Comprehension of pretense in children with autism

Symbolic Play among Children with Autism Spectrum Disorder: A Scoping Review

Symbolic play is considered an early indicator in the diagnosis of autism spectrum disorder (ASD) and its assessment. The objective of this study was to analyze the difficulties in symbolic play experienced by children with ASD and to determine the existence of differences in symbolic play among children with ASD, children with other neurodevelopmental disorders and children with typical development. A scoping review was carried out in the Web of Science (WoS), Scopus, ERIC, and PsycInfo databases, following the extension for scoping reviews of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The number of papers included in the review was 22. The results confirm that children with ASD have greater difficulties with symbolic play than children with other neurodevelopmental disorders and children with typical development, even when controlling for their verbal age. Difficulties are greater in situations of free or spontaneous play. Results evidenced that the absence or deficiency in the symbolic play can serve as an early indicator of ASD between the first and second year of life, the developmental moment in which this type of play begins.

Qualitative Differences in Attribution of Mental States to Other People in Autism and Schizophrenia: What are the Tools for Differential Diagnosis?

The differential diagnosis between schizophrenia spectrum disorders (SSD) and autism spectrum disorders (ASD) remains an important clinical question, because they have overlap in clinical diagnosis. This study explored the differences between ASD (n = 44) and SSD patients (n = 59), compared to typically developing peers (n = 63), in completing an advanced Theory of Mind (ToM) task. The outcome found several differences between groups. The SSD patients showed greater difficulty in understanding social scenarios, while ASD individuals understood the stories, but did not correctly identify the protagonist’s intention. The interesting aspect of the results is that some ToM stories are more informative about the mentalistic reasoning of the two clinical groups, namely, the stories that investigate pretend, persuasion, double bluff and ironic joke constructs.

Predictors and Moderators of Spontaneous Pretend Play in Children with and without Autism Spectrum Disorder

Although pretend play has long been linked to children's normative cognitive development, inconsistent findings call for greater rigor in examining this relation (Lillard et al., 2013). Spontaneous pretend play is often impacted in atypical development, notably in autism spectrum disorder (ASD). Since ASD traits exist along a continuum in the general population, investigating how pretend play varies across the range of ASD symptoms by indexing variations in ASD traits in both typically developing and ASD populations may provide insight into how ASD symptoms may influence the relation between pretend play and associated processes in cognitive development. This study used rigorous observational methods to assess spontaneous pretend play. Specifically, 5-min free-play sessions with two discrete toy sets were double-coded by blinded coders (coder assignment counterbalanced). Key facets of pretense development [attribution of pretend properties (APP), object substitution (OS), imaginary objects] were examined. These facets of pretend play production were then analyzed in relation to ASD symptoms, as well as plausible, long-theorized correlates [theory of mind (ToM), verbal ability, familiarity, and interest in specific toys]. Forty children (M_age = 6;5, SD_age = 1.45; 29 males), six of whom met the threshold for ASD diagnosis via parent-reported ASD symptoms, participated in play sessions and completed measures of verbal IQ and ToM. Besides the measure of child ASD symptoms, parents completed a survey of their child's interest in and familiarity with the play session toys. Overall, greater ToM predicted more APP, and more interest in the toys presented predicted more OS. In terms of overall pretend play production, two results were counterintuitive. First, among children with more ASD symptoms, verbal ability marginally negatively predicted pretend play production. Second, among children with fewer ASD symptoms, ToM negatively predicted pretend play production. Further probing revealed that the negative effect of ASD symptoms on pretend play was simultaneously moderated by both variables: low ToM and high verbal ability both related to less pretend play production among children with more ASD symptoms. Implications for assessment and subsequent treatment for pretend ability among children with varying degrees of ASD symptoms, as well as for future research, are discussed.

Dysregulation of pretend play and communication development in children with autism

We hypothesized that the difficulties of the child with autism originate from disorders of organization and regulation of actions according to environmental changes. Autism impoverishes general mental representation skills, which are the basis of symbolic play and the development of communication. Twenty-one children with autism were compared with 14 children with global intellectual impairment and 15 matched typically developing children, on both regulation of play activities and communication development. Regulation of play was very disordered in children with autism, with breaking off, dissociation and instability of actions. However, in directed play their actions were more structured and corresponded to a better developmental level. In addition, dysregulation was associated with delayed, heterogeneous development of communication skills. The results of this study are in line with our hypotheses and emphasize the role of symbolic play in differential diagnosis and the value of therapies based on regulation processes and symbolic play.

