Play Assessments and Developmental Skills in Young Children With Autism Spectrum Disorders

Abstract

Appropriate play behaviors facilitate language skills, increase cognitive skills, and provide opportunity for social interaction. However, play skills often present differently in children with Autism Spectrum Disorders (ASD). Currently, there are several global standardized ASD measures used during diagnostic evaluations that include, but are not limited to, assessment of play. However, it is unclear whether these measures examine similar aspects of play. This uncertainty is important to explore to better understand the whole profile of children’s play competencies to implement developmentally appropriate interventions and create fitting goals. The current study explored the relations of children’s play measured by clinicians’ observations (Autism Diagnostic Observation Schedule [ADOS], Childhood Autism Rating Scale–Second Edition [CARS2-ST]) and parents’ reports (Adaptive Behavior Assessment System–Second Edition [ABAS-II], Communication and Symbolic Behavior Scales Developmental Profile–Infant/Toddler Checklist [CSBS DP-ITC]). Participants (n = 34) were toddlers and preschool-aged children with ASD. A play composite was created for each aforementioned measure, which included extracted items that specifically examined play skills. Initial results suggested minimal similarities in play composites across measures. Play composites were also compared with children’s developmental skills (Mullen Scales of Early Learning [MSEL]) to explore the reciprocal relationship between play/developmental skills. Results revealed that expressive and receptive language skills, fine motor skills, and visual reception skills (from MSEL) were significantly correlated with specific play composites. This study’s innovative identification of play composites from standardized ASD diagnostic measures highlights the importance of (a) using multiple methodologies to gain a whole profile of children’s play/developmental skills, and (b) selecting interventions matched on children’s current play/developmental skills.

Keywords

autism ASD play assessment intervention

Play is an integral part of early childhood experiences that aid in fostering a number of developmental milestones. For example, appropriate play behaviors facilitate language skills (Beeghly, Weiss-Perry, & Cicchetti, 1990; Lewis, Boucher, Lupton, & Watson, 2000; Lifter & Bloom, 1989), provide opportunity for social interaction (Garvey, 1974; Hobson, Lee, & Hobson, 2009), and increase cognitive skills (Bergen, 2002; Piaget, 1952). Given these reasons, play is often infused into interventions for children with developmental delays, disabilities, and other disorders (Kok, Kong, & Bernard-Opitz, 2002; Lifter, 2000; Lifter, Sulzer-Azaroff, Anderson, & Cowdery, 1993). Specifically, numerous play-based interventions are implemented with children diagnosed with Autism Spectrum Disorder (ASD; Goldstein & Cisar, 1992; Fox & Hanline, 1993; Haring, 1985; Ingersoll & Dvortcsak, 2009; Stahmer, 1995; Thorp, Stahmer, & Schreibman, 1995).

It is known that the quality and sophistication of play are impaired in children with ASD (Baron-Cohen, 1987; Blanc, Adrien, Roux, & Barthelemy, 2005; Jarrold, Boucher, & Smith, 1996; Rutherford & Rogers, 2003; Sigman & Ungerer, 1984) and that these impairments often distinguish children with ASD from children with typical development (Linder, 1993; Ungerer & Sigman, 1981). What remains less clear is (a) how play skills are measured and discussed in the context of assessment and (b) how assessment findings related to play are applied to intervention context and selection of goals. Although the assessment of play is frequently included in an ASD diagnostic battery, it is unclear whether these various measures are assessing similar play composites. For example, children who can successfully participate in play routines may demonstrate a greater response to strategies frequently implemented by early interventionists (Lieberman & Yoder, 2012). Considering the important role of play as both a component of intervention and an outcome measure for young children with ASD, it is important to examine how play is measured to better understand implications for intervention (Hobson et al., 2009).

