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A Preliminary Investigation of the Relationship Between Sensory Processing and Social Play in Autism Spectrum Disorder

Heather Miller Kuhaneck, PhD; Preston A. Britner, PhD

key words: autism, play, sensory motor performance

ABSTRACT

There are well-documented play deficits in autism beginning with infant object and social play. To create effective interventions, the predictors of play deficits in autism must be established. Individuals with autism spectrum disorder (ASD) frequently report sensory processing difficul- ties including poor praxis; however, these are potential predictors of play that have not been well studied. Using a data set of 162 individuals with ASD, this study examined the direct and indi- rect relationships between sensory processing and social play performance via structural equation modeling. The best fitting model suggested that sensory system functions predict praxis and play in combination, providing preliminary evidence that sensory functions are related to social play in combination with praxis in children with ASD. The findings suggest future avenues for research. [OTJR: Occupation, Participation and Health 2013;33(3):159-167.]

O ccupational therapists have long espoused the importance of play (Reilly, 1974). Play is one of the primary occupations of child-

hood and restrictions in play opportunities may deprive a child of a necessary developmental context (American Occupational Therapy Association, 2008a, 2008b) and meaningful and important childhood experiences. Many authors, as well as the American Academy of Pediatrics, have publicly recognized the importance of play for health and learning (Brown, 2009; Elkind, 2007; Ginsburg, American Academy of Pediatrics Committee on Communications, & American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health,

2007; Pellegrini, 2009). Play is also enjoyable and

may provide a type of “environmental enrichment” that influences neurologic functioning as it alters developmental trajectories in a positive manner. Autism spectrum disorder (ASD) is a develop- mental disorder with an unknown etiology. Preva- lence was recently reported as 1 in every 50 children in the United States (Blumberg et al., 2013). Primary characteristics of ASD include difficulties with so- cial interaction and communication and restricted and repetitive behaviors. Play deficits are also com- mon. A large body of literature has documented the atypical play of children with ASD (Dominguez, Ziviani, & Rodger, 2006; Hobson, Lee, & Hobson, 2009; Holmes & Procaccino, 2009; Holmes & Wil- loughby, 2005; Jarrold, 2003; Jordan, 2003; Williams,

Heather Miller Kuhaneck, PhD, is Assistant Professor, Department of Occupational Therapy, Sacred Heart University, Fairfield, Connecticut. Preston A. Britner, PhD, is Professor, Department of Human Development and Family Studies, University of Connecticut, Storrs, Connecticut. Submitted: January 3, 2013; Accepted: May 13, 2013 The authors have no financial or proprietary interest in the materials presented herein. Correspondence: Heather Miller Kuhaneck, PhD, Sacred Heart University, 5151 Park Avenue, Fairfield, CT 06825. E-mail:

kuhaneckh@sacredheart.edu doi: 10.3928/15394492-20130614-04

2003). These studies suggest that across all catego- ries of play, including social play, children with ASD demonstrate qualitative differences in the way that they play. Research has also supported the notion that children with ASD have specific difficulty with social play, with generating flexible and novel ideas for play, and with engaging in play with and with- out peers, with spontaneity and pleasure (Craig & Baron-Cohen, 1999; Dichter, Lam, Turner-Brown, Holtzclaw, & Bodfish, 2009; Hobson et al., 2009; Jor- dan, 2003; Lewis & Boucher, 1988, 1991, 1995; Ruth- erford & Rogers, 2003; Skaines, Rodger, & Bundy,

2006).

