Subjects

Background

Play is widely recognised as an important feature in the education and overall development of a child (Kossyvaki and Papoudi, 2016) whereby social and cognitive skills such as problem solving, turn-taking, sharing and cooperating with others can develop (Lindsey, 2014).  During play social language is supported and self-esteem, emotional development (Goleniowska, 2014) and friendships can be constructed.   How we define play is open to interpretation as it is a complex and ambiguous concept (Eberle, 2014) which encompasses a range of human experiences.  

Children with disabilities and those with autism often engage in restrictive play activities when compared to their typically developing peers (Wolfberg, Bottema-Beutel, and De Witt 2012).  This is due to the nature of autism, a lifelong disability characterised with difficulties in communication, social interaction and by the presence of restrictive interests and behaviours (Duffy and Healy, 2011; APA, 2013).   In addition, engaging in play may be hindered for those with autism as many exhibit difficulties in sensory processing (Case-Smith, Weaver and Fristad, 2015) and in symbolic thinking (Wing and Gould 1979), which is evident from early infancy (Charman, Swettenham, Baron Cohen, Cox, Baird and Drew 1997).

 As defined by Wolfberg (1999), play involves engaging in  voluntary and inherently motivated activities which are linked with recreational pleasure and enjoyment.  This interpretation of play may therefore include leisure activities experienced by adolescents.

Adolescents with autism, and more specifically adolescent girls with autism, are considered vulnerable to increased social demands and the complexities of social interaction (Jamison and Schuttler, 2015).  This may be due to male adolescent relationships being largely based on ‘doing’ whereas female adolescent relationships involve more conversing (Nicholas, Moraveik and Tetenbaum 2009).  Within school, older children with autism who are cognitively able experience significant social challenges, displaying limited social encounters with peers (Dean, Kasari, Shih, Frankel, Whitney, Landa et al 2014). Challenges are associated with difficulties recognising subtle social cues and emotions of others i.e. deficits in Theory of Mind (Baron-Cohen, Leslie and Frith, 1985), an incapability to take another’s viewpoint, leading to naive reactions and hypersensitivity in social situations. 

Combining a range of play and leisure intervention strategies to support the development of social communication skills are important for adolescents with autism across their lifespan.

Objectives

This article describes a transdisciplinary approach with three adolescent girls with autism who attend mainstream school settings.  The approach involved blending key psychosocial interventions through the introduction of ‘play’ activities to develop and support essential communication and social skills.  

Method

Design

A multiple case study design was employed with six months follow up.

Ethics

Informed consent to report and publish information was sought in accordance with Middletown Centre for Autism (MCA) research procedures from all adolescents, caregivers and professionals at school.

Participants

Three females aged thirteen to seventeen years (Ashley, Amanda and Noleen) were referred to Middletown Centre for Autism (MCA). To protect the identity of participants and to ensure confidentiality and anonymity pseudonym’s have been applied.  

Ashley is a thirteen-year-old girl who was referred to MCA due to selective mutism.   She did not engage with teachers or peers, refusing to complete or participate in class tasks.  Ashley could be articulate and had an extensive knowledge of a range of topics, however, her expressive communication was affected by her anxiety.  Ashley experienced difficulties with another student and in the absence of adaptive skills to cope, withdrew at home and school. Her interests were restricted to books, animals and art and she struggled to participate in less preferred activities.

Amanda is a fifteen-year-old girl with autism, reactive attachment disorder and Attention Deficit Hyperactivity Disorder (ADHD).  She was referred to MCA due to elevated levels of anxiety related to transitioning to another school and a family bereavement.  Continuous behavioural difficulties at home and community settings, combined with a deterioration in communicative abilities, when stressed and anxious, led to verbal processing difficulties within school.   Amanda had a strong rigidity of thought, low self-esteem and experienced sensory processing difficulties.  Amanda enjoyed communicating and wished to improve her peer relationships as interactions often resulted in negative peer reactions.    Amanda had an interest in books and films but played with childhood toys and games.  Gross motor difficulties proved challenging when participating in physical activities.

 

Noleen is a seventeen-year-old girl who was not accessing the curriculum appropriately.  She was creative and interested in art.  Noleen had extensive vocabulary with articulate verbal skills, however this deteriorated when she was upset.   Noleen engaged in little spontaneous conversation with peers experiencing heightened anxiety in social situations and only engaging in relaxed conversation at home.   Noleen rarely made eye contact and spoke in a low tone.  She attended few family social outings except church.  Noleen was aware of her autism diagnosis and its impact on her social and learning potential, expressing that difficulties included concentrating at school and being self-critical of her abilities especially her art.   Noleen neglected areas of personal care and found it difficult to cope with unexpected change in the classroom triggering behaviours which challenge.

All of the adolescents referred required social skills support using ‘play’ based activities to help improve their social communication skills with school peers.