Purpose of Current Study

No research, to date, has examined the relations of play composites across a variety of measures frequently administered during an ASD diagnostic evaluation. Therefore, it is probable that each of these standardized measures assess different aspects of play (i.e., object vs. symbolic vs. creativity). It is important to acknowledge whether these measures do indeed assess different aspects of play to understand a child’s unique play profile and to, ultimately, tailor appropriate intervention strategies and goals. Thus, this research primarily explored relations of how play is assessed across four standardized measures used during diagnostic evaluations: (a) Adaptive Behavior Assessment System–Second Edition (ABAS-II; Harrison & Oakland, 2003), (b) Autism Diagnostic Observation Schedule (ADOS; Lord, Rutter, DiLavore, & Risi, 2002), (c) Childhood Autism Rating Scale–Second Edition (CARS2-ST; Schopler, Van Bourgondien, Wellman, & Love, 2010), and (d) Communication and Symbolic Behavior Scales Developmental Profile–Infant/Toddler Checklist (CSBS DP-ITC; Wetherby & Prizant, 2002). That is, the present study explored the degree to which play skills from each of these measures agreed with or differed from the other measures (i.e., concurrent validity).

Secondarily, this study examined whether play composites from the four aforementioned measures related to children’s developmental profiles measured by the Mullen Scales of Early Learning (MSEL; Mullen, 1995). Overall, this study aimed to (a) identify relations of play composites from four standardized measures, and (b) assess the relationship between children’s developmental skills and the play composites from four standardized measures (i.e., ADOS, CARS2-ST, ABAS-II, and CSBS DP-ITC). In general, these aims are purposeful in guiding appropriate selection and implementation of play-based interventions for children with ASD by understanding profiles of play skills and developmental skills.

Play in Children With ASD

Young children with ASD often display repetitive, nonfunctional behaviors (e.g., spinning or lining up objects) to a degree that differentiates them from toddlers with developmental delays and typical development (Morgan, Wetherby, & Barber, 2008; Richler, Bishop, Kleinke, & Lord, 2007; Wetherby et al., 2004). These repetitive behaviors interfere with the development of joint attention (Bruckner & Yoder, 2007) and play (Honey, Leekam, Turner, & McConachie, 2007). In addition, delays in more complex play behaviors (e.g., pretend play) persist across childhood, which is corroborated by a variety of studies showing impoverished pretend play skills evident throughout preschool and elementary years (Gould, 1986; Riguet, Taylor, Benaroya, & Klein, 1981; Sigman & Ungerer, 1984; Ungerer & Sigman, 1981; Wing, Gould, Yeates, & Brierly, 1977).

Indeed, atypical development of play is considered a core diagnostic symptom of ASD (Diagnostic and Statistical Manual of Mental Disorders [4th ed., text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000]) in which play might be used informally as an early diagnostic indicator. However, little is know about the diagnostic value of play relative to intervention context and intervention goals. The goals of the current study are important for practical applications because early intervention models often occur in play contexts (Fox & Hanline, 1993; Goldstein & Cisar, 1992; Haring, 1985; Ingersoll & Dvortcsak, 2009; Stahmer, 1995; Thorp et al., 1995). Thus, it is important to ensure that children’s play skills are matched with appropriate play-based interventions. Because of the link between play skills and language development in children with typical development, interventions for young children with ASD often focus on teaching pretend play (Kasari, Gulsrud, Wong, Kwon, & Locke, 2010). Indeed, children with ASD are capable of engaging in pretend play, especially when guided by another individual (e.g., parent/peer; Charman et al., 1997; Jarrold, Boucher, & Smith, 1993; Stahmer, 1995; Wolfberg, 2009). Therefore, it is critical to better understand the aspects of play assessed by frequently used diagnostic measures, how these measures relate with one another, and how they relate to concurrent developmental skills.

How Play Is Measured in ASD

Despite the importance of play in both the diagnosis and treatment of toddlers and preschool-aged children with ASD, there is little research on the effective measurement of play in this population. It is often difficult to assess play as children might not show the same play behaviors in the clinic or classroom that they show at home in their natural environments (Kasari et al., 2010; Sherratt, 2002). This suggests that a combination of parent reports and clinician observations may be needed to ensure that children have optimal opportunity to reveal their competent play skills (Kasari et al., 2010). Therefore, a goal of this study was to examine parents’ and clinicians’ reports/observations of children’s play through standardized measurements and identify whether play skills assessed through these measurements are related (i.e., concurrent validity).

