Educational Psychology in Practice

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Developing Play Skills in Children with Autistic

Spectrum Disorders

Nicky Thomas & Caroline Smith

To cite this article: Nicky Thomas & Caroline Smith (2004) Developing Play Skills in Children
with Autistic Spectrum Disorders, Educational Psychology in Practice, 20:3, 195-206, DOI:
10.1080/0266736042000251781

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Published online: 19 Jan 2007.

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Educational Psychology in Practice,
Vol. 20, No. 3, September 2004

Developing Play Skills in Children

with Autistic Spectrum Disorders
Nicky Thomasa* and Caroline Smithb
a
Havant Local Education Of®ce, UK; bLincolnshire County Psychology Service, UK

(Received February 2003; accepted after revision, December 2003)

This pilot study is an exploratory investigation into the effectiveness of the routine and systematic
use of a speci®c play intervention common in many mainstream early years settings meeting the
needs of children with autistic spectrum disorders. The intervention, known locally as Tabletop
Identiplay, combines the use of a play script with adult mirroring. The study uses video
observations and key worker questionnaires to assess children's play behaviour pre-intervention
and post-intervention. It follows a single case design involving three children, all with a diagnosis of
autism. It was found that all three showed positive changes in their play behaviour, both in terms of
the functional use of toys and in their social interactions with peers. The ®ndings are discussed with
regard to the possible mechanisms underpinning such changes and recommends further activity in
the ®eld of play and children with autism.

Introduction
For most children the development of play follows a predictable course. In children
with autistic spectrum dif®culties (ASD) this development is impaired, with play often
appearing repetitive, sensory, isolated, concrete and lacking in imagination. When
these children use toys in their play, they often play with a very limited range of toys
and use them atypically (e.g., spinning wheels, lining up cars, ¯icking or ¯apping
cards).
It is understandable that the play of these children is as it is. The impact of the triad
of impairments (Wing & Gould, 1979) is often seen in the children's lack of social
motivation, social experience and understanding; the limited use of functional
language and the lack of ¯exibility, all requirements for the development of play.
Without focused support, the play of children with ASD is likely to continue to
develop slowly and atypically with consequent rami®cations for their inclusion in the
play activities of their peers. The play of children with ASD does not set them up to be

*Corresponding author: Havant Local Education Of®ce, River Way, Havant, Hants, UK.
Email: nicky.thomas@hants.gov.uk
ISSN 0266±7363 (print)/ISSN 1469±5839 (online)/04/030195-12
ã 2004 Association of Educational Psychologists
DOI: 10.1080/0266736042000251781
196 N. Thomas and C. Smith

the playmate of choice with their peers, hence their initial play limitations are added to
by their limited exposure to the play skills of others.
In the past, despite the acknowledged importance of providing regular and routine
play opportunities for typically developing children, enhancing the play of children
with autism has had a relatively small role in their education and treatment (Wolfberg,
1999). One explanation for this is that play is notoriously dif®cult to de®ne, to
measure and to identify progress. Because of the bene®ts of play in typical
development, a growing interest in the area of autism and play is emerging
(Delamain & Spring, 2000; Gutstein & Sheely, 2002; Sherratt & Peter, 2002;
Sussman, 1999).
There are now a number of play interventions being developed and introduced into
pre-school settings, which draw on both directive and non-directive approaches (e.g.,
modelling, mirroring, play routines, play scripts, action songs, parallel play). These
vary in their focus and teaching style, with some promoting only certain aspects of
play, such as the functional use of toys, while others attempt to cover a wider range of
play skills, including social interaction.
This paper evaluates the effectiveness of one particular play intervention, which is
popular in a range of early years settings, within the local education authority. The
speci®c intervention combines a play script with tabletop mirroring using two sets of
identical toys. This approach, developed from the work of Beyer and Gammeltoft
(2000), is known locally as ``Tabletop Identiplay''.
The evaluation study sought to answer three key questions:

d Does the intervention increase speci®c play behaviours?

d Are these play behaviours then evident across different play contexts?
d Do the improved play behaviours lead to an increase in social interaction?

The study gathered direct video evidence and key worker's views regarding the
changes in each child's play behaviour.