Transfer of the Picture-in-the-Head Analogy to Natural Contexts to Aid False Belief Understanding in Autism

Interventions to build false belief understanding in people with autism have successfully used a picture-in-the-head technique to illustrate that seeing directs actions. However, participants who subsequently passed some novel false belief tasks could not do so in real-life settings. The present intervention aimed to bridge this gap in understanding by using teaching methods that linked picture-in-the-head dolls to videos of actors in natural settings. The intervention comprised three levels. At level 1, participants were taught that seeing leads to knowing. At level 2, they were helped to pass false belief scenarios using picture-in-the-head dolls. At level 3, they were guided from these scenes to similar stories on video in which people acted out the false belief events. At post-test, seven out of ten subjects (mean verbal mental age 4:2 years) passed at least two out of three novel video-recorded false belief stories. However, some participants required narration in order to complete the tasks. Observation of the learning process across individuals indicated that there are subgroups of people with autism who have different areas of difficulty.

A Review of Research into Pretend Play in Autism

Autism is currently diagnosed, in part at least, on the basis of problems in imagination. The article reviews the empirical evidence of difficulties in pretend play in autism, and focuses in particular on individuals’ ability to engage in pretence in free play conditions, to produce pretence in more structured situations, and to make sense of pretend actions carried out by another person. These data suggest that individuals with autism have a marked difficulty in producing pretend play, but one that is reduced by providing substantial structure to the play situation or by testing comprehension of pretence. The implications of these findings for theories of pretend play in autism, in terms of an inability to conceive of non-literal situations, a difficulty in imposing a pretend usage on an object, or a failure to gain a benefit from engaging in pretend play, are discussed.

Social cognition and psychopathology: a critical overview

The philosophical and interdisciplinary debate about the nature of social cognition, and the processes involved, has important implications for psychiatry. On one account, mindreading depends on making theoretical inferences about another person's mental states based on knowledge of folk psychology, the so-called "theory theory" (TT). On a different account, "simulation theory" (ST), mindreading depends on simulating the other's mental states within one's own mental or motor system. A third approach, "interaction theory" (IT), looks to embodied processes (involving movement, gesture, facial expression, vocal intonation, etc.) and the dynamics of intersubjective interactions (joint attention, joint action, and processes not confined to an individual system) in highly contextualized situations to explain social cognition, and disruptions of these processes in some psychopathological conditions. In this paper, we present a brief summary of these three theoretical frameworks (TT, ST, IT). We then focus on impaired social abilities in autism and schizophrenia from the perspective of the three approaches. We discuss the limitations of such approaches in the scientific studies of these and other pathologies, and we close with a short reflection on the future of the field. In this regard we argue that, to the extent that TT, ST and IT offer explanations that capture different (limited) aspects of social cognition, a pluralist approach might be best.

Autism and epistemology IV: Does autism need a theory of mind?

In their article, "Does the autistic child have a 'theory of mind'?," Baron-Cohen et al. [1985] proposed a novel paradigm to explain social impairment in children diagnosed as autistic (AD). Much research has been undertaken since their article went to print. The purpose of this commentary is to gauge whether Theory of Mind (ToM)-or lack thereof-is a valid model for explaining abnormal social behavior in children with AD. ToM is defined as "the ability to impute mental states to oneself and to others" and "the ability to make inferences about what other people believe to be the case." The source for their model was provided by an article published earlier by Premack and Woodruff, "Does the chimpanzee have a theory of mind?" Later research in chimpanzees did not support a ToM in primates. From the outset, ToM as a neurocognitive model of autism has had many shortcomings-methodological, logical, and empirical. Other ToM assumptions, for example, its universality in all children in all cultures and socioeconomic conditions, are not supported by data. The age at which a ToM emerges, or events that presage a ToM, are too often not corroborated. Recent studies of mirror neurons, their location and interconnections in brain, their relationship to social behavior and language, and the effect of lesions there on speech, language and social behavior, strongly suggests that a neurobiological as opposed to neurocognitive model of autism is a more parsimonious explanation for the social and behavioral phenotypes observed in autism.

Symbolic play of preschoolers with severe communication impairments with autism and other developmental delays: more similarities than differences

Children with autism are often described as having deficient play skills, particularly symbolic play. We compared the play of 35 children with autism to 38 children with other developmental delays. All children were preschool-age and produced less than 20 different words. Results indicated no significant differences across the two groups in their play. Children with autism engaged in more conventional play, that is, putting objects together according to how the toys were constructed (e.g., pieces in a puzzle, lid on a teapot). Results also indicated high correlations between play, language, and cognitive measures. Findings indicate that play relates to language and cognitive levels yet may not discriminate children with autism and children with other developmental delays early in their development.

Play behaviours and play object preferences of young children with autistic disorder in a clinical play environment

Play is the primary occupation of childhood and provides a potentially powerful means of assessing and treating children with autistic disorder. This study utilized a cross-sectional comparison design to investigate the nature of play engagement in children with AD (n = 24), relative to typically developing children (n = 34) matched for chronological age. Play behaviours were recorded in a clinical play environment. Videotapes comprising 15 minutes of the children's spontaneous play behaviour were analysed using time-interval analysis. The particular play behaviours observed and play objects used were coded. Differences in play behaviours (p < 0.0001) and play object preferences (p < 0.0001) were identified between the groups. Findings regarding play behaviour contribute to contention in the literature surrounding functional and symbolic play. Explanations for play object preferences are postulated. Recommendations are made regarding clinical application of findings in terms of enhancing assessment and intervention by augmenting motivation.