There are a variety of parent-report and clinician observation measures that are used during ASD diagnostic evaluations, which each measure contains items that address children’s play skills and abilities. However, little is known about the concurrent validity of these measures given that a variety of play skills are assessed by parent-report and clinician observation measures. Therefore, the purpose of the present study is to examine the relation between four commonly used standardized diagnostic instruments that include, but are not limited to, items that measure play skills: (a) ABAS-II, (b) ADOS, (c) CARS2-ST, and (d) CSBS DP-ITC.

Considering the essential role of play as both a component of intervention and an outcome measure for young children with ASD, it is important to examine how play is measured. Although play is frequently measured in an ASD assessment battery using different autism-specific and developmental assessments, it is unclear whether these various measures are assessing similar play skills. Therefore, it is probable that each of these standardized measures assess different aspects of play (e.g., object vs. symbolic). Few studies have directly compared different assessment tools used in autism evaluations, which leaves clinicians with little guidance regarding measurement selection (Ozonoff, Goodlin-Jones, & Solomon, 2005). Furthermore, no research, to date, has examined the similarities of play skills across a variety of measures frequently administered during an ASD diagnostic evaluation. Therefore, the current study is influential for two primary reasons. First, it highlights the importance of evaluating play as an intrinsic window into development, and second, it can inform best practices for therapy because early intervention is often delivered within a play context.

Thus, this research primarily explored relations of how play is assessed across four standardized measures: (a) ABAS-II (Harrison & Oakland, 2003), (b) ADOS (Lord et al., 2002), (c) CARS2-ST (Schopler et al., 2010), and (d) CSBS DP-ITC (Wetherby & Prizant, 2002).

Secondarily, this study examined whether play skills from the four aforementioned measures related to children’s developmental skills using the MSEL (Mullen, 1995). Previous research (Stanley & Konstantareas, 2007; Thiemann-Bourque, Brady, & Fleming, 2012) suggested that play and developmental skills are reciprocal in ASD. That is, as play skills improve, developmental skills (e.g., language) also improve. Therefore, it is important to examine whether common assessments that measure aspects of play are related to measures of developmental skills in very young children with ASD. If this relationship is confirmed in young children with ASD, important early intervention considerations may be suggested. That is, individualized goals to improve an aspect of development (e.g., language) should be matched to a child’s level of play to maximize treatment success. Overall, this study aimed to (a) identify correlations between play skills from four standardized measures and (b) assess the relations between children’s developmental skills from the MSEL and play skills from the ADOS, CARS2-ST, ABAS-II, and CSBS DP-ITC.

Method

Participants

Participants were 34 toddler and preschool-aged children diagnosed with ASD (M = 33 months; SD = 8.33 months; range = 19.5–56 months; 28 males and 6 females) recruited from a university based multidisciplinary ASD research clinic. The inclusion criteria for this study were young children with (a) a diagnosis of ASD and (b) normal hearing. Clinicians trained in early identification of ASD, including the second and last authors, diagnosed children with ASD using a comprehensive assessment battery that included formal and informal measures of autism symptoms, developmental skills, receptive and expressive language skills, adaptive behavior, repetitive behavior, and play skills (see Table 1). Diagnostic evaluations typically occurred across two half-day sessions and involved the child’s caregivers in addition to the multidisciplinary professional team (e.g., clinical psychologist, speech–language pathologist, pediatrician).

Table 1.

Reports of Descriptives From Play Composites on ADOS, ABAS-II, CARS2-ST, and CSBS DP-ITC, and Developmental Skills on MSEL.

Measure	n	M	SD	Range
Play composites
ADOS	22	2.46	1.57	0–5
ABAS-II	31	33.97	10.33	6–49
CARS2-ST	31	6.65	1.41	4–9.5
CSBS DP-ITC	23	11.00	2.66	2–11
MSEL: Developmental skills
Visual reception	34	21.00	9.01	1–42
Fine motor	34	21.68	6.34	6–37
Receptive language	34	14.74	7.51	2–33
Expressive language	34	14.38	8.98	5–33
Overall	34	71.79	29.00	15–132

Note. The maximum score for each play composite from the following measures are as follows: ADOS = 9; ABAS-II = 66; CARS2-ST = 12; CSBS DP-ITC = 11. ADOS = Autism Diagnostic Observation Schedule; ABAS-II = Adaptive Behavior Assessment System–Second Edition; CARS2-ST = Childhood Autism Rating Scale–Second Edition; CSBS DP-ITC = Communication and Symbolic Behavior Scales Developmental Profile–Infant/Toddler Checklist; MSEL = Mullen Scales of Early Learning.