The Current Study

This study follows Beyer and Gammeltoft's (2000) and Sherratt's (1999) direction on
teaching play sequences to children with ASD. Both emphasise the importance of
using structure throughout the play intervention, for instance:

d a narrative structure, giving the play activity a reason, a framework and an end to the
play act; and
d a visually clear structure, giving the child clear information about what toys are
theirs to play with, in what space and, initially, in what way.

Sherratt (1999) further emphasises the importance of using simple language to

communicate affective as well as semantic meaning. He believes that the fun and
excitement that the adult communicates through face, voice and body are crucial. In
 Play Skills in Children with Autistic Spectrum Disorders 197

Figure 1. Neural processes in play (Sherratt & Peter, 2002, Figure 2.1, p. 33)

behavioural terms the child's feelings of well-being experienced in a successful play

activity become associated with the play experiences, thereby increasing motivation.
The adult has to play and enjoy it! The key elements of Sherratt's (1999) process are
described in Figure 1.
198 N. Thomas and C. Smith

Table 1. Percentage of free-play time spent by each participant in different play situations, during
pre-test and post-test observations

Participant A Participant B Participant C

Pre-test Post-test Pre-test Post-test Pre-test Post-test

Alone 90 73 45 38 98 55
Tolerating others 10 27 15 20 10 10
Joint attention 10 10 10 35 10 45
Initiating play 10 10 12 18 10 10

Method
Three pre-school children aged between 3 years 4 months and 4 years 1 month,
each with a diagnosis of autism and attending a mainstream pre-school, took part in
this study. The play intervention took place over a two-week period, with each
participant receiving ®ve minutes' daily input, working on a speci®c tabletop play
sequence. The study used video observations and key worker questionnaires to assess
children's play behaviour and social interactions before and after the two-week
intervention.
The children's initial play skills varied considerably, ranging from no language,
sorting all toys by colour, throwing and hand ¯apping to a child who was verbal,
played alongside others and was beginning to engage with them in some functional
play.
The video observations (10 minutes on each occasion), focused on free-play
activity. They recorded the play activities that each child engaged in (e.g., what
toys were played with and in what way), the social behaviours (e.g., playing alone
or with another child), and initiating, responding to or tolerating play and
children's verbal and non-verbal communication skills. Three measures were
obtained: namely, duration, (i.e., the proportion of total time that the participant
spent in each play category), frequency, (i.e., the total number of occurrences of each
play act), and diversity (i.e., the number of changes between different play activities,
in contrast with the number of repeated activities). The observations were analysed
using 15-second time-interval sampling. The behaviours were coded by two
researchers (Appendix 1) and the coding was tested for inter-rater reliability
(Appendix 2).
The key worker questionnaires (Appendix 3) detailed each participant's play
behaviours, including the social elements of play, before the intervention and one
week after the intervention. Key workers were asked to rate the child's behaviour in a
range of situations on a four-point Likert-type scale, based on their regular
observations of the children within the nursery. The questionnaire was based on
elements taken from The Hampshire Play Pro®le (Smith, 2001), a tool developed
speci®cally to identify the play skills of children with ASD.
 Play Skills in Children with Autistic Spectrum Disorders 199

Figure 2. Percentage of time spent using the toys from the script in pre-test and post-test
observations during free play

The Play Intervention

The equipment for the play intervention, referred to as Tabletop Identiplay, consists
of:

d a table divided in two using coloured sticky tape, offering a clear area for the child's
toys and a clear area for the adult's;
d two chairs set out face to face on either side of the table;
d a pack containing two identical sets of toys (initially two or three toys of interest to
the child, which can be linked in a story form); and
d a typed script detailing both the layout of the toys on the table and what the adult
will say and do with the toys.