Occupational therapists might consider these def- icits within a framework of dyspraxia (Ayres, 1979; May Benson & Cermak, 2007). Dyspraxia has also been repeatedly documented in individuals with ASD and some researchers have suggested that mo- tor planning is a primary problem (Dowell, Mahone, & Mostofsky, 2009; Dziuk et al., 2007). Children with ASD also consistently demonstrate a variety of ad- ditional sensory processing difficulties (Ben-Sasson, Hen, et al., 2009; Marco, Hinkley, Hill, & Nagara- jan, 2011; Schoen, Miller, Brett-Green, & Nielsen, 2009). These sensory-processing deficits are now considered part of the diagnostic criteria for ASD, within the category of restricted repetitive behaviors (American Psychiatric Association, 2013). A large body of work links sensory functions such as modu- lation, discrimination, and perception to praxis (see Parham & Mailloux, 2010 for a review of this work) and Ayres’ sensory integration theory suggests a relationship between praxis and play (Ayres, 1979). Social play in particular may require strong praxis skills for children with ASD because they must ne- gotiate rapid changes in play schemes and introduc- tion of novel play ideas from others. Because the earliest stages of object and social play are both sensorimotor and imitative in nature and be- gin early in infancy as body awareness is developed, it is likely that impaired sensory processing could lead to impaired play; however, this has not been well stud- ied. Lower scores were found on a measure of play in children with sensory processing dysfunction than in children without the disorder, although play prefer- ences were similar between the two groups and many of the children with sensory processing disorder com- pensated well, despite poorer motor control (Bundy, 1989; Clifford & Bundy, 1989). One study found that children with sensory processing dysfunction have poorer scores on playfulness than typically develop- ing controls (Bundy, Shia, Qi, & Miller, 2007). Although still relatively playful, those with the disorder tend to engage in sedentary rather than active play. Honey,

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Leekam, Turner, and McConachie (2007) used a parent- report measure to examine the relationship between play behavior, level of play, and repetitive behaviors. Using a 31-item scale developed specifically for their study, the researchers compared 117 typically develop- ing children with 79 children with ASD. The children with ASD received higher scores that indicated more repetitive behavior and lower scores on play behavior than the typically developing children. However, the items used to measure repetitive behavior could also be considered measures of atypical sensory processing. The items addressed unusual interest in smell, bright, shiny objects, touching parts of the body, spinning, and rocking. Many scale items referenced some aspect of sensory processing. Therefore, perhaps sensory pro- cessing is the predictor of play behavior rather than repetitive behavior. Sensory processing is theoretically related to play performance and may be a predictor of social play deficits (Ayres, 1979). However, no studies to date have examined the relationships between the types of sensory functions (modulation, discrimination, perception, and praxis) and social play in this pop- ulation. Therefore, the purpose of the current study was to complete a preliminary investigation of these relationships in a sample of children with ASD. Struc- tural equation modeling (SEM) (Bryne, 2010; Kline, 2005) provides a tool to investigate the following hy- potheses: Sensory system function will predict praxis; Praxis will predict social play; and Sensory system function will predict social play directly.

Methods

Participants The data set was obtained from the clinical sam- ple used to examine discriminant validity during the development of the home forms of the Sensory Pro- cessing Measure (SPM) (Parham, Ecker, Miller-Ku- haneck, Henry, & Glennon, 2006) and the SPM-Pre- school (SPM-P) (Miller-Kuhaneck, Ecker, Parham, Henry, & Glennon, 2010). One hundred eight chil- dren from the SPM sample and 55 children from the SPM-P sample were diagnosed as having ASD, for a total sample of 162 children. Children in the clini- cal sample were provided by school personnel. As a secondary data analysis, this project was deemed ex- empt from review by the institutional review board.

Measures The SPM is intended for use with children in kindergarten through grade 6 and the SPM-P is for children 2 through 5 years of age who have not yet entered kindergarten. Both tools examine sensory processing, praxis, and social participation. Items

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within the social-participation scale examine social play performance (Plays with friends cooperatively; Shares things when asked; Joins into play with oth- ers without disrupting the ongoing activity). Each item is scored with a 4-point Likert-type response scale ranging from never to always. A higher raw score on the SPM is suggestive of greater dysfunc- tion. The SPM and SPM-P both demonstrate ad- equate psychometrics (Miller-Kuhaneck et al., 2010; Parham et al., 2007). To develop the measurement model, the two home forms of the SPM and the SPM-P were com- pared to select the identical items between the two within the chosen scales. No items were moved from their original categories, as determined by prior ex- pert and clinician review during development of the assessment tools. However, items were dropped from the original scales if they were not included in both versions. This resulted in scales compris- ing fewer items than were reflected in the published tools. Summed scale scores were used in the model analysis. A final list of items is presented in Table 1.