Measures

Licensed clinical psychologists, a licensed speech–language pathologist, and graduate clinical psychology students who were trained and were proficient in early autism assessments administered the evaluation measures. In addition, caregiver(s) completed the parent-report measures. The entire battery of assessments was completed during diagnostic session(s), with the following questionnaires/screeners extracted from the clinical database: (a) ADOS, (b) ABAS-II, (c) CARS2-ST, (d) CSBS DP-ITC, and (e) MSEL. Specifically, clinicians administered the MSEL to establish children’s developmental level and administered the ADOS to assess ASD symptoms.

Measures of play skills

The following measures were completed by the clinical multidisciplinary team and caregivers during the diagnostic assessment battery. Individual items that evaluate play skills were aggregated to form individual play composites for each measure.

Clinician measures

ADOS

The ADOS (Lord et al., 2002) is a structured play session conducted by clinicians, which includes a series of social communication and play “presses” to diagnose ASD. For younger children, social interest, joint attention, communication, symbolic play, and repetitive behaviors are assessed (Ozonoff et al., 2005). The current study included the Toddler Module and Module 1 based on the language skills present in children with ASD between 18 and 48 months of age. Validity on these modules ranges from .72 to .78 and reliability ranges from .80 to .92 (Lord et al., 2002). Sensitivity for these modules ranges from .80 to 1.0, and specificity ranges from 73 to 100 (Lord et al., 2002). Considering the “gold standard” for autism assessments, the ADOS is commonly used in combination with other measures of development to determine whether a child has an ASD (Gotham, Risi, Pickles, & Lord, 2007). Few studies have compared constructs assessed with the ADOS with other assessment tools that measure similar constructs (i.e., play). For the ADOS play composite, there were a maximum of three items (depending on which module was administered) that addressed play (i.e., functional play with objects, imagination/creativity, and functional/symbolic imitation). Scores from these specific items were isolated to create the play composite from the ADOS. For example, during the ADOS, the examiner creates a pretend birthday party with a doll, play-dough cake, candles, a cup, napkin, and utensils. A child’s functional play skills are also observed during a free play/warm-up time at the beginning of the assessment. Toys presented could elicit functional play skills with objects that might include playing with a pop-up toy, stacking blocks, or using a play phone. The imagination/creativity scale is scored based on a child’s spontaneous, creative, or original use of objects. The examiner follows a script designed to engage the child while maintaining a flexible but standard format to observe autism symptoms as well as play skills.

CARS2-ST

The CARS2-ST (Schopler et al., 2010) is a 15-item measure that clinicians complete based on observations from the child and subsequent interviews with the caregivers. There are 15 domains on the CARS2-ST that include (a) relating to people; (b) imitation; (c) emotional response; (d) body use; (e) object use; (f) adaptation to change; (g) visual response; (h) listening response; (i) taste, smell, and touch response and use; (j) fear or nervousness; (k) verbal communication; (l) nonverbal communication; (m) activity level; (n) level and consistency of intellectual response; and (o) general impressions. Each of these domains is scored by clinicians from 1 (i.e., representative of typical development) to 4 (i.e., representative of atypical development) to indicate the severity of ASD. The total score on the CARS2-ST reflects the symptom level of ASD with lower scores indicating minimal ASD symptoms and higher scores representing severe ASD symptoms. Validity is .83 and reliability is .71 for the CARS2-ST. Specifically, from the 15 domains on this measure, item scores from 3 domains (i.e., imitation, object use, and activity level) were isolated for the play composite from the CARS2-ST, given that these domains reflect skills used during play.

