Impaired Competence for Pretense in Children with Autism: Exploring Potential Cognitive Predictors

Playing to Pretend or "Pretending" to Play: Play in Children with Autism Spectrum Disorder

Children diagnosed with autism spectrum disorder (ASD) exhibit early delays and deficits in play. In infancy, they engage in unusual exploratory behaviors with toys. As toddlers, they are slow to develop functional play, and in preschool some children with ASD fail to develop symbolic play despite having the necessary cognitive and language skills. Furthermore, when children with ASD are engaged in play, they demonstrate less playfulness. This article reviews the literature on the characteristics of exploratory, functional, and symbolic/pretend play in children with ASD and possible reasons for their unusual patterns of play development. Increased quantity and quality of play are frequent therapeutic goals for children with ASD. If play interventions are to be successful, it is critical that speech-language pathologists have an adequate assessment of children's play skills. Several frameworks and tools appropriate for assessing play in typical children and children with ASD are described.

An Analogical Model of Pretense

We argue that pretense can be viewed as analogical projection: a structural comparison between the pretend scenario and its real-world counterpart that leads to inferences about the pretend scenario. For example, in pretending to make a phone call with a banana, a number pad might be projected on the banana's surface. We model two empirical studies of early childhood pretense, and show how successful pretense requires making and accepting such inferences, while failed pretense can be traced to failure of such projection. Other models of pretense, both theoretical and computational, and their relationships to our model, are discussed.

The process of Learn to Play Therapy with parent-child dyads with children who have autism spectrum disorder

INTRODUCTION

Learn to Play Therapy aims to build children's ability to spontaneously initiate pretend play. The purpose of this study was to explore evidence for this therapy for children with autism spectrum disorder by investigating the changes in a child's pretend play and key techniques used in the process of therapy.

METHODS

Six children with a diagnosis of autism spectrum disorder (mean age = 3.8 years; SD = 1.2 years) were engaged in therapy sessions with a parent. Four therapy session videos for each child were selected across four time points from 15 videos of each child, representing 6 months of therapy. Retrospective video analysis was used to investigate the changes in the child's ability by coding six play skills and enjoyment of play. Key techniques in the process of Learn to Play Therapy were analysed by frequency of occurrence during sessions.

RESULTS

There was a significant increase in the child's pretend play ability for play scripts (p = .042), sequences of play actions (p = .043), object substitution (p = .043), doll/teddy play (p = .028), social interaction (p = .043) and enjoyment (p = .026). There was a mirroring of the therapist, parent and child for all key techniques, with parents showing increased frequency rates after Time 1. Repetition with variation decreased by Time 4. Challenging the child showed higher rates in Times 2 and 4. Focussed attention remained stable, and the child's talk during play had the highest total frequency.

CONCLUSION

Learn to Play Therapy is an effective therapy in building pretend play ability in children with autism, with parents increasing their involvement in using the key techniques after Time 1. The results inform therapists on how the key techniques were used within the therapy sessions to increase the child's pretend play ability.

Specificity of executive function and theory of mind performance in relation to attention-deficit/hyperactivity symptoms in autism spectrum disorders

Background

Individuals with autism spectrum disorder (ASD) frequently demonstrate symptoms of attention-deficit/hyperactivity disorder (ADHD). Previous findings in children with ASD have suggested that these symptoms are associated with an impairment in executive function (EF) abilities. However, studies rarely considered this association within a single framework that controls for other related factors such as Theory of Mind (ToM) abilities and ASD symptoms.

Methods

We used structural equation modeling to explore the relations among EF, ToM, and symptoms of ASD and ADHD, using data from a population-based sample of 100 adolescents with ASD and full-scale IQ ≥ 50 (the Special Needs and Autism Project (SNAP) cohort). The study used a multi-measure and multi-informant approach, where performance of inhibition, planning, switching, and working memory tasks indexed EF and performance on tasks involving mentalizing indexed ToM. Measures of ASD and ADHD symptoms included parent and teacher reports and direct observation of the children. Shared source of symptom reporting was accounted for with a parental rating latent factor indexed by symptom measures reported by parents.

Results

Impairments in EF abilities were specifically associated with ADHD symptoms while impaired ToM was specifically associated with ASD symptoms, when accounting for the associations of each cognitive domain with the other factors. ASD and ADHD symptom latent factors were also correlated, but this association became nonsignificant once the shared source of reporting from parents was accounted for and within a model that also controlled for the correlated pathway between EF and ToM factors. The specific relations between the cognitive domains and behavioral symptoms remained even after controlling for IQ.

Conclusions

In this ASD sample, symptoms of ADHD and ASD are underpinned by separate cognitive domains. The association between EF and ToM impairments is a likely partial explanation for the co-occurrence of ADHD symptoms in ASD, but the role of shared reporting effects is also important and supports the inclusion of independent informants and objective measures in future research.