Data Analysis Data analysis was completed with SPSS 16.0 and AMOS 16.0 software (SPSS, Inc., Chicago, IL) follow- ing procedures outlined by Bryne (2010) and Kline (2005). The analyses included descriptive statistics, examination of the normalcy of the distribution, and the correlations between the selected scales and SEM. A Cronbach’s alpha was calculated to examine the reliability of the scale scores for the children with ASD. Relationships between the variables and scales were examined via Pearson product-moment corre- lations. Univariate skew and kurtosis and multivari- ate normalcy were tested. With any set of data, more than one model can fit. Therefore, after examining the fit of the hypoth- esized model, the next step was to compare alterna- tive models that might better fit the data. The alter- native models were based on Ayres’ prior research (see Parham & Mailloux, 2010 for a review of this body of work) and discussion with current experts in Ayres’ Sensory Integration®. The models are de- scribed in Table 2. During each step of the process, the model fit was examined using measures of goodness of fit. Model fit was examined using chi-square, the comparative fit index (CFI), root mean square of error approxima- tion (RMSEA), and the root mean square residual (RMR). Multiple authors have suggested viewing and reporting multiple measures when examining model fit (Bryne, 2010; Hooper, Coughlan, & Muellen, 2008; Kline, 2005). Chi-square measures the magnitude of

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the difference between the covariance matrices. A sig-

nificant chi-square value suggests a difference between the covariance matrices. Therefore, a good model fit

to the data provides an insignificant chi-square result

(Hooper et al., 2008). Chi-square is the most commonly used measure of fit; however, it is affected by sample size (Gao et al., 2008; Hooper et al., 2008). Many authors suggest also using the CFI when determining model fit (Gao et al., 2008; Hooper et al., 2008). The CFI performs well even with a smaller sample size. The measure assumes the latent vari- ables are uncorrelated and compares the sample co- variance matrix with the null model. Values closer

to 1 indicate good fit. For this study, the CFI was ex-

amined and the cutoff value was greater than 0.95 as

is currently recommended within related literature

(Hooper et al., 2008). RMSEA is a measure of how well the model

would fit the population covariance matrix if it had optimal parameter estimates. This measure is often selected because it is sensitive to the number of pa- rameter estimates, and it favors both the best fit and the most parsimonious model (Hooper et al., 2008).

A range of values have been proposed for cutoffs of

the RMSEA. For purposes of this study, values of the RMSEA were examined and the cutoff used was 0.06. RMR is the square root of the difference between the residuals of the covariances matrices (Hooper et al., 2008). Values range from zero to 1 and good-fitting models should have values less than 0.05, with zero suggesting a perfect fit.

Results

The participants in this study had ages ranging from 2 years and 2 months to 13 years and 6 months, with an average age of 7 years and 2 months. As was expected with a sample of individuals with ASD, 82.7% were male. Other sample demographics are provided in Table 3. For the 162 participants in the current study, there were no missing data in any of the items provided in the data set. Scale scores, used as indicators in the model test- ing, were summed item scores. Cronbach’s alpha for the scales used in this study ranged from .66 for the vision scale to .83 for the praxis scale, with the rest of the scales in the .73 to .78 range. There were no items that, if deleted, would have substantially altered the alpha levels for any scale. Skew and kurtosis data indicated that the majority

of the scales were positively skewed, with the excep-

tion of play, which was negatively skewed. The Kol- mogorov–Smirnov tests were significant for each of the scales, indicating data that are different than nor-

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Table 1

Selected Items From the Sensory Processing Measure and Sensory Processing Measure–Preschool Used to Develop the Structural Equation Model

Scale Category

Item

Play performance

Plays with friends cooperatively

Shares things when asked

Joins into play with others without disrupting the ongoing activity

Vision

Seems bothered by light, especially bright light (blinks, squints, cries, closes eyes, etc.)

Has difficulty recognizing how objects are similar or different based on their colors, shapes, or sizes

Has trouble finding an object when it is part of a group of other things

Enjoys watching objects spin or move more than most kids his/her age

Walks into objects or people as if they were not there

Likes to flip light switches on and off repeatedly

Enjoys looking at moving objects out of the corner of his/her eye

Touch

Pulls away from being touched lightly

Prefers to touch rather than to be touched

Becomes distressed by having his/her finger- or toenails cut

Seems bothered when someone touches his/her face

Avoids touching or playing with finger paint, paste, sand, clay, mud, glue, or other messy things

Has an unusually high tolerance for pain

Dislikes teeth brushing, more than most kids his/her age

Seems to enjoy sensations that should be painful, such as crashing onto the floor or hitting his/her own body

