Mental State Expression During Peer Play: A Comparison of Typically Developing Children and Children With Autism Spectrum Disorder

Abstract

This study examined the relationship between mental state term use in children with autism spectrum disorder (ASD) and typically developing (TD) children engaged in play. Expression of mental state terms was used as an indicator of theory of mind (ToM) skills. Archived data were used to compare mental state term use for five ASD-TD dyads engaged in various play contexts. During imaginative play, children with ASD used fewer cognition mental state terms than TD children but used a similar number of emotion mental state terms. In combination play, both groups used similar numbers of cognition and emotion mental state terms. Play context implicates use of mental state terms in expression in children with ASD. Scaffolding use of mental state terms during play may provide an opportunity for children to use more advanced levels of ToM, including cognitive mental state term expression, when engaged with peers.

Keywords

autism spectrum disorders children mental state terms play theory of mind

Children use play as a context for developing, interacting, and reflecting on the people and objects they encounter and to “construct and reconstruct their understanding of their world” (P. A. Prelock, 2019, p. 183). There are extensive multidirectional relationships between play, communication, and social development as described in the literature review below. To understand the importance of the relationship between theory of mind (ToM), mental state term use, and play in persons with autism spectrum disorder (ASD), three primary research areas are briefly discussed. First, the social communication characteristics of ASD are reviewed. Next, ToM is defined and discussed regarding the impact on children with ASD and its effect on mental state term use. Finally, play is described in the context of children with ASD and their social and language development. Knowledge of the social communication and ToM challenges children with ASD experience are important considerations in understanding how play might facilitate these skills. Therefore, this study examines the frequency of mental state term expression in the context of specific play behaviors. It compared children with ASD and typically developing (TD) peers engaged in play in a natural environment.

Social Communication Deficits in ASD

It is well established that children with ASD demonstrate marked social impairments, including appropriate coordination and understanding of nonverbal behaviors, social communication, and restricted and repetitive interests and behaviors. Because of the challenges in understanding unwritten social rules (Grandin & Barron, 2005), children with ASD are often unable to engage in and develop successful peer relationships or show spontaneous interest in social interactions. Persons with ASD often experience social rejection resulting from a lack of understanding of the norms required for appropriate social interactions, including disinterest in others to wanting to be social but not having the skills to do so (Kovshoff et al., 2006).

Fewer instances of pretend play also characterize the core deficits of ASD—a component of the social communication impairment that interferes with relationship development (American Psychiatric Association [APA], 2013). Pretend play involves children’s abilities to manipulate their external world through internal representations (P. A. Prelock, 2019). Children with ASD often require specific instruction in imitation and imaginative play scenarios, and fail to create spontaneous imaginative play (Baron-Cohen, 1987; Jordan, 2003; Rutherford et al., 2007; Stanley & Konstantareas, 2007). In addition, although TD children are able to learn behaviors by watching peers or adults, children with ASD may require specific guidance in this type of play, which creates difficulties when integrating children with ASD into peer play interactions (Kovshoff et al., 2006).

As maintaining reciprocal conversations, understanding unwritten social rules, and engaging in pretend play may be challenging for individuals with ASD, social interactions can be extremely limited and thus inhibit the development of meaningful relationships (P. J. Prelock & Nelson, 2012). Social cognition, the ability to understand the self in relation to others, and social appropriateness are challenges for children with ASD particularly as they attempt to participate in day-to-day interactions, such as family life and school situations (Senju, 2012). These challenges in social interaction and understanding others’ perspectives have implications for play.

ToM/Mental State Terms

ToM is a complex and multifaceted construct that requires an ability to consider the thoughts, feelings, and beliefs of oneself and others and to understand that others may have thoughts, feelings, beliefs, emotions, and perspectives that are different from one’s own (Baron-Cohen et al., 1985; Hutchins & Prelock, 2008; Hutchins et al., 2016). ToM embodies a number of different constructs, including but not limited to understanding false beliefs, second order thinking, and the understanding and production of mental state terms (Hutchins & Prelock, 2008).