The tabletop process begins by the adult setting out the two sets of toys on
the tabletop, one set in each of the two areas of the table. The adult models the
simple playscript, watching and waiting for the child's engagement. In those
situations in which the child does not engage, various options are likely (i.e., the
adult might put the toys away, saying ``play ®nished'' and repeat the process the
next day, or brie¯y prompt the child's involvement). Initially the purpose of the
Tabletop Identiplay was to increase the repertoire of toys with which the child will
200 N. Thomas and C. Smith

Figure 3. Percentage of time participants spent on each type of play during the pre-test and post-test
free-play observations

play, but as the child relaxes and creates his/her own play sequence, the adult joins the
child's play imitating his/her actions and sounds, sensitively adding to the play, but
reverting to mirroring or repeating the play sequence when additions are unwelcome
to the child.
Tabletop Identiplay facilitates many of the key elements found to be dif®cult for
young children with ASD:

d shared focus;
d imitation;
d parallel play;
d play dialogue;
d narrative structure; and
d ¯exibility.

Outcomes
This study posed three research questions, each of which are now considered.

Does the Intervention Increase Speci®c Play Behaviours?

The post-intervention data showed that:

d the children spent more time playing more appropriately with the tabletop toys (see
Figure 2); and
d the children learnt and used all, or some, of the taught identiplay sequence.
 Play Skills in Children with Autistic Spectrum Disorders 201

Are these Play Behaviours then Evident across Different Play Contexts?
The video analysis identi®ed that, post-intervention:
d All of the children played more and more purposefully, with the tabletop toys in
free-play session. For one child this re¯ected a shift from playing appropriately with
a toy for 10% of the time to 100%.
d Similarly each child included, in some way, part of the taught play sequence. Two of
the three used the taught sequence creatively, reproducing it in free-play sessions
and adding their own additional ideas to it.

Do the Improved Play Behaviours Lead to an Increase in Social Interaction?

The post-intervention evidence showed that the children:
d spent an increased amount of time playing alongside other children in parallel play
and/or playing with other children (see Table 1 and Figure 3); and
d spent a greater amount of time engaged in social interaction, showed by frequency
of eye contact and increase in verbal communication.

Case Studies
Participant A
In the pre-test observations, Participant A spent approximately 50% of the time not
playing at all. This was observed as behaviours such as pacing around, sitting, rocking
and throwing objects. Post-intervention, she showed very little functional play, time
spent not playing had decreased and she spent 20% of her time engaged in social play,
(e.g., tickling, lap games and so on with peers) (see Figure 3). The functional play
seen in the post-test was all carried out using the play script toys, in contrast to the
pre-test when she played only with the more familiar toys from the pre-school.

Participant B
Participant B spent very little time not playing, and for the majority of the ®rst
observation playing functionally with the play script toys. This observation led to the
development of an extension script to include more advanced skills. Following the
intervention he engaged in some pretend play, adding to the original script, in
addition to continued high levels of functional play.

Participant C
Participant C spent approximately 50% of the pre-test observation not playing at all
and less than 50% of the time spent playing functionally (see Figure 3). He spent
202 N. Thomas and C. Smith

100% of his post-test observation playing functionally with the play script toys. He
carried out the taught script and also added small changes to the script. These
additional sequences all included actions that were part of the original script, just
presented in a different order or with different toys from the pack.

Discussion and Implications

In order for a play intervention to be described as effective, measurable changes in
play need to be observed after the intervention. Following the intervention, the
children all increased the amount of time spent playing with the script toys, using the
script sequence as a basis for their play and using functional play in their free-play
time.
The increased skills with the tabletop toys and the spontaneous use of the script
re¯ect the importance of the speci®c teaching element of the Tabletop Identiplay.
This accords with Wolfberg (1999); that without speci®c teaching, children with ASD
are unlikely to engage in functionally appropriate play. Further research suggests that
the repetitive nature of their play may be underpinned by a fundamental dif®culty in
generating alternative behaviour, linked with the impairment in imagination and
¯exible thinking (Jarrold, 1997). Without stimulation from others, the children are
left with their own, limited ideas of interesting actions (Lord, 1985).
However, some similar studies, involving play interventions, have found that post-
test behaviours were exact replicas of the training that each child had received (for
example, Libby, Powell, Messer, & Jordan, 1997). It can be speculated that the
process of Tabletop Identiplay, with its balance between skill teaching and mirroring,
provided a suf®ciently structured learning experience to not only start the play off, but
also give the children enough con®dence to do something new.
Levels of functional play increased after the intervention in free-play situations. In
the initial observations, two of the children spent the majority of time not playing.
Instead they paced around, sat still, rocked or threw objects. Having been taught a
script for playing with the set of toys, these two children spent less time alone engaged
in repetitive play. The third child used functional play to begin with, and an extension
script was designed for him. Following the intervention he showed some pretend play
during free play, including some ``theory of mind'' actions whereby he talked about
the character being hurt and feeling sad.
Post-intervention measures identi®ed higher levels of social behaviour in partici-
pant children with participants spending less time alone and more time engaged in
joint attention play.
It is important to consider the mechanisms behind these changes. This may be due
to the increase in functional play, which, in turn, may encourage peers to play with the
children. In addition, the children's eye contact and verbal communication showed
some improvements. It seems to be the case that by learning what to do with the toys,
the children began to have something in common with the other children. This
encouraged others to come alongside, providing communicative models for the child
 Play Skills in Children with Autistic Spectrum Disorders 203

