Relationship Between Sensory Processing and Pretend Play in Typically Developing Children

Design and Participants

The research study used a nonexperimental cross-sectional design. Forty-two children (17 girls, 25 boys) between ages 5 yr, 7 mo, and 7 yr, 4 mo, received parental consent to participate in the study. Parents verified that their child had not received psychology, occupational, speech, or physiotherapy interventions for any concerns. The mean age of the sample was 6 yr, 3 mo (standard deviation = 0.52 yr). All participating children spoke English as their first language and had attended the school for at least 6 mo. All attended mainstream schools and lived in a large regional city in Australia.

A minimum sample size of 40 children was required to provide power of .83, with α set at .05 and an r value estimated to be .45 (moderate; Portney & Watkins, 2000). The sample of 42 children was estimated as providing acceptable power to answer the research question posed.

Instruments

The Child-Initiated Pretend Play Assessment (ChIPPA; Stagnitti, 2007) is a norm-referenced standardized assessment of the quality of a child’s ability to self-initiate pretend play. It was standardized on 410 typically developing Australian children. The ChIPPA was designed for children ages 4–7 yr and takes 30 min to administer. It is administered with the child playing on the floor. There are two 15-min sessions in the ChIPPA; they are called the conventional–imaginative play session and the symbolic play session.

The ChIPPA measures the elaborateness of a child’s play (this reflects the complexity and organization of the play) by means of three subscales: (1) Percentage of Elaborate Play Actions (PEPA); (2) Number of Object Substitutions (NOS; the ability of a child to use symbols in play); and (3) Number of Imitated Actions (NIA), which is used if a child relies on someone else for play ideas. A PEPA, a NOS, and a NIA score is calculated for each ChIPPA play session. Clinical observations that describe typical indicators of play and play deficits are recorded after each play assessment. The ChIPPA has established interrater reliability (κ = .7; Stagnitti, Unsworth, & Rodger, 2000; Swindells & Stagnitti, 2006), test–retest reliability (intraclass correlation = .82; Stagnitti & Unsworth, 2004), and discriminant validity for children with suspected academic problems compared with typically developing children (p = .0001; Stagnitti et al., 2000). Higher ability to play is reflected by higher scores in elaborate play; higher scores in object substitution; and low scores in imitated actions, indicating that children can self-initiate their own play.

The SPM provides norm-referenced standard scores for sensory processing. The Home and Main Classroom AutoScore Print Forms of the SPM were standardized on a sample of 1,051 typically developing children between ages 5 and 12 yr. Internal consistency and test–retest reliability data for the Home Form were reported as .77–.95 and .94–.98, respectively. For the Main Classroom form, internal consistency scores ranged from .75 to .95, and test–retest estimates ranged from .95 to .98 (Parham, Ecker, Miller-Kuhaneck, Henry, & Glennon, 2007). Content validity was established through the use of expert review panels, and factor analysis was used to provide evidence of SPM scale construct validity (Parham et al., 2007). The Home form was found to be significantly correlated with the Sensory Profile (Dunn, 1999), providing evidence of convergent validity (Parham et al., 2007). Discriminant validity has been proven in that both the Home and Main Classroom forms were able to differentiate between typically developing children and those with clinical disorders (Parham et al., 2007).

For the purpose of the present study, SPM items were reverse-scored to assist with the interpretation of results; that is, they were reverse-scored to reduce the potential misinterpretation of the statistically analyzed data. Misinterpretation could have occurred because low scores on the SPM indicate typical responses, whereas low scores on the ChIPPA are indicative of atypical responses. By reverse scoring the SPM items a positive correlation would result from high scores on the ChIPPA (indicating well-developed play ability) and high scores on the SPM (indicating no problems with sensory processing).