Mental state terms are words used to describe one’s understanding of beliefs, desires, and thoughts of self and others. Mental state terms are often believed to be the expression of emotions, but they involve a much broader range of understanding of the mind. Examples of mental state terms include emotion terms (e.g., “happy,” “sad”, “mad,” “scared”) and cognition terms (e.g., “think,” “believe,” “know”). Patnaik and Babu (2001) suggest that acquiring a ToM is foundational to daily social exchanges and language use and TD children are able to talk about their own and others’ mental states and are aware of their own and others’ expected and past experiences by 3 years of age (Bretherton & Beeghly, 1982). The ability to mentalize supports the development of shared attention with others, learning word meanings, and imitating actions with intent. In addition, verbalization of mental states is dependent on the ability to construct meta-representational processes (Nielson & Dissanayake, 2000). Studies have found that there is a strong correlation between achievement on ToM evaluations and frequency of mental state term use (Grazzani & Ornaghi, 2012; Hale & Tager-Flusberg, 2005; Ruffman et al., 2002; Symons, 2004; Tager-Flusberg & Sullivan, 1995; Ziatas & Durkin, 1998).

The ToM deficit in children with ASD affects their ability to be successful social communicators as they are challenged to recognize perspectives that differ from their own (Baron-Cohen et al., 1985; Hutchins et al., 2016). Children with ASD may be unable to participate in shared attention, point to objects of interest (Frith, 2001), or coordinate eye gaze and gestures with vocalizations (P. J. Prelock & Nelson, 2012). Challenges in joint attention often hinder their ability to participate in imaginative play (Mundy, 2016; Rutherford et al., 2007; Wolfberg, 1999).

Play

Play is an important and influential domain for observing the knowledge of a child.

P. A. Prelock (2019) describes play as children constructing learning through physical engagement, social connection, and reflection on experiences. Through play, children use their previous knowledge to create new knowledge (Lifter et al., 2011). Play provides children with an internal desire to discover the world and to construct an understanding of their surroundings (P. A. Prelock, 2019). As children develop, their play progresses to more complex, imaginative, and creative play behaviors (Mastrangelo, 2d009).

Lifter et al. (1988), Kasari et al. (2006), and Freeman and Kasari (2013) identified 14 play categories (see Table 1), which can broadly be understood as phases. Typically, the first phases of play in early childhood include simple manipulation of objects and relational play, where the child is interested in the explicit physical properties of objects and demonstrates this interest by touching, banging, or putting objects near the mouth. Children then begin to combine and create relations between objects (i.e., combination play). The next general phase of play is the functional ability to demonstrate direct acts using dolls, objects, caregivers, and oneself. The final stage of play is symbolic play (also referred to as imaginative or pretend play). Symbolic play involves using objects, dolls, self, and others in imaginative scenarios using a chain of events (Lifter et al., 2011). Mastrangelo (2009) describes symbolic play as expressing the ability to believe, expect, hope, and manipulate relationships with others. This definition explicitly illustrates the connection between symbolic play and ToM. It is important to recognize the extent to which communication and social skills develop during play. Both play and language allow for purposeful communication with others and relationships between objects and self (Mastrangelo, 2009). Social play begins when a child shifts from play alone to recognizing the play of others. To participate in conversation-based play, a child must be able to engage in reciprocal turn taking with another person.

Table 1.

Developmental Play Skill Levels Adapted from Freeman and Kasari (2013), Kasari et al. (2006), and Lifter et al. (1988).