Proprioception

Grasps objects (such as a pencil or spoon) so loosely that it is difficult to use the object

Seems driven to seek activities such as pushing, pulling, dragging, lifting, and jumping

Seems unsure of how far to raise or lower the body during movement such as sitting down or stepping over an object

Seems to exert too much pressure for the task, such as walking heavily, slamming doors, or pressing too hard when using pencils or crayons

Jumps a lot

Tends to pet animals with too much force

Bumps or push other children

Chews on toys, clothes, or other objects more than other children

Vestibular

Seems excessively fearful of movement, such as going up and down stairs or riding swings, teeter- totters, slides, or other playground equipment

Avoids balance activities, such as walking on curbs or on uneven ground

Falls out of a chair when shifting his/her body

Fails to catch him/herself when falling

Seems not to get dizzy when others usually do

Spins and whirls his/her body more than other children

Shows distress when his/her head is tilted away from the upright, vertical position

Shows poor coordination and appears to be clumsy

Leans on other people or furniture when sitting or when trying to stand up

Praxis

Has trouble figuring out how to carry multiple objects at the same time

Seems confused about how to put away materials and belongings in their correct places

Fails to complete tasks with multiple steps

Has difficulty imitating demonstrated actions, such as movement games or songs with motions

Has trouble coming up with ideas for new games and activities

Tends to play the same activities over and over, rather than shift to new activities when given the chance

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Table 2

Proposed and Alternative Models

Model

Description

Proposed

The scales of vision (7 items), touch (7 items), vestibular (9 items), and proprioception (9 items) load on one factor called sensory functions, which is directly related to praxis (6 items) and play (3 items). Praxis is directly related to play and also serves as a mediator between sensory functions and play.

Model 2

All indicators could load on one factor of general ability because the data are from a sample of children with autism spectrum disorder and, perhaps, their scores were simply reflective of a common measure of the lower ability with autism spectrum disorder.

Model 3

The sensory scales of vision, touch, vestibular, and proprioception could load on one factor of sensory func- tions, whereas play and praxis load on another of higher general ability.

Model 4

The three near-body senses of touch, vestibular, and proprioception could load on one factor, with vision and praxis loading on another and play alone.

Model 5

The scales of vision, touch, vestibular, proprioception, and praxis could load on one factor (i.e., sensory inte- gration) and play could remain alone as an indicator of higher function.

Final Model

The scales of vision, touch, vestibular, proprioception load on one factor and play and praxis combine in another factor. This is model 3 with correlated error. See Figure 1.

mally distributed data. This was addressed in SEM with the bootstrapping procedure. Two age groups were combined in this data set (SPM and SPM-P), but Levine’s test of the homogeneity of variance for each of the scale scores examining the two groups based on age was not significant, suggesting that the homo- geneity of variance assumption was met between the younger and older participants. The AMOS assess- ment of data normality and Mahalanobis d-squared results suggested no cases to be deleted. Each of the scales was moderately correlated with the other. Table 4 provides these correlations. The proposed model was estimated and subsequently compared to the four alternative models described, because the proposed model did not fit the data. The Bollen-Stine bootstrap value and measures of model fit for each of the models are provided in Table 5. An AMOS diagram of the final model with the esti- mates is provided in Figure 1. The optimal model was the model of sensory functions predicting a combined play and praxis factor of higher ability. However, this model did not obtain adequate fit to the data with- out correlating error. The practice of correlating error terms is controversial in SEM (Hooper et al., 2008; Kline, 2005). Correlated error is the variance across measures that is not explained by the constructs and is from some common cause. The unknown, shared “something” can be a common method of measure- ment, measurement of a construct unrepresented by the model, or similar wording between items. There- fore, theory and prior research, along with an exami- nation of item wording and prior item categorization, were considered in the process of correlating errors in this study. The final model proposes that, in children

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Table 3

Sample Demographics

Demographic

% of Sample

Ethnicity

American Indian/Native Alaskan

1

Native Hawaiian/Pacific Islander

3

Black

5

Hispanic

7

Asian

3

White

80

Other

1

Education level of parent

Did not complete high school

4

High school degree

20

Some college

22

Bachelor degree or higher

54

Region of the country

Northeast

11

South

10

Midwest

50

West

29

with ASD, vision, proprioception, and tactile and ves- tibular functioning are strongly related to praxis and social play ability in combination.