For example, during an evaluation, a child was given a box of racecars. He carefully lined each racecar up on the table then, one by one, picked up a car and repetitively spun the wheels. The examiner modeled rolling the cars, crashing the cars, and racing the cars. The child attended to the clinician’s play, without imitating any of her actions. This child was given a score of 3 for object use (Moderately inappropriate interest in, or use of, toys and other objects, or may be preoccupied with using an object or toy in some strange way. He or she may focus on some insignificant part of a toy, become fascinated with light reflecting off the object, repetitively move some part of the object, or play with one object exclusively) and a 3 on Imitation (Moderately abnormal imitation—The child imitates only part of the time and requires a great deal of persistence and help from the adult; frequently imitates only after a delay). It is important to note that scores from the CARS2-ST would not solely be based on one example, such as the previous scenario. Rather, this example would be considered along with other relevant observations during a 10- to 15-min interval, which, together, would contribute to each domain score.

Parent measures

CSBS DP-ITC

This screener contains 24 items and assesses children’s communication and play skills (Wetherby & Prizant, 2002). The CSBS DP-ITC is used to screen and evaluate children for communicative delays or disabilities using the following seven domains: (a) emotion and eye gaze, (b) communication, (c) gestures, (d) sounds, (e) words, (f) understanding, and (g) object use. Sensitivity for the CSBS DP-ITC is .78, and specificity is .84 (Wetherby et al., 2004). This measure is intended for assessment of children between 6 and 24 months of age. However, the screener may be used descriptively in older children who demonstrate substantial communication delays. Specifically, scores from the four items within the “object use” domain were isolated for the play composite from the CSBS DP-ITC. Questions include, “About how many blocks (or rings) does your child stack?” and “Does your child pretend play with toys (for example, feed a stuffed animal, put a doll to sleep, put an animal figure in a vehicle)?”

ABAS-II

The ABAS-II (Harrison & Oakland, 2003) is a 242-item questionnaire that assesses 10 skill areas of individuals: (a) communication, (b) community use, (c) functional preacademics, (d) home living, (e) health and safety, (f) leisure, (g) self-care, (h) self-direction, (i) social, and (j) motor. Caregivers completed this questionnaire by rating each item from 0 (i.e., child is not able to perform the skill) to 3 (i.e., child [almost] always performs the skill). Scores from the 22 items within the leisure section were extracted to isolate a play composite from the ABAS-II. Questions from the leisure section include, “Plays simple games like ‘peek-a-boo’ or rolls a ball to others?” and “Plays with toys, games, or other fun items with other people?” Validity for ABAS-II is .82 and reliability is .85.

Measure of developmental skills

The following measure was completed by the clinical team during the diagnostic assessment battery and contains domains that evaluate developmental skills.

MSEL

The MSEL (Mullen, 1995) is a standardized screening/diagnostic tool conducted by a clinician that examines the following domains of children’s developmental skills: (a) gross motor, (b) visual reception, (c) fine motor, (d) receptive language, and (e) expressive language. This tool is targeted to assess skills from infancy through early childhood. Validity for the MSEL is .65 to .82 and reliability is .8.

Procedure

To begin, caregivers of each child signed consent forms to allow data collected from his or her child’s diagnostic evaluation to be entered into a longitudinal database associated with the university based ASD research clinic. All data were obtained from children’s diagnostic evaluations that occurred on 1 to 2 days for each participant. A multidisciplinary team (e.g., licensed clinical psychologists, licensed speech-language pathologist, pediatrician, and graduate students) collaboratively conducted the diagnostic evaluations with each child, as aforementioned.

Results

The following results report, first, on descriptives of play composites and developmental skills and, second, on play composites’ correlations and play composites’ correlations with developmental skills.

Play Composites’ Descriptives

For the direct assessment measure, the ADOS play composite scores (i.e., three items that assessed functional play with objects, imagination/creativity, and functional/symbolic imitation) ranged from 0 to 5 with higher scores indicating more ASD qualities and poorer play skills observed by the clinician (n = 22; M = 2.45, SD = 1.57), with aggregate scores on the ADOS play composite ranging from 0 to 5. For the clinical summary assessment, the CARS2-ST play composite consisted of three items ranging from 1 to 4 (n = 31; M = 6.65, SD = 1.41), with aggregate scores on the CARS2-ST play composite ranging from 4 to 9.5. Higher scores indicated more ASD qualities (i.e., severe symptomatology) and poorer play skills observed by the clinician. Finally, for the parent-report measures, the CSBS DP-ITC play composite consisted of four items from the “object use” domain ranging from 0 to 11 (n = 23; M = 7.22, SD = 2.66), with aggregate scores on the CSBS DP-ITC play composite ranging from 2 to 11. Higher scores indicated parents reporting better development in play skills whereas lower scores indicated poorer development in (e.g., less appropriate) play skills. The ABAS-II play composite scores (i.e., leisure subset) consisted of 22 items ranging from 0 to 3, with the aggregate score ranging from 6 to 49. Higher scores indicated that parents reported the skill occurring more frequently such that children had better developed play skills (n = 31; M = 33.97, SD = 10.33).