Phase	Play category	Definition
1	Indiscriminate actions	All objects are treated alike (e.g., all objects are mouthed)
2	Discriminative actions	Differentiates among objects, preserving their physical or conventional characteristics (e.g., rolls round beads, squeezes stuffed animal)
3	Takes apart combinations	Separated configurations of objects (e.g., takes pieces out)
4	Presentation combinations	Re-creates combinations of objects according to their presentation configuration (e.g., puts puzzles pieces into puzzle; nests the nesting cups)
5	General combinations	Creates combinations of objects that result in simple, nonspecific configurations such as container/contained relations (e.g., puts beads and puzzle pieces in the cup)
6	Pretend self	Relates objects to self, indicating a pretend quality to the action including using body as objects (e.g., brings empty cup to mouth to drink)
7	Physical and conventional combinations	Preserves unique physical characteristics of objects in the configuration (e.g., stacks cups, strings beads in necklace) and unique conventional characteristics of object in the configuration (e.g., places cup on saucer)
8	Child as agent	Extends familiar actions to toy figures, with child as agent of the activity (e.g., extends cup to doll’s mouth)
9	Single-scheme sequences	Extends same familiar action to two or more figures (e.g., extends cup to baby doll, to stuffed lamb, to interactant)
10	Substitutions	Uses one object to stand in place for another (e.g., bowl as hat)
11	Substitutions without object	Pretends to use something that is not there (e.g., shakes an imaginary salt shaker)
12	Toy as agent	Moves toy figures as if they are capable of action (e.g., moves figure to load blocks in a truck, puts mirror into doll’s hand as if to see itself)
13	Multischeme sequences	Extends different actions to same figure (e.g., feeds doll with spoon, gives doll bath, then puts to bed)
14	Thematic/fantasy play	Adopts various familiar roles in play theme (e.g., plays house, assigning the various roles) or of fantasy characters (e.g., plays “Superman” or “Wonderwoman,” assigning the various roles)

Children with ASD participate in exploratory and relational play but explore objects much less and show more repetitive behaviors and a limited number of relations between objects (Mastrangelo, 2009). In contrast to TD children, a child with ASD often has difficulties engaging in functional play with objects, caregivers, and/or self and may often prefer to play with objects alone instead of referencing dolls or others. They also often lack interaction typically involved in the play which compromises their ability to learn the appropriate function(s) of objects (Mastrangelo, 2009). Children with ASD have challenges engaging in symbolic play due to impairments in social communication and a lack of social awareness (APA, 2013). The lack of symbolic play has been linked to an inability to think abstractly and express and sustain symbolic ideas (Mastrangelo, 2009). Due to deficits in social cognition required to participate in integrative forms of play, children with ASD may avoid these types of play and therefore miss out on the social experiences associated with them (Manning & Wainwright, 2010).

Study Purpose

This study examined the play behaviors and expression of mental state terms (specifically emotion and cognition terms) in children with ASD and TD peers. The frequency of mental state terms expressed by the children was used as an indicator of their perspective taking abilities and ToM proficiencies. The setting in which mental state term use occurred was especially important to this study. Interactive play contexts are important in autism research as they are where social relationships are formed. Multiple studies have provided evidence of ToM impairments as well as mental state term expression in children with ASD, but no research exists that specifically examines children’s mental state term use in a natural peer play setting or during the types of play that might provoke mental state term use. For the purpose of this study, mental state terms are categorized as emotion (associated with positive or negative affect) or cognition (associated with belief or knowing) terms. The following research question addressed a current gap in the literature: How does the use of mental state terms (emotion and cognition) differ between TD children and children with ASD while engaged in combination and imaginative play? It was hypothesized that TD children would use more mental state terms across all play behaviors compared with children with ASD. Considering the core deficits described for children with ASD, it was also hypothesized that imaginative play would occur less often than other types of play.

Method

Design

This was a quasi-experimental, descriptive study that used archived data to compare the frequency of mental state terms in specific types of play behaviors within five ASD-TD dyads.