Transdisciplinary Intervention Programme

The transdisciplinary model involves any member of the Learning Support team within MCA acting as a lead Coordinator.  The Coordinator capitalises on the experience of a team of professionals comprising teachers, speech and language therapists, autism intervention officers and occupational therapists. This model allows for skills to be transferred between team members, extending traditional roles and working in a coordinated way with one another, across three school terms, with each adolescent, their caregivers and other educational and health professionals.  During an initial observation period of ten to twelve weeks, the Coordinator in conjunction with other transdisciplinary team members, assesses and addresses identified needs, strengths and challenges across home, school and community environments.  A Learning Support Plan is subsequently established, outlining the development of a holistic intervention supporting the adolescent, their family and educational and health professionals working in the school setting

 (See Tables 1 to 3).

Table 1:   Examples of leisure strategies employed to develop social communication skills with Ashley.

Baseline Description

Goal set

Strategies/Resources employed

  • When stressed, Ashley found it difficult to communicate with others especially when routines changed, she had low self-esteem and was easily distracted.
  • To communicate with school staff and peers when required and to speak aloud when doing so.
  • Utilised high-preference leisure items and activities such as art and board games.  A board game involved counting points from 1-10 for demonstration of target behaviours.  The points were rewarded with a desired leisure activity such as reading a magazine or going for an ice-cream.
  • When under stress communicative abilities deteriorated.
  • Difficulty tolerating crowded and noisy environments.
  • Learn strategies to manage stress, including feelings of anger, sadness and anxiety.
  • Direct teaching and raising awareness of the benefits of participating in leisure activities such as art, using construction resources and exercises to help feel ‘calm’.
  • Teaching through using a ‘tool box’ from the Exploring Feelings programme by Dr Tony Attwood
  • Interests restricted to books, animals and art, struggled to participate in less preferred leisure and self-care activities.
  • To promote independent living skills and self-care in the home environment.
  • Ashley went for walks, played sports, went to yoga and swimming initially with parental support and MCA Co-ordinator.
  • Points / reward resources required to carry out leisure activity.

 

 

Table 2: Examples of some leisure strategies employed to develop social communication skills with Amanda

Baseline Description

Goal set

Strategies/Resources employed

  • Difficulties with impulse control and found social interaction anxiety provoking.
  • To develop social skills and positive relationships with peers in school.
  • Drawing on Amanda’s interests in books and films activities such as video modelling and role playing were employed.  Reading books such as ‘Social Fortune or Social Fate: A Social Thinking Graphic Novel Map for Social Quest Seeker’s, this comic book by Pamela Crooke and Michelle Garcia- Winner adopted a playful way to highlight two different points of view. 
  • Student workshops with peers were established increasing awareness and understanding of autism.
  • School staff kept records when pro-social behaviour and positive social skills were displayed and when Amanda experienced difficulties.  This helped to individualise intervention content.

For example, Amanda would repeatedly text a friend several times if she had not heard back from them. 

 

 

  • Regularly presented with behaviours that challenged. Triggered when demands were placed on her she felt anxious, was unsure of what was expected from her or when she felt unwell. 
  • At school behavioural presentations differed from home particularly when trying to fit in with peers she often scratched her skin.
  • Amanda also had a negative mindset and feared things would happen.
  • Promote the consistent use of adaptive strategies to regulate emotions, during times of stress and anxiety.
  • Amanda will reflect on positive experiences.
  • Amanda will recognise the changes that occur in physiology, thinking, behaviour and speech when she is feeling anxious, angry or stressed.
  • A range of regulating exercises were demonstrated to maintain a calm and alert state. These were shared within home and school using visuals (5 point emotional scale) and breathing exercises which acted as a relaxation/leisure activity. 
  • Took part in female exercise classes, and kept a memory book, detailing positive activities completed.
  • Considering Amanda’ s interest in films, video footage to identify feelings and changes in others was used as a leisure activity in addition to role-playing scenarios.

 

Table 3: Examples of some strategies and supports used to develop social communication skills with Noleen

Baseline Description

Goal set

Strategies and Resources employed

  • Engaged in very little spontaneous conversation with peers.
  • Presents with anxiety in social situations.   Only engaged in relaxed conversation at home.  
  • To become more comfortable with social interaction by engaging in spontaneous interaction with a peer or adult in school each week
  • Social Skills workshops were set up with 3 peers.
  • Utilised the Attention Autism (AA) Post Primary Model by Gina Davis. Using dramatic and visual activities.  Objects/activities used were age appropriate and motivating drawing upon Noleen’s interests e.g. drawing still art, spinning paint, Inflating balloons.
  • At home, comic strip conversations were used to help with anxiety.
  • Henry OT ‘Tools for Teens’ resource used to introduce the importance of exercise and movement.
  • Noleen rarely went on any social outings.   Never ate out in public and ate very little at school limiting social communication opportunities.
  • Build confidence in weekly social skills groups at school and at home, leading to eating out once a month. Noleen will begin with preferred food and tolerating the environment for 10 minutes, building upon this.
  • Attended weekly social skills groups in school increasing social outings.
  • Capitalising on her interest in books, Noleen was encouraged to keep a diary to plan outings and to read about other girls’ social experiences who have Asperger syndrome.
  • Support was provided from MCA staff preparing outings using activity worksheets based on principals of Cognitive Behaviour Therapy.