Discussion

This study provides preliminary evidence that sensory functions are related to social play/praxis

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Table 4 Scale Correlations a Scale Play Vision Touch Proprioception Vestibular Praxis Play 1.000 Vision
Table 4
Scale Correlations a
Scale
Play
Vision
Touch
Proprioception
Vestibular
Praxis
Play
1.000
Vision
0.322
1.000
Touch
0.441
0.639
1.000
Proprioception
0.404
0.574
0.538
1.000
Vestibular
0.226
0.527
0.477
0.481
1.000
Praxis
0.519
0.496
0.439
0.345
0.446
1.000
a All p < .01, two tailed.
Table 5 Model Fit Indices Bollen-Stine Model Bootstrap Chi-square CFI RMSEA Decision Proposed p =
Table 5
Model Fit Indices
Bollen-Stine
Model
Bootstrap
Chi-square
CFI
RMSEA
Decision
Proposed
p = .015
23.1 (8), p = .003
0.957
0.108
Not a good fit to data
Model 2
p = .000
40.4 (9), p = .000
0.910
0.147
Not a good fit to data
Model 3
p = .026
23.1 (8), p = .003
0.957
0.108
Not a good fit to data; suggested correlated
error that made sense based on scale items
Model 4
p = .000
40.3 (7), p = .000
0.904
0.172
Not a good fit to data
Model 5
p = .000
40.4 (9), p = .000
0.910
0.147
Not a good fit to data
Final Model
p = .803
9.14 (6), p = .166
0.991
0.057
Acceptable fit to data and theory
CFI = Comparative Fit Index; RMSEA = Root Mean Square of Error Approximation
Fit Index; RMSEA = Root Mean Square of Error Approximation Figure 1. The final two-factor structural

Figure 1. The final two-factor structural model with correlated error. Standardized estimates are indicated. prop = proprioception; vestib = vestibular

in children with ASD as measured by the SPM and SPM-P. The final model, with a collapsed social play/praxis factor, is likely a better fit to the data because of the items that make up the scales. Items in the praxis scale include two that are worded to measure ideation but also overlap considerably with items that would be in a scale of play performance. One of these items states “has trouble coming up

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with ideas for new games and activities” and the other states “tends to play the same activities over and over, rather than shift to new activities when given the chance.” It was decided early in the development of this study to avoid moving items from the scales within which they were originally placed during develop- ment of the SPM tools; these two items therefore re- mained within the praxis scale. However, given the clear relationship with play in these two ideational praxis items, doing so may have created the need to combine the scales to obtain adequate model fit. The correlation between these two scales was mod- erate (r = 0.519). Three of the six items within the praxis scale are related to either imitation or genera- tivity, both of which have been addressed in studies of play in children with ASD (Hobson et al., 2009; Lewis & Boucher, 1991, 1995). Therefore, the combi- nation of praxis and play into one factor is under- standable. The combined factor could also imply that rather than being a separate construct from play skill or other higher level skills, praxis may be an integral part of higher level functioning, as has been suggested by researchers studying motor cognition (Gallese, Rochat, Cossu, & Sinigaglia, 2009).

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A relationship between sensory functions and praxis is well supported with Ayres’ research, as well as a more recent reexamination of data that related sensory functions and praxis in ASD (see Parham & Mailloux, 2010 for a review of Ayres’ work; Mail- loux et al., 2011). Theoretically, children must have adequate processing of sensation to determine how to move their bodies appropriately. However, body awareness and the ability to process sensory infor- mation may also be related to both imitation and generativity, because these abilities were measured within the praxis scale. These relationships have been suggested by other researchers in imitation and dys- praxia in ASD (Roeyers, Van Oost, & Bothyne, 1998; Williams et al., 2006). Perhaps basic body awareness is necessary to perform creative motions of the body in relation to objects for play and to learn through the senses that objects can be used in novel ways. The link between sensory processing and play found in this study is not yet well supported within related literature. Research has found that children with sensory-processing difficulties perform some- what more poorly during play (Bundy, 1989; Bundy et al., 2007; Clifford & Bundy, 1989). However, none of these studies focused on children with ASD and all used different measures than implemented in the current study. One such study of play in children with ASD examined items that could be considered measures of sensory processing. Children exhibit- ing more repetitive behaviors—many of which were measures of sensory seeking—had lower scores on play behavior (Honey et al., 2007), suggesting a rela- tionship between repetitive sensory-seeking behav- ior and poor play. Past research that has examined children with ASD in natural settings found that the children tend to prefer sensorimotor activities, often engaging in sensory-seeking play, which suggests an influence of sensory-seeking preferences on play choices (Holmes & Procaccino, 2009). Although the items used in the current study were more balanced between sensory-seeking and sensory-defensive items, the participating children with ASD generally had more atypical scores on the sensory-seeking, praxis, and play items. These two results together suggest that perhaps the relationship between sen- sory-processing issues and poor social play perfor- mance is due to sensory seeking that interferes with more developed modes of play. However, varied as- pects of sensory processing could, theoretically, have different effects on play behavior.