Participants

The participants in this study were drawn from a larger intervention study examining the effects of adult and peer mediation to facilitate joint attention, social interaction, and behavior regulation during play between children with and without ASD. The original study used a single subject multiple baseline design with a 10-week intervention in the home of children with ASD with data collected during a 5-year period from 2003 through 2007 (references removed for submission purposes). Data from archived transcripts for 10 participants (five children with ASD; five TD children) were used. Participant ages ranged from 4 to 6 years. The ASD-TD dyads were matched by chronological age (ASD: M = 5.1; TD: M = 5.2). TD peers were selected by the families of children with ASD and usually were classmates or neighbors of the child with ASD. It was important that families of the ASD-TD dyads were willing and able to participate and that there would be opportunities to continue playdates post intervention to support friendship development. To be included in the study, children with ASD and their TD peers were required to exhibit language levels of at least 30 months on the MacArthur Communication Development Inventory (Fenson et al., 1993). Mean length of utterance (MLU), a measure of linguistic productivity, was calculated for each participant by a speech language pathologist versed in the Systematic Analysis of Language Transcripts (SALT) program. The average MLU for children with ASD was 4.55 and the average MLU for TD children was 5.37. Although there was a difference in the average MLU across the two groups, this was expected. The intervention study only required that children be able to respond to questions asked and make simple comments during play which children with ASD in the study were able to do. Children with ASD were previously diagnosed with ASD by a developmental pediatrician or psychologist with experience in the diagnosis of autism using the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) criteria (APA, 2000) and/or administering the Autism Diagnostic Observation Schedule–Generic (ADOS-G; Lord et al., 1999). Children with other developmental disabilities, uncorrected vision impairment, or hearing loss were excluded from participation in the study. TD children were enrolled in a general education program and none of the children were on an individualized education program (IEP) or 504 plan. The children with ASD were in special education programs receiving community services. None of the children were engaged in peer or adult mediated peer play intervention in the home setting at the time of the study. All children with ASD and all but one TD peer were White. English was spoken in the homes of all children. See Table 2 for the descriptive data of each participant.

Table 2.

Characteristics of Participants in Mental State Term Use Study.

Participants	Gender	Age (months)	MLU	Maternal role	Paternal role
Dyad 1
ASD	M	49	5.85	At-home-mom	Engineer
TD	M	45	5.68	At-home-mom	Computer analyst
Dyad 2
ASD	M	77	5.66	Attorney	Attorney
TD	M	79	4.31	Sonographer	Attorney
Dyad 3
ASD	M	76	3.82	Child care	Computer analyst
TD	M	69	5.56	Teacher	Teacher
Dyad 4
ASD	M	48	1.27	Engineer	Butcher
TD	F	52	6.96	Researcher	Special educator
Dyad 5
ASD	M	56	6.13	At-home-mom	Clerk
TD	F	67	4.33	At-home-mom	Carpenter
M
ASD (SD)		61.20 (15.3)	4.55 (2.04)
TD (SD)		62.40 (13.5)	5.37 (1.10)

Note. MLU = Mean length of utterance; ASD = children with autism spectrum disorder; TD = typically developing children.

The Committees on Human Research at (removed for submission purposes) approved the human research subjects’ protocol submitted for this study.

Procedure

All play interactions occurred in the home of the child with ASD. Parents of TD children dropped their children off and, if the parent stayed, both children’s parents conversed away from the intervention. Interventions involved a variety of age appropriate play including games, cars, blocks, and outdoor play. Interventionists ensured a sufficient amount of play choices and did not dictate types of play. For a full description of the peer play intervention project, see Prelock, Prendeville, and Unwin (2006).

For each of the five dyads, there were 10 intervention transcripts, each 30 minutes in length, available for coding. Consequently, a total of 50 intervention transcripts and approximately 1500 minutes of conversation were transcribed and proofed. The transcripts included each dyad’s verbal script, as well as a description of the play interaction.

Coding

Both mental state terms and types of play behaviors were coded for the 50 transcripts. Echoed responses were not counted for either group. Undergraduate and graduate students trained in the transcription process coded the data. A coding scheme based on the mental state term guidelines of Bretherton and Beeghly (1982) was modified for this study, collapsing related terms (i.e., emotion and desire) and omitting terms (e.g., sensation) that were absent or infrequent. Mental state terms were categorized into two types: emotion and cognition. The category of emotion terms is associated with positive or negative affect (Bretherton & Beeghly, 1982), including the terms “happy,” “sad,” “mad,” and “scared.” Terms that involve volition and ability, such as “want” and “need,” were considered desire terms (Bretherton & Beeghly, 1982) and thus collapsed under the category of emotion terms. The category of cognition terms encompassed a child’s expression of words that are associated with beliefs, such as knowledge, memorization, certainty, dreams, reality, or imagination (Bretherton & Beeghly, 1982). Examples of cognition terms are “think,” “know,” and “believe.” Trained researchers coded all transcripts using this coding scheme. A frequency count was used and the number of mental state terms for each participant was recorded. Inter-rater reliability for coding number and type of mental state terms reached a minimum level of .80 for point-to-point agreement and .60 for Cohen’s kappa.