 

 

 

 

 

 

Outcome Measures

The transdisciplinary model commences with a period of formal and informal assessment with the individual with autism, caregivers and professionals working with the young person within the school and community.  In collaboration with caregivers and teachers, the Coordinator creates an individualised child centred set of goals and a tailored intervention programme to facilitate achievement of each goal.

Once intervention commences the Coordinator liaises regularly with all relevant parties, across settings reviewing and monitoring progress.

 

Six months following intervention, semi-structured interviews are conducted with caregivers and where possible the young person with autism.  This allows participants to express their views on intervention effectiveness and how the process has affected their home and school environments.   Education and health professionals involved in the intervention process are also invited to complete a self-report questionnaire evaluating intervention effectiveness, strategies, support and advice employed by MCA.

 

Results

Ashley

School staff reported that Ashley now speaks freely to her Classroom Assistant and can verbalise if she needs to leave the class when feeling anxious and explains why she is stressed or anxious.   School staff report that Ashley is more interactive with her peers, has cooperatively worked with a peer on a project, speaking throughout. She also speaks aloud to almost all her teachers and recorded a full presentation for her English Teacher on an iPad. Ashley continues to require support, guidance and reinforcement to increase her fluency when speaking to teachers however progress has been made.

Amanda

During one to one intervention sessions Amanda demonstrated an elevated level of insight into the impact her behaviour had on the reactions of her peers.  Areas such as repeatedly saying “hello” to peers, asking irrelevant questions in class, and feeling worried that peers were looking at her were discussed.   Using visual supports such as comic strips and social stories and engaging in exercise classes Amanda has been supported to regulate her emotions and these have helped her with her social communication difficulties.  Although Amanda continues to have difficulties with impulse control and still finds social interaction anxiety provoking, she benefits from having time to discuss social interactions with adults.

Amanda’s peers completed a peer awareness session on autism. Both Amanda and school staff report an increase in peer supportiveness because of the awareness sessions.

Noleen

The MCA Coordinator reported that Noleen attended and participated fully in all social group skills activities.  Noleen also joined her peers on a trip to a local community centre and on walks to the local shop, her first time to have been on a school trip.

Within the home environment, the Coordinator supported Noleen in candle and jewelry making with a sibling.  Both the Coordinator and her parents reported that Noleen was very relaxed and open to conversation and social interaction.   School staff also reiterated this openness to communicate.

Six Month Follow-up

Ashley

Ashley’s Classroom Assistant reported that interaction with peers has improved.  Using visuals makes things definite for her at school and she is more aware of her emotions. 

Ashley’s mother reported improvements in her daughter’s social communication skills, indicating that she has started to speak and learn more. This she felt was attributed to her emotional understanding which resulted in her being calmer at home and at school.  Ashley’s’ mother stated that:

“…before Ashely was alone there was no enjoyment and no engagement. She is more helpful and enjoys everything much more. She is more social now whereas before she just went to her room. She now helps me with cooking and cleaning, my daughter is back and is happier”. 

Amanda

Amanda's teacher reported that although Amanda still struggles to form friendships her social skills have improved, as she has a greater understanding of her autism and her emotions. The awareness workshops have given her peers a greater understanding of how Amanda’s autism impacts on her behaviours and difficulties in forming relationships. Some of her peers now actively attempt to include her within the class group.

Noleen

Noleen’s parents reported that she is equipped with new coping skills.  The entire family and the school have benefited having learned helpful guidelines for and about Noleen.  Building a trusting relationship with the Coordinator helped and as a result her interests have extended, to eating out and shopping.  Parents also reported moderate improvements in Noleen’s social skills such as her ability to converse and approach others.

Conclusions

Lacking social and communication “know how” amongst adolescents with autism can result in heightened anxiety within school and home environments.  This can result in increased cognitive and practical impairments.  The evidence reported in this research indicates that adopting a range of play and leisure strategies delivered via a transdisciplinary approach centering on the strengths, interests and needs of each young person can support and improve this area of deficit.

Including and educating peers also positively helps raise awareness and knowledge of autism whilst offering opportunities to forge peer relationships which may otherwise prove difficult for the young person with autism.

 

References

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Kossyvaki, L.; Papoudi, D. (2016). A Review of Play Interventions for Children with Autism at School. International Journal of Disability, Development and Education, 63(1), pp. 45-63.

Lindsey, E. W. (2014). Physical Activity Play and Preschool Children's Peer Acceptance: Distinctions Between Rough-and-Tumble and Exercise Play.  Early Education and Development, 25(3), pp.271-294.

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Wolfberg, P, Bottema-Beutel, K. and De Witt, M. (2012). Including Children with Autism in Social and Imaginary Play with Typical