Limitations Although there were benefits to using the large preexisting data set available to this study, there were

OTJR: Occupation, Participation and Health • Vol. 33, No. 3, 2013

also limitations. First, children to be included as hav- ing ASD were gathered by school professionals and there was no way to confirm diagnosis. Therefore, it is possible that some of the children included in the sample were misdiagnosed. Second, because there was no measure of symptom severity in the original data set, it is impossible to know whether some of the relationships found between the scales are due merely to the confounding relationship with overall symptom severity. The one finding that argues against this inter- pretation is the poor model fit when all indicators were placed as loading on one factor of general ability. A second important limitation is the small number of items available to create the play scale. The origi- nal social participation scale was much more broadly defined and included items in addition to play. There- fore, only certain items could be pulled from the social participation scale to form the play scale. To achieve the larger sample of this study by combining data from the SPM and SPM-P, certain items could not be included that were not available on both measures. Although there is evidence that scales can be reduced to two to three items and maintain their reliability (Moran, Guyatt, & Norman, 2001), construct and con- tent validity is diminished with scales of fewer items. One could not argue that the social play scale of three items could adequately comprise a complete assess- ment of play. The three items that made up the play scale are important aspects of social play with peers. However, deficits in social interaction in this popula- tion are complex and the items of social play likely also reflect many other aspects of performance in chil- dren with ASD. The relationships between sensory processing and other forms of play might be different in this population. For example, one could argue that the relationships between sensory processing abilities and sensory-motor play might be stronger. These is- sues will need to be explored in future research with a different and more comprehensive play measure. Finally, reduction of items within the scales also reduced score reliability somewhat. Although most of the scales maintained adequate internal consis- tency, Cronbach’s alpha measures of the vision and vestibular scales were low for current accepted use in test development. Therefore, for all of these rea- sons, the results of this study must be considered preliminary in nature.

Future Research Future study of the relationship between sensory processing and play must use a well-established play assessment with more comprehensive coverage of the construct of play and a measure of ASD symp- tom severity and cognitive ability. Future research

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could more specifically examine types of sensory- processing dysfunction and their specific outcomes in terms of play performance. Theoretically, a child with sensory defensiveness would avoid activities in play that provide sensory stimuli that are uncom- fortable. Similarly, a child exhibiting sensory-seek- ing behavior would be expected to engage in gross motor play that provides preferred sensory experi- ences. These relationships could be examined more carefully in a naturalistic study conducted in the home or classroom.

Clinical Implications The findings of this study suggest that perhaps sen- sory processing is an area to assess in relation to social play deficits in children with ASD. The relationship found between sensory functions and the combined praxis and play factor within this data set was strong. The praxis scale of the SPM and SPM-P includes items that measure generativity and imitation, suggesting that sensory functions may also be related to these con- structs. If these relationships can be further supported, these results might suggest that greater attention to the sensory elements of play could be beneficial in future research and play interventions.

Conclusion

This study provides preliminary evidence of a relationship between sensory functions and social play in combination with praxis. Despite the neces- sary caution in interpretation and the limitations in measurement, the study has two primary strengths. First, a common problem in ASD play research is the use of small samples, and this research was complet- ed with a large sample of children with ASD. Sec- ond, although there is a large body of work suggest- ing sensory-processing deficits including dyspraxia and poor play performance in children with ASD, this is the first study to examine these constructs together to consider the potential impact of sensory processing on social play. The findings suggest fu- ture avenues for research.

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