Coding for types of play was based on Lifter and colleagues’ (1988) play analysis framework, the Developmental Play Assessment (DPA) instrument. The DPA is a systematic cognitive measure for characterizing the play activities demonstrated by children with disabilities to assess their current knowledge and learning potential (Lifter, 2000). The DPA was “conceptualized from a cognitive/developmental perspective” and distinguishes 14 levels of increasingly complex play to best interpret the inner workings of a child’s mind” (Lifter, 2000, p. 229). For this study, the descriptions of the 14 levels of play (see Table 1) have been adapted from Freeman and Kasari (2013), Kasari et al. (2006), and Lifter et al. (1988).

Although children may have been engaged individually in play acts, this study focused primarily on play that involved social interactions with peers. Play acts were defined as spontaneous, naturally occurring activities with connected play associated with a topic or object of shared interest and attention (Lifter, 2000; Lifter & Bloom, 1998). In this sense, play acts began with the initiation of an act through a command, suggestion, or imitation. The play act ended with the abandonment of the play or the initiation of a new play act (Freeman & Kasari, 2013).

All 50 transcripts were read three times by two individual coders, first to determine the beginning and end of the play acts, then to designate a play level based on the above definitions, and finally to determine the duration of the play act and number of utterances. For analysis, the 14 play levels were combined into four levels—simple object manipulation (indiscriminate acts, discriminate acts, takes apart combinations), combinations (general, presentation, conventional), child as agent (pretend self, child as agent, single-scheme sequences), and imaginative (substitutions, doll as agent, multischeme sequences, thematic and sociodramatic play) following Freeman and Kasari (2013). Inter- and intrarater reliabilities were performed on 20% of the data for the coding of the start and end of play acts and defining play acts. For interrater reliability, there was 82% agreement on starts, 84% agreement for ends, and 84% agreement on play level, with an overall agreement of 83%. For intrarater reliability, there was 92.6% agreement on starts, 85.2% agreement for ends, and 92.6% agreement on play level, with an overall agreement of 90.1%.

Results

Coding schemes for frequency of mental state term use and play levels were combined for statistical analysis. Frequency of mental state term expression was compared between children with ASD and TD children for combination play and imaginative play. Simple object manipulation and child as agent of play were removed from analysis due to lack of occurrence. Frequency of utterances and mental state terms by play category are shown in Table 3. Mean values and standard deviations for mental state terms were calculated as percentages of the number of utterances to account for differences in amount of talk for each child and the child’s opportunity to use mental state terms (see Table 4). Mental state term use mean values for the two groups were compared using t-tests. Mental state terms were counted for each play level and calculated as percentages of total mental state term use for each of the two groups, comparing children with ASD and TD peers, which was also performed for combination and imaginative play (see Table 5).

Table 3.

Frequency of Utterances and Mental State Terms by Play Category.

Play category	Play acts (total n)	Utterances (total n)	Emotional terms (total n)	Cognitive terms (total n)
Simple object manipulation
ASD	8	82	7	10
TD	8	62	6	1
Combinations
ASD	47	1828	93	49
TD	47	1489	86	39
Child as agent
ASD	3	57	6	3
TD	3	39	2	3
Imaginative
ASD	83	3403	118	97
TD	83	3392	128	184

Note. ASD = children with autism spectrum disorder; TD = typically developing children.

Table 4.

Mean Values and Standard Deviations of Mental State Terms in Combination and Imaginative Play.