with ASD while also increasing the opportunities for the child with ASD to
communicate verbally and non-verbally.
It is likely that learned play behaviours may have a role in reducing sensorimotor
behaviour and self-stimulation, which consequently makes those with autism more
attractive playmates (Libby et al., 1997). It is possible that by providing the children
with a sequence of activities to carry out and familiarising them with sets of toys, they
may carry out more of the types of behaviour, which makes them attractive and
approachable to their peers.
The ®ndings suggest that this structured play intervention is effective in teaching
pre-school children with ASD new play skills. There are probably positive effects both
in terms of speci®c play skills, generalised learning and social interaction of
implementing this type of play intervention. However, as in all real-world research,
the experience of the children did not stand still for the period of the study. Each child
continued to receive other pre-school experiences with opportunities for social games
and pretend play. Indeed, some of the changes in play behaviour may not be
attributed to the teaching that occurred during the intervention, but several of the
changes re¯ected so closely the tabletop intervention that claiming some element of
cause and effect is defensible.
Play scripts with tabletop mirroring appear to teach young children with autism a
sequence that they can apply in their free play. This can make them more
approachable to their peers, consequently improving social interactions in the pre-
school setting. For those with higher order skills, it can also provide a basis on which
to experiment and apply their own play ideas, contributing to the development of
spontaneous imaginative play.
This small-scale study begins to highlight the possible advantages for children with
ASD when part of their education plan focuses, routinely, and in a structured way, on
the development of play skills. Further research in this area is now required, with
additional consideration given to:
d sample size;
d utilising a comparison group (i.e., ``control group'');
d matching participants by age and skill level; and
d increasing the intervention period.

The short intervention period in this study and the small number of participants could
usefully be increased in a follow-up study to increase validity, and further observations
over time may give a clearer indication of whether any learned behaviour was
maintained or developed over time.
It was noted in this study that the participant with the most limited functioning at
the start showed the least change. The other participants demonstrated good skills in a
number of areas of development at the outset. Further research is required to
determine whether such an intervention is more appropriate for those who are
functioning at a higher level and whether there other interventions that are more
effective for children who have key skills they needed to acquire ®rst.
204 N. Thomas and C. Smith

A more reliable design alternative may be the ABA design, whereby changes can be
more reliably attributed to the intervention by returning to a stable baseline, and
therefore eliminating threats to validity, such as maturation, other interventions and
skills in repertoire that are not seen in the initial observation.
In the real-world research of practising educational psychologists, tight experi-
mental design can pose ethical and practical issues (e.g., which children to include in
an intervention). However, this small-scale study highlights the potential positive
outcomes that can occur when speci®c focus is placed on the play of children with
ASD. The authors are aware of the wide range of directive and non-directive
approaches that have proved successful with children with ASD, and welcome further
discussion and debate.

