits of
Learn to Play
 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
 1 group with a play program (Learn to Play)
Specialist
school
 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
 Began with only 1 action (feed doll a doll using a
spoon), no symbols in play. Elaborate symbolic play
ability 2.5%
Bill
 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
Development
continued after the
program
Karen Stagnitti (c) July 2014
 6 year old boy
 ID and autism
 Language but no pretend play
 First session: working hard to engage him
Ned
 By 8 weeks in, mother reported his ability to selfinitiate 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
thankyou
Question?
Karen Stagnitti (c) July 2014