Mental state and group	Combination play			Imaginative play
Mental state and group	n	M	SD	N	M	SD
Emotional
ASD	47	1.98	2.19	83	1.42	2.16
TD	47	1.83	2.00	83	1.54	2.23
Cognitive
ASD	47	1.04	2.15	83	1.17	2.27
TD	47	0.83	1.15	83	2.22	4.90
Emotional by percentage
ASD	47	6.64	10.72	83	3.95	6.20
TD	47	8.74	15.72	83	4.43	6.51
Cognitive by percentage
ASD	47	2.28	3.80	83	2.22	3.94
TD	47	2.92	4.66	83	3.98*	5.44

Note. Mental state terms were calculated as a percentage of the number of utterances to account for the differences in amount of talk produced by each child and their opportunity to use mental state terms. ASD = children with autism spectrum disorder; TD = typically developing children.

p = .018.

Table 5.

Mental State Term Count by Category and by Percentage of Total Mental State Term Expression in Combination Play, Imaginative Play, and Total Expression.

Mental state	Combination		Imaginative		Total expression
Mental state	ASD	TD	ASD	TD	ASD	TD
Emotional
Count	93	86	118	128	224	216
Percentage within mental state	52.0%	48.0%	48.0%	52.0%	50.9%	49.1%
Cognitive
Count	49	39	97	184	150	227
Percentage within mental state	55.7%	44.3%	34.5%	65.5%	39.8%	60.62%*

Note. ASD = children with autism spectrum disorder; TD = typically developing children.

p = .001.

Analysis of Mental State Terms for Children With ASD and TD Children

The mean values and standard deviations for emotion and cognition mental state terms were calculated for combination and imaginative play as percent of utterances spoken. For combination play, the mean number of emotion terms was 6.64 (SD = 10.72) for children with ASD and 8.74 (SD = 15.72) for TD children; the mean number of cognition terms was 2.28 (SD = 3.8) for children with ASD and 2.92 (SD = 4.66) for TD children. The t-tests were performed to compare the mean values of mental state term use of the two groups engaged in combination play. There were no significant differences between emotion (p = .452) or cognition (p = .462) mental state term expression between TD children and children with ASD during combination play.

For imaginative play, the mean number of emotion terms was 3.95 (SD = 6.2) for children with ASD and 4.43 (SD = 6.51) for TD children; the mean number of cognitive terms was 2.22 (SD = 3.94) for children with ASD and 3.98 (SD = 5.44) for TD children. A t-test for equality of mean values indicated no significant differences (p = .631) in emotion mental state term expression between TD children and children with ASD. Cognition mental state term expression as a percent of total utterances, however, was significantly higher for TD children than children with ASD (p = .018) in imaginative play.

No significant differences in percent of total emotion term expressions were found between children with ASD (50.9%; n = 224) and TD children (49.1%; n = 216). A significant difference between the percent of cognition term expressions was found between children with ASD (39.8%, n = 150) and TD children (60.62%; n = 227; p = .001).

Discussion

The purpose of this study was to examine the association between play behaviors and mental state term expression in TD children and children with ASD. The prevalence of mental state terms is used as an indicator of a child’s ability to understand perspectives and provides implications for ToM knowledge and application. Mental state terms have been previously studied in structured tests and laboratory settings with results providing evidence of ToM deficits associated with communication and play in children with ASD (Baron-Cohen et al., 1985). The current study examined children’s use of mental state terms while engaged in spontaneous, peer motivated play acts with a TD peer in a natural setting. Investigating play and mental state term expression in a natural setting provided insight into the social communication behaviors of children with ASD compared with TD peers. This study also allowed for the examination of specific types of play that generate the most mental state terms in both populations.

This study hypothesized that children with ASD would use fewer mental state expressions compared with TD children in all types of play. Our findings only partially supported this hypothesis. Significant differences in mental state term use were only found in cognition terms during imaginative play. This suggests that TD children and children with ASD use a comparable amount of emotion and cognition mental state terms when engaged in combination play. The literature suggests that children with ASD are more likely to communicate successfully in a social interactions when they engage in play they have mastered (Lifter et al., 2011) and that children’s social coordination decreases when engaged in unmastered play behaviors (Pierce-Jordan & Lifter, 2005). Combination play (typically involving play with toys such as race cars and marbles) is a more basic level of play compared with imaginative play, and children with ASD may feel more comfortable communicating during this type of play and, thus, be able to use mental state terms (both emotion and cognition) as often as TD children. As play becomes more complicated (as is the case during imaginative play), the social cognition and communicative ability of children with ASD may be challenged, resulting in the use of fewer cognition terms. This may be further explained by the concept of “allocation of resources” (Goldknopf, 2013; Hutchins & Brien, 2016). Under this hypothesis, the child with ASD may allocate more cognitive resources to the play act, which would limit the cognitive resources available for language production, particularly cognition mental state terms (Pierce-Jordan & Lifter, 2005).