Data Analysis

The data were entered into IBM SPSS Statistics (Version 22; IBM Corp., Armonk, NY) for analysis. To answer the research questions and Hypotheses 1 and 2, a Spearman’s ρ correlation was computed between the SPM and ChIPPA data, because the data did not meet the assumptions of normality. A coefficient of determination was calculated as an estimate of effect size between sensory processing and pretend play. For correlations, we used the inverted T scores for each of the subtest scores for the Home and Main Classroom SPM forms and the raw scores for all PEPA items, object substitution for the symbolic play session (NOS Symbolic), and the combined score for NOS. The PEPA Conventional score gives information about a child’s ability to elaborately play with toys, and the PEPA Symbolic score gives information about a child’s ability to elaborately play with unstructured objects. NOS scores across both ChIPPA sessions give information about a child’s ability to symbolize in play. A regression analysis was completed in which the ChIPPA scores were the dependent variables and the Home SPM scores were the independent variables. For Hypothesis 3, we used descriptive statistics for the results of the Main Classroom and Home versions of the SPM. The descriptive statistics from each form were then compared.

Procedure

Before the research commenced, ethics approval was obtained from the Deakin University Department of Education and Training (HEAG Project Reference 74_2105; DET Project Reference 2015_002735). An invitation to participate in the study was sent to principals of all nongovernment schools in a large regional city in Australia with the aim of recruiting a minimum of 40 children ages 5–7 yr. After receiving organizational consent from five principals, written consent was obtained from the teachers involved. An invitation to participate in the study was sent home to parents, seeking their consent and the assent of their child. The five consenting schools provided access to a quiet small space to complete the ChIPPA at the school. All the children verbally assented to completing the play assessment.

Child participants were assessed on the ChIPPA by a pediatric occupational therapist with 20 yr experience and who was trained in the administration of the ChIPPA. The therapist traveled to each school, where the assessments were completed at a time during the standard school day suggested by the classroom teacher. This was done to minimize disruptions to the children’s learning opportunities at school and avoid any time conflicts with their extracurricular or special events. Data collection took approximately 30 min per child. Teachers and parents were sent the Main Classroom and Home SPM forms, respectively, and were asked to return them to the first author by means of a prepaid envelope. Eligible participants were advised and reminded that their involvement was voluntary and that any decision to not participate would have no impact on their relationship with the university or the school. The teachers and parents were not aware of the play assessment results when they completed their SPM. The ChIPPA assessments were completed and scored before the SPM forms were viewed and scored.

Eleven teachers from five schools consented to be in the study. These teachers had taught the children for a minimum of 6 mo before they filled in the Main Classroom SPM. All teachers were women in the age range of 25–50 yr. The schools represented a range of sizes, from large schools of 600 children to smaller rural schools of 150 children. The Main Classroom SPM (62 items) was filled out by the child’s primary classroom teacher. The parents of the 42 children in the study completed the Home SPM.

Relationship Between SPM Home and ChIPPA Scores

There were moderate significant positive correlations between touch, body awareness, balance, and social scores on the Home SPM and elaborate play ability on the ChIPPA (Table 2). PEPA Conventional scores had the strongest relationship with body position (r = .62, p = .001). The largest coefficient of determination was r ² = .38 (p = .05), showing a shared variance of 38.4% between body position and PEPA Conventional.

Relationship Between Main Classroom SPM and ChIPPA Scores

The Social subtest of the SPM was significantly and moderately related to object substitution scores in the symbolic play session (NOS Symbolic: r = .45, p < .01) and combined score (NOS Combined: r = .37, p < .05). The shared variance between the ability of a child to use object substitution in the symbolic play session of the ChIPPA and the social domain part of the Main Classroom SPM was 16% (r ² = .16, p < 01).