MSEL Descriptives

The following are results of children’s developmental skills according to raw scores on the MSEL. First, MSEL visual reception raw scores ranged from 1 to 42 (M = 21.00, SD = 9.01). Raw scores on MSEL fine motor ranged from 6 to 37 (M = 21.68, SD = 6.34). MSEL receptive language raw scores ranged from 2 to 33 (M = 14.74, SD = 7.51). Last, MSEL expressive language raw scores ranged from 5 to 33 (M = 14.38, SD = 8.98). Overall raw scores across these four developmental domains ranged from 15 to 132 with higher scores indicating better developmental skills. Given the heterogeneous nature of developmental and symptom profiles seen in very young children with a diagnosis of ASD, the range of developmental scores in this sample is not uncommon (see Table 1).

Play Composites’ Correlations

Next, Pearson’s correlations were conducted to assess the concurrent validity among play composites from the four assessment measures. That is, correlations were conducted to determine the degree to which play composites agreed across the CSBS DP-ITC, ADOS, CARS2-ST, and ABAS-II. Again, the aforementioned play-related items from each measure were isolated to form four play composites. Pearson’s bivariate correlations revealed that relationships across all play composites, significant and non-significant, were in the expected direction. In other words, parents and clinicians observed and reported similar levels of play skills in children (see Table 2).

Table 2.

Relationship of Play Composites on ADOS, ABAS-II, CARS2-ST, and CSBS DP-ITC (Pearson’s r Reported).

Parent and clinician measures	ABAS-II	CARS2-ST	CSBS DP-ITC
ADOS	−.318	.328	−.248
ABAS-II		−.395*	.586**
CARS2-ST			−.423*

Note. Lower scores on ABAS-II and CSBS DP-ITC reflect more autism symptoms. ADOS = Autism Diagnostic Observation Schedule; ABAS-II = Adaptive Behavior Assessment System–Second Edition; CARS2-ST = Childhood Autism Rating Scale–Second Edition; CSBS DP-ITC = Communication and Symbolic Behavior Scales Developmental Profile–Infant/Toddler Checklist.

p < .05. **p < .005.

Specifically, the correlations of the play composites that were significant are highlighted below. The ABAS-II play composite significantly correlated with the CARS2-ST play composite (r = −.395, p = .034) and the CSBS DP-ITC play composite (r = .586, p = .005). In other words, children’s play skills were similar as reported by parents on the ABAS-II, clinicians on the CARS2-ST, and parent reports on the CSBS DP-ITC play composite. In addition, the CARS2-ST play composite was significantly correlated with the CSBS DP-ITC play composite (r = −.423, p = .044). That is, play skills of children from parent reports on the CSBS DP-ITC and observed by clinicians on the CARS2-ST were similar. Interestingly, no other play composites were significantly correlated. For example, the ADOS (i.e., clinician report) did not significantly correlate with any other of the play composites whether reported by parents or observed by clinicians. This suggests that independent measures examine varying aspects of play (e.g., object vs. symbolic play) across multiple reporters, which highlights the importance of multiple informants (e.g., obtaining parent reports in conjunction with clinician observations on children’s play).