Our findings are consistent with previous research describing children with ASD as being able to understand and use mental state terms associated with emotion and desire words more frequently than cognition or belief words (Tager-Flusberg, 1992). Tager-Flusberg (1992) found that, compared with children with Down syndrome, children with ASD were significantly worse at referencing attention and cognitive mental states. Furthermore, Ziatas and Durkin (1998) found that belief comprehension was especially difficult for children with ASD, as well as performance on belief expression tasks compared with children with other developmental disorders. Similar to the findings in this study, emotion term use was similar for TD children and children with ASD, although type of play influenced the frequency of use of cognition terms.

Our findings suggest that in both combination and imaginative play, children with ASD may possess an element of ToM that allows them to use simple emotion terms. When children with ASD are in a comfortable play setting and engaged in play they have mastered, they may be better able to understand perspectives and express that understanding using mental state terms. It is important to note, however, that although children with ASD and TD children expressed mental state terms in similar frequency during combination play, this does not necessarily mean that they have equal cognition and emotion understanding. Although some children with autism are able to use mental state terms, “these children still lack social intuition” (Tager-Flusberg, 2007, p. 313). It is also possible that the low levels of mental state term use across both groups in both the combination and imaginative play settings resulted in the insignificant findings seen in this study.

It was also hypothesized that children with ASD would engage in fewer imaginative play acts than other acts. In the current study, imaginative acts accounted for 59% of the total play acts. One explanation for the high frequency of imaginative play is the age of the children in the study. The DPA is an assessment tool designed for children aged 8 to 60 months (Lifter et al., 2011). The average age, in months, of the dyads in this study was slightly above this range (ASD: M = 61.2, TD: M = 62.4), indicating that the children’s play should be near the ceiling for this assessment. Furthermore, the number of imaginative play acts does not reflect the multiplicity of factors influencing ToM in the child with ASD. This study did not code which child initiated play acts, but it was evident through the video recordings and transcript reviews that the majority of pretend play acts was initiated by the TD child. These results are in line with those of Libby et al. (1998) who compared children with autism, children with Down syndrome, and TD children and found that children with ASD had the greatest difficulties with symbolic play. Although less likely to intiate pretend play, it has been found that children with ASD can follow along when they are prompted and can produce imaginative play when it is modeled (Kovshoff et al., 2006; Libby et al., 1998). The absence of production of imaginative play sequences may be attributed to some of the behavioral characteristics of children with ASD (e.g., repetition, lack of creativity, stereotyped habits). Children with ASD are also able to replicate pretend play acts, but this does not necessarily demonstrate evidence of an understanding of the associated concepts (Libby et al., 1997). The significant difference between TD children and children with ASD in cognition mental state term use could also indicate that TD children think about play acts in a symbolic/representational sense while children with ASD do not. When pretend play is modeled or prompted by a peer or parent, a child with ASD learns the theme of the act, but it may be a memorized or scripted routine. In this scenario, the child with ASD is unable to expand the play or choose new play behaviors (Kovshoff et al., 2006). This creates the probability for scripted play routines rather than true pretend play acts that exemplify ToM proficiency.