Multiple Linear Regression

In Table 3 we present the results of the regression analysis. The subtest scores of the SPM Home were entered as the independent variable, with the dependent variable being ChIPPA scores that were significantly correlated with the subtest scores. A child’s body awareness as reported by parents on the Home SPM predicted their ability to elaborately engage in play with both sets of materials, R ² = .38, F (1, 35) = 2.36, p = .05, and their ability to use symbols in play, R ² = .39, F (1, 35) = 2.45, p = .047. A child’s body awareness as reported by parents also predicted a child’s ability to elaborately play with toys, R ² = .58, F (1, 35) = 5.22, p = .001. A child’s balance scores as reported by parents on the Home SPM predicted his or her ability to elaborately play with toys, R ² = .46, F (1, 35) = 3.25, p = .012. A child’s touch processing scores as reported by parents on the Home SPM predicted the ability to elaborately play with unstructured materials, R ² = .57, F (1, 35) = 3.21, p = .009.

Relationship Among Body Awareness, Balance, Touch, and Pretend Play

For children who are developing typically, the quality of their ability to engage elaborately in play with toys on the floor shares the highest variance with body awareness in the home. We found that when typically developing children engaged in pretend play on the floor with toys, they positioned their body optimally to set up the play and manipulate toys. Mische Lawson (2006), in her study of typically developing preschool children, found statistically significant relationships between sensory avoiding behaviors and body position in play. She suggested that children tend to change body positions in an effort to avoid or adjust sensory input during play in an attempt to meet their sensory preferences or needs. In contrast, the findings of the current study indicate that typically developing children adjusted their body position when they were engaged in quality elaborate pretend play. This suggests that when children engage in the play process they adjust their bodies to continue to organize and extend their play elaborately.

Balance scores on the Home SPM were related to children’s ability to play elaborately with toys in the home environment. Balancing, maintaining body position, and orientation to gravity influenced a child’s movement and manipulation of toys during play. Our findings suggest that children in the home environment have opportunities to frequently change body position in relation to gravity, which is a vestibular demand; for example, a child moves fluently from lining up a train track in a prone position on the floor to half-kneeling so as to extend the play to the sofa or a coffee table. The relationship among pretend play, body position, and balance can be seen when thinking of the “flow” of the well-developed player. As children play, they make unconscious adjustments governed by the vestibular system, and this supports the fluency seen in competent players. By considering an occupation-centered approach in which play is a main occupation of childhood, we found that typically developing children engaged in high-quality, complex, elaborate play and positioned their bodies, using their balance and touch, to manipulate play materials and engage in complex self-initiated play with logical sequential actions.

A child’s touch processing scores, as reported by parents on the Home SPM, were related to the ability to elaborately pretend play with toys and unstructured materials. In regard to children with atypical sensory responses, Jasmin et al. (2009) found that the tactile function of children with autism spectrum disorder was linked to their ability to manipulate objects and play items. The results of the current study similarly indicate that touch is likely to influence elaborate play with toys and unstructured objects in typically developing children, suggesting that touch is implicated in manipulation and movement of play materials.

Relationship between Social Abilities and Pretend Play

We found a significant relationship between a child’s ability to use symbols in play (object substitution) and the social domain on the Home and Main Classroom SPM forms in this study. This finding concurs with those of Uren and Stagnitti (2009) and McAloney and Stagnitti (2009), who found that social interaction, as assessed by teachers, was significantly positively correlated with a child’s ability to substitute objects. It also is consistent with past work on play and social contexts that has stated that reduced social opportunities, and the absence of other persons to play with, can have a profound effect on children’s play (Knox, 2010). Although social skills are not considered a sensory modality in themselves, Parham et al. (2007) stated that the SPM’s social items “reflect higher level integrative faculties that have a direct bearing on adaptive behavioral functioning” (p. 69), much like play itself. The ability to use symbols in play is a higher cognitive play ability (Stagnitti, 2017).

Sensory Processing and Environment

The home and school environments influenced the relationship between pretend play and sensory processing. There were more and stronger correlations for pretend play on the Home SPM compared with the Main Classroom SPM. This may be due in part to children having more play time and spending more time on the floor at home, in contrast to having less time for such experiences in the classroom environment. In the classroom, children are expected to complete structured learning tasks, follow instructions, and maintain seated positions on their chairs or the floor to complete tasks. Although many children are more physically active at school during recess and lunch breaks, the Main Classroom SPM does not record this.