Play Composites’ and Developmental Skills’ Correlations

Following the correlations of the play composites with each other, the play composites were also independently compared with children’s developmental skills based on raw scores from MSEL. Overall, results revealed that receptive language skills, fine motor skills, and visual reception skills were significantly correlated with specific play composites. More specifically, using Pearson’s correlation for the following analyses, children’s receptive language skills significantly correlated with ABAS-II (r = .486, p = .006), CARS2-ST (r = −.468, p = .008), and CSBS DP-ITC (r = .573, p = .004). Children’s expressive language skills were significantly correlated with the play composites from ADOS (r = −.464, p = .03) and CSBS DP-ITC (r = .593, p = .003). Children’s fine motor skills correlated with all play composites: ADOS (r = −.505, p = .017), ABAS-II (r = .534, p = .002), CARS2-ST (r = −.666, p < .001), and CSBS DP-ITC (r = .751, p < .001). Finally, children’s visual reception skills correlated with play composites from CARS2-ST (r = −.465, p = .008) and CSBS DP-ITC (r = .731, p < .001; see Table 3).

Table 3.

Relationship of Developmental Skills and Play Composites (Pearson’s r Reported).

	MSEL: Developmental skills
Play composites	Expressive language	Receptive language	Fine motor	Visual reception
ADOS	−.464*	−.323	−.505*	−.228
ABAS-II	.339	.486*	.534**	.343
CARS2-ST	−.303	−.468*	−.666**	−.465*
CSBS DP-ITC	.593**	.573**	.751**	.731**

Note. Lower scores on ABAS-II and CSBS DP-ITC reflect more autism symptoms. MSEL = Mullen Scales of Early Learning; ADOS = Autism Diagnostic Observation Schedule; ABAS-II = Adaptive Behavior Assessment System–Second Edition; CARS2-ST = Childhood Autism Rating Scale–Second Edition; CSBS DP-ITC = Communication and Symbolic Behavior Scales Developmental Profile–Infant/Toddler Checklist.

p < .05. **p < .005.

Discussion

Play is an important behavior that fosters developmental and social skills in children with ASD. Play and developmental skills are known to have a reciprocal relationship such that children who have minimal play skills generally exhibit delayed or impaired developmental skills (Stanley & Konstantareas, 2007). Play comes in many forms and often varies by setting (home vs. clinic). Thus, it is important to assess various types of play via both clinician and parent report to understand the whole profile of children’s play skills. This is crucial for determining an appropriate play context for intervention. Because play is ubiquitously imbedded into interventions for children (Kok et al., 2002; Lifter, 2000; Lifter et al., 1993), especially for children with ASD (Fox & Hanline, 1993; Goldstein & Cisar, 1992; Haring, 1985; Stahmer, 1995), it is important to examine how play is measured to better understand a child’s unique profile and to select the appropriate intervention context and goals. Thus, this study highlights the importance of assessing play through a variety of measures and informants (e.g., parents/clinicians), as not all items on these measures address similar aspects of play.

The first aim of this study was to assess concurrent validity of the global play composite across various measures frequently used during ASD diagnostic evaluations. In fact, many of the play composites did not correlate with each other. There are various reasons that could contribute to this. It is important to consider that although each of these tools assesses aspects of play, they are each designed to measure different skill domains. That is, the ADOS is considered to be the gold-measure assessment of autism symptomology that examines communication, social interaction, and atypical behaviors within an interactive, semi-structured format. The CARS2-ST is a rating scale for autism symptoms completed by a clinician. The CSBS DP-ITC is a caregiver-completed screener that measures communication, social, and symbolic play skills. Finally, the ABAS-II is a caregiver-completed assessment of adaptive behavior skills. None of these measures was designed to directly or completely tap play skills, although all of them include items related to play and contribute to individualized symptom profiles. For example, some assess functional play more whereas others focus more on symbolic play. In addition, these measures were administered/completed by different informants (i.e., parents and clinicians), such that parents and clinicians could both observe and report differently about children’s play skills. Likewise, the context of children’s play skills could vary. That is, parents have a more holistic observation of children’s play skills whether at home or in a clinic setting. However, clinicians’ reports are based primarily on children’s play skills that are evident during the brief evaluation assessments. Given vast differences of these standardized measures that assess ASD globally, there is variability in the types of play skills each measurement examined (e.g., CSBS DP-ITC focuses on object play). Because play composites from these diagnostic evaluation measures were not all significantly correlated, it suggests that (a) these global measures assess different aspects/types of play and (b) the context of play observations matters. Although play is not the primary skill of interest measured by these standardized assessment tools and it was not possible to compare the same play skills across these common assessments of ASD, this research is indeed the first step in comparing play assessments that contribute to overall measurement of ASD symptoms/adaptive behavior.