It is important to appreciate the significance of the relationship between communication, play, and social development. The expression of mental state terms can be used as one indicator of ToM, and a developed ToM affords an individual the ability to make sense of one’s own and others’ emotions and intentions. ToM is a necessary requirement for advanced levels of play, specifically symbolic and imaginative play, that involve an understanding of others’ perspectives and spontaneous imaginative scenarios. Therefore, for a child to successfully engage in pretend play, she must demonstrate some level of ToM. This is extremely important for social development because play provides an opportunity for social learning and for children to develop prosocial skills while interacting with peers. It has been found that children who engage in more advanced play are more successful socially (Manning & Wainwright, 2010). Having the ability to use and understand the appropriate language while socializing is critical for building friendships, enjoying interactions, and participating in life experiences. Not being able to understand others’ reactions and/or respond appropriately interferes with an individual’s social competence and ability to form meaningful relationships (Sigman et al., 1999). In this study, the children with ASD had the cognitive ability to engage in lower levels of play, but the significant difference in cognition term use in imaginative play suggests that this ability was not fully developed in higher play levels. It is important to note, however, the success of children with ASD in combination play as a necessary step in the development of mental state terms to form initial cognitive understandings. The ability of children with ASD to to conceptualize symbolic representations is critical if they are to be successful play partners in imaginative play.

Clinical Implications

Important implications for practice can be drawn from the present study. Results indicated that TD children and children with ASD use emotion and cognition mental state terms similarly during combination play. Initiating this type of play could be a way for caregivers and providers (e.g., teachers, speech language pathologists, and special educators) to lay the foundation for ToM mastery for children with ASD. As ToM proficiencies are achieved, engaging with children with ASD in imaginative play settings and scaffolding the use of mental state terms during play may provide an opportunity for children to use more advanced levels of ToM, including cognitive mental state term expression. With this knowledge, certain types of play could be initiated in interactive play contexts that would increase mental state term expression in children with ASD. Increased mental state term use is important to facilitate the social communication and developing ToM of children with ASD as it provides a means for expression during play as well as promotes social and emotional awareness of others (Mastrangelo, 2009).

Furthermore, this study suggests the significance of peer play for children with ASD. In comparison to play with professionals or caregivers, peer play may provide a more appropriate way to evaluate the spontaneous language expression of a child with ASD. Peer play may also facilitate spontaneous language expression—providing a setting for children with ASD to observe and learn from TD children. Engaging in play with peers, instead of professionals and caregivers, also provides more social opportunities to children with ASD.

Study Limitations

There are limitations to this study that are important to address. First, this study used archived data and thus the researchers did not have control over the data that was collected. Of particular note, no formal measures of ToM were collected for any of the children. ToM is a complex and multifaceted construct. Mental state terms do not fully capture ToM knowledge or application and, therefore, other aspects of ToM should be assessed in play contexts. In addition, the sample size of this study was small and decreased the power of a study. A larger sample size would allow for more robust findings. The use of the DPA also narrowed the parameters for considering types of play acts, especially with the older participants. There were play behaviors, such as games with rules, that possess spontaneous aspects of play that were not accurately captured by the DPA, which was designed for a more structured play environment. Using a different play framework that includes more complex levels of play (such as role assignments, rules, and planning) could better capture available play behaviors in children with ASD. In terms of mental state terms, emotion and desire mental state terms were combined into one single category which could potentially influence the strength of the findings.

Implications for Future Research

Results of this study suggest the need for further research including a longitudinal study of mental state term use in play acts comparing children with and without ASD from early childhood throughout preschool as this would allow for conclusions about the simultaneous development of communication, play, and ToM. A replication of the current study using children with other disabilities to capture differences in play and ToM development among different clinical populations would be important. A larger sample size would allow for more powerful results. Data from this study were taken from a larger intervention study and it would be interesting to compare the play behaviors, mental state term use, and overall ToM competencies prior to and following intervention. Such an analysis could provide information about the way play and communication changes as children build peer relationships. In addition, future research could explicitly examine ToM skills in TD children and children with ASD to compare mental state term use during play with a more formalized and comprehensive ToM assessment. Finally, examining adult scaffolding could inform effective ways to shape peer play and mental state term use.

Footnotes

Acknowledgements

This research was completed in partial fulfillment of the first author’s requirements for a senior Honors College thesis at the University of Vermont. The authors thank Alan Howard for statistical analysis assistance and Brenda Hamel-Bissell and Youngok Yung for their guidance.

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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