References
Beyer, J. & Gammeltoft, L. (2000). Autism and play. London: Jessica Kingsley.
Cohen, J. (1960). A coef®cient for agreement for nominal scales. Educational and Psychological
Measurement, 20, 37±46.
Delamain & Spring, J. (2000). Developing baseline communication skills. Oxford: Winslow Press.
Fleiss, J.L. (1987). Statistical methods for rates and proportions. (2nd edn). New York: Wiley.
Gutstein, S. & Sheely, R. (2002), Relationship development intervention with young children: social and
emotional development activities for Asperger's syndrome, autism, PDD and NLD. London:
Jessica Kingsley.
Jarrold, C. (1997). Pretend play in autism: executive explanations. In J. Russell (Ed.), Autism as an
executive disorder. Oxford: Oxford University Press.
Libby, S., Powell, S., Messer, D. & Jordan, R. (1997). Imitation of pretend play acts by children
with autism and Downs Syndrome. Journal of Autism and Developmental Disorders, 27, 365±
383.
Lord, R. (1985). Autism and the comprehension of language. In E. Shopler & G. Mesibov (Eds.),
Communication problems in autism. New York: Plenum Press.
Sherratt, D. (1999). The importance of play. Good Autism Practice, September, 23±41.
Sherratt, D. & Peter, M. (2002). Developing play and drama in children with autistic spectrum
disorders. London: Fulton.
Smith, C. (2001). The Hampshire play pro®le. Retrieved from caroliner.smith@lincolnshire.gov.uk
Sussman, F. (1999). More than words: helping parents promote communication and social skills in
children with autistic spectrum disorder. Oxford: Winslow Press.
Wing, L. & Gould, J. (1979). Severe impairments of social interactions and associated
abnormalities in children: epidemiology and classi®cation. Journal of Autism and
Developmental Disorder, 9, 11±29.
Wolfberg, P. (1999). Play and imagination in children with autism. New York: Teachers College
Press.
 Play Skills in Children with Autistic Spectrum Disorders 205

Appendix 1

Codes used for video observations to record types of play behaviour

Play Code Type Code Behaviour Code

Alone A Repetitive R Eye contact E

Watching others W Functional F Verbal communication V
Remains with peer St Pretend P Physical contact Ph
Leaves peer L Other/no play N
Initiates play IP
Tolerates peer's play TP
Joint attention JA

Appendix 2
The two sets of codings for each participant were compared using Cohen's Kappa (Cohen, 1960),
which corrects for chance and is therefore preferable to simple agreement percentages.

Results of Cohen's Kappa for Inter-rater Reliability on Coding of Behaviour in the Pre-test Observations

Pre-test observation Participant Cohen's Kappa

Play with others (alone, tolerating, joint attention, etc.) A 0.89

B 0.75
C 1
Type of play (functional, repetitive, social, etc.) A 0.83
B 0.71
C 0.89

Results of Cohen's Kappa for Inter-rater Reliability on Coding of Behaviour in the Post-test Observations

Post-test observation Participant Cohen's Kappa

Play with others (alone, tolerating, joint attention, etc.) A 0.68

B 0.85
C 0.56
Type of play (functional, repetitive, social, etc.) A 0.77
B 0.62
C 1

The accepted level for inter-rater reliability with Kappa is 0.5 and the measures of reliability meet
this for all observations. Fleiss (1981) characterises Kappa=0.6±0.75 as good and Kappa > 0.75 as
excellent. Therefore, the results of the video observations can be assumed to be reliable.
206 N. Thomas and C. Smith

Appendix 3
Keyworkers' Questionnaire
Scaling: 1 ± never
2 ± sometimes; seldom
3 ± sometimes; about half the time
4 ± often
11. Does the child engage in repetitive play, e.g., lining up objects?
1 2 3 4
12. Does the child play alone?
1 2 3 4
13. Does the child seek joint play with other children?
1 2 3 4
14. Does the child engage in functional play, e.g., using toys for what they were designed to do?
1 2 3 4
15. Does the child watch other children at play, without joining in?
1 2 3 4
16. Does the child play alongside other children, using the same or similar toys/apparatus?
1 2 3 4
17. Does the child initiate joint play with other children?
1 2 3 4
18. Does the child continue to play when another child comes alongside?
1 2 3 4
19. Does the child take part in turn taking activities with other children with adult support?
1 2 3 4
10. Does the child engage in pretend play, e.g. using objects for different purposes, pretending that
they are real or using things differently to how they were designed?
1 2 3 4
11. Does the child tolerate the involvement of other children in his/her play, e.g., putting sand into
his/her bucket?
1 2 3 4
12. Do other children initiate joint play with the child?
1 2 3 4
13. Does the child take part in turn taking activities with other children independently?
1 2 3 4