The second aim of the study was to examine whether the four play composites related to children’s developmental profiles on MSEL. Similar to existing literature (Stanley & Konstantareas, 2007; Thieman-Borque et al., 2012), it is suggested that play and developmental skills are reciprocal. That is, as play skills improve, developmental skills (e.g., language) also improve. Results revealed that play composites were significantly related to children’s developmental profiles, which corroborates previous research findings that play is related to developmental level (Baron-Cohen, 1987; El’Konin, 1999; Gould, 1986; Stanley & Konstantareas, 2007). Given that play and developmental skills share a reciprocal relationship, this study corroborates the need for selected interventions to match both play and developmental skills.

As suggested by the correlations with developmental skills and play skills, children who displayed better play skills (as measured by the play composites from ADOS, ABAS-II, CARS2-ST, and CSBS DP-ITC) also displayed better developmental skills (as measured by MSEL). These findings are also corroborated by past research (Mundy, Sigman, Ungerer, & Sherman, 1987). The significant correlations between children’s developmental skills and independent play composites, again, emphasize the importance of choosing an intervention matched on children’s current skills that meet both developmental and play goals. For example, if a child demonstrates a deficit in symbolic play on one of these ASD measures, this might provide further insights into their developmental progression. However, if a child demonstrates fragile development skills with regard to symbolic understanding in language, intervention should target this through play, by introducing symbolic play incrementally. Thus, conducting a comprehensive assessment through strategically selected measures that match children’s developmental level and their play styles would be important to best inform therapy goals. For example, it could be suggested to implement an intervention model that captures a child’s initial play skills (Kasari, Paparella, Freeman, Jahromi, 2008; Lieberman & Yoder, 2012). That is, if a child does not engage in socially reciprocal play with a caregiver, intervention should begin by building this level of social play, embedding social communication goals. Once this foundation is established, the clinician could incorporate object play with slightly more complex social communication targets, that is, to follow the typical trajectory of play development. In turn, this could provide the rich, interactive context for social communication development and ideally help a child to be more successful. Alternatively, many early interventionists apply intervention strategies that fit the diagnosis of children (i.e., autism) rather than a unique developmental symptom profile. Therefore, beginning intervention sessions may focus on interactive play routines involving toys with linguistic mapping that may be too sophisticated for particular children, thus compromising children’s intervention success.

Admittedly, there are various measures used during ASD diagnostic evaluations that may contain latent measures of play. Future research could explore these measures to determine whether any of them are valid and reliable measures of play. For example, the Pervasive Developmental Disorder Screening Test-II (PDDST-II; Siegel, 2004; Siegel & Hayer, 1999) is also used during diagnostic evaluations and examines various components of autism behaviors such as common deficient areas (e.g., play). In addition, other developmental measures similar to the MSEL could be compared with these play composites to corroborate prior research of reciprocal relationships between play and developmental skills. For example, the Preschool Language Scale–Fourth Edition (PLS-4; Zimmerman, Steiner, & Pond, 2002) assesses children’s receptive and expressive language, which could correlate with children’s play skills. Another tool that could be incorporated into an autism assessment and/or intervention is a play specific scale. For example, Lifter’s (2000) Developmental Play Assessment (DPA) or the Structured Play Assessment (Ungerer & Sigman, 1981) could be used to systematically identify the level of children’s current play skills to bring them to their potential level of play skills (Kasari, Freeman, & Paparella, 2006).

In conclusion, these data emphasize the importance of using a variety of methodologies to assess children’s play skills. This is important because each standardized measure might not exhibit similar play composites, as evident in this study, such that using a variety of measures and multiple reporters could provide a better profile of children’s play abilities. Overall, it is necessary to have an array of measures to examine various levels and types of children’s play across multiple settings from a variety of reporters. More importantly, this will allow interventionists to select an appropriate intervention or intervention context (skill targets, materials, objects) and develop goals matched on children’s current skills within an appropriate context of play.

Footnotes

Acknowledgements

We thank the children and parents who participated in this study, as well as the personnel at the Autism Spectrum Disorders Clinic who collected the data.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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