Theory of mind predominantly associated with the quality, not quantity, of pretend play in children with autism spectrum disorder

This study aimed to clarify the relationships between theory of mind and pretend play in children with autism spectrum disorder, using refined assessments of theory of mind and pretend play while controlling for autistic behaviors and verbal comprehension. A total of 92 children with autism spectrum disorder aged 4-10 years were enrolled. In two visits, the children were assessed with the Theory of Mind Task Battery, the Child-Initiated Pretend Play Assessment, the Childhood Autism Rating Scale, and the Verbal Comprehension Index of the Wechsler Intelligence Scales, respectively, for their theory of mind, pretend play performance, autistic behaviors, and verbal comprehension. The hierarchical regression models showed that in addition to the contributions of the autistic behaviors and verbal comprehension scores, the theory of mind scores positively predicted (p < 0.001) the elaborateness scores of pretend play in the conventional imaginative and symbolic play contexts, respectively, accounting for an additional 8.1 and 18.5% of the variance, but did not predict the scores for number of object substitutions or imitated actions. The findings demonstrate that theory of mind has a predominant role in the quality, not the quantity, of pretend play of children with autism spectrum disorder, when the children's autistic behaviors and verbal comprehension are considered. This study fills a gap in the previous literature and provides information useful for clinicians and researchers on the relationships between theory of mind and pretend play in children with autism spectrum disorder.

Theory of Mind Deficit is Associated with Pretend Play Performance, but not Playfulness, in Children with Autism Spectrum Disorder

Objective/Background

This study aimed to examine the relationships of theory of mind (ToM) to both pretend play and playfulness in children with autism spectrum disorder (ASD).

Methods

Twenty children with ASD aged between 3 years and 7.11 years were assessed with the ToM test, and then placed in a free play condition and a pretend play condition to assess pretend play and playfulness with the Child-Initiated Pretend Play Assessment and Test of Playfulness, respectively. In addition, the children's symptom severities of ASD and verbal abilities were also assessed with the Childhood Autism Rating Scale (CARS) and Receptive and Expressive Vocabulary Test—second edition, respectively.

Results

The results of the regression analysis confirmed that ToM significantly predicted pretend play variables, namely, Number of Object Substitutions (R² = .158, p = .002) and Number of Imitated Actions (R² = .175, p = .001), but not playfulness. The CARS score was a significant predictor of the Percentage of Elaborate Pretend Play Actions of pretend play (R² = .075, p = .034), as well as the internal control (R² = .125, p = .006) and framing (R² = .071, p = .039) variables of playfulness.

Conclusion

The findings support the idea that children with ASD who have better ToM might be able to develop better pretend play, but not better playfulness, which might be more strongly related to their autistic severity.

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.

Measuring the development of inhibitory control: The challenge of heterotypic continuity

Inhibitory control is thought to demonstrate heterotypic continuity, in other words, continuity in its purpose or function but changes in its behavioral manifestation over time. This creates major methodological challenges for studying the development of inhibitory control in childhood including construct validity, developmental appropriateness and sensitivity of measures, and longitudinal factorial invariance. We meta-analyzed 198 studies using measures of inhibitory control, a key aspect of self-regulation, to estimate age ranges of usefulness for each measure. The inhibitory control measures showed limited age ranges of usefulness owing to ceiling/floor effects. Tasks were useful, on average, for a developmental span of less than 3 years. This suggests that measuring inhibitory control over longer spans of development may require use of different measures at different time points, seeking to measure heterotypic continuity. We suggest ways to study the development of inhibitory control, with overlapping measurement in a structural equation modeling framework and tests of longitudinal factorial or measurement invariance. However, as valuable as this would be for the area, we also point out that establishing longitudinal factorial invariance is neither sufficient nor necessary for examining developmental change. Any study of developmental change should be guided by theory and construct validity, aiming toward a better empirical and theoretical approach to the selection and combination of measures.

Pretend play

Pretend play is a form of playful behavior that involves nonliteral action. Although on the surface this activity appears to be merely for fun, recent research has discovered that children's pretend play has connections to important cognitive and social skills, such as symbolic thinking, theory of mind, and counterfactual reasoning. The current article first defines pretend play and then reviews the arguments and evidence for these three connections. Pretend play has a nonliteral correspondence to reality, hence pretending may provide children with practice with navigating symbolic relationships, which may strengthen their language skills. Pretend play and theory of mind reasoning share a focus on others' mental states in order to correctly interpret their behavior, hence pretending and theory of mind may be mutually supportive in development. Pretend play and counterfactual reasoning both involve representing nonreal states of affairs, hence pretending may facilitate children's counterfactual abilities. These connections make pretend play an important phenomenon in cognitive science: Studying children's pretend play can provide insight into these other abilities and their developmental trajectories, and thereby into human cognitive architecture and its development.

Exploring the ‘fractionation’ of autism at the cognitive level

Autism spectrum disorders are defined by difficulties across a range of areas: social and communication difficulties and restricted and repetitive behaviours and interests. It has been suggested that this triad of symptoms cannot be explained by a single cause at the genetic, neural or cognitive level. This article reviews the evidence for a ‘fractionable’ autism triad at the cognitive level, highlighting questions for future research.