Weak central coherence, poor joint attention, and low verbal ability: independent deficits in early autism

C. Jarrold, W. Butler, E. M. Cottington, and F. Jiminez (2000) proposed that weak central coherence is a primary cognitive deficit in autism and speculated that it may even account for theory of mind impairments. The current study investigated whether weak central coherence could account for deficits in 2 behaviors purported to tap capabilities fundamental to a theory of mind: joint attention and pretend play. Twenty-one children (ages 3-5 years) with autism spectrum disorders were matched to 21 control children on chronological age, nonverbal ability, and gender. Pretend play did not differentiate the groups. Weak central coherence, poor joint attention, and low verbal ability contributed significantly and independently to the prediction of autism group membership, a finding consistent with 3 independent cognitive deficits underlying autism.

Cognitive underpinnings of pretend play in autism

This article examines the cognitive underpinnings of spontaneous and prompted pretend play in 28 young children with autism, 24 children with other developmental disorders, and 26 typical children. The article compares theories that consider either theory of mind (ToM) or executive function (EF) to be causally important deficits in the development of pretend play in autism and important factors in pretend play. Each of these two theories posits a cognitive precursor to pretense, which would need to be present in typical development, and the absence of which could explain pretend play deficits in children with developmental disabilities such as autism. We tested which of these theories better predicts a child's production of pretend play. Children with autism were significantly delayed on pretend play scores. They also had significant deficits in our ToM measure, but not our EF measures. Regression analyses suggested a role for our measure of generativity, one of the EF measures.

Spontaneous play in children with autism: a reappraisal

Much controversy remains regarding the ability of children with autism to engage in spontaneous play. In this study children with autism, Down syndrome and typical development with verbal mental ages of approximately 2 years were assessed for play abilities at three data points. Even in this group of children with autism, who had relatively low verbal mental ages, symbolic play skills were not totally absent. However, it was possible to distinguish their pattern of play behaviors from the other two groups. Consequentially, it is argued that there are unusual features in early spontaneous play in children with autism and these atypical patterns are not restricted to their difficulties in the production of symbolic play. Such differences in early spontaneous play raise interesting questions about the etiology of autism, the direction of future research, and the theoretical models that can account for the condition.

Imitation of pretend play acts by children with autism and Down syndrome

Although there has recently been considerable research interest in the difficulties that children with autism have engaging in pretend play, little attention has been paid to the ability of these children to imitate pretend play acts. Furthermore, suggestions that children with Down syndrome have relatively advanced abilities in pretend play have not been accompanied by an examination of their capacity to imitate pretend play. Three groups of children: autistic, Down syndrome, and normally developing were studied for their capacity to imitate single pretend acts and a series of pretend acts that formed scripts. While the children with autism were surprisingly better than the other two groups on the single-scheme task, they demonstrated specific difficulties on the multischeme task. Results are discussed in relation to current theories of autism and the notion of imitation.

Autism: towards an integration of clinical, genetic, neuropsychological, and neurobiological perspectives

Autism constitutes one of the best validated child psychiatric disorders. Empirical research has succeeded in delineating the key clinical phenomena, in demonstrating strong genetic influences on the underlying liability, and in identifying basic cognitive deficits. A range of neurobiological abnormalities has also been found, although the replicability of specific findings has not been high. An understanding of the causal processes leading to autism, and accounting for the marked variability in its manifestations, requires an integration across these different levels of enquiry. Although this is not yet possible, a partial integration provides a useful strategy for identifying key research questions, the limitations of existing hypotheses, and future research directions that are likely to prove fruitful. The research findings for each research level are critically reviewed in order to consider how to move towards an integration across levels.

Generativity in the play of young people with autism

Examines the ability of young people with autism to generate ideas for play. Young people with autism, children with learning difficulties, and younger normal children were asked to generate 12 different actions and follow 12 instructions with a car and a doll. The young people with autism were impaired, relative to the controls, at generating original actions with the car, but were as able as the controls to follow the instructions. However, the young people with autism were not impaired at generating original actions with the doll. All three groups produced similar amounts of symbolic play. Possible explanations for the difference in results for the two toys are discussed.

Executive function deficits and the pretend play of children with autism: a research note

The failure to produce pretend play seen in autism may arise from executive deficits associated with the syndrome. This experiment investigated the ability of children with autism to use various objects in pretence, the prediction being that they would have particular difficulty using props with a clear function (e.g. a pencil) to perform a different pretend function (e.g. to act as a toothbrush). However, children with autism were as likely as controls to select a prop with an inappropriate function from amongst other, nonfunctional props, suggesting that executive deficits of this particular kind cannot readily explain an absence of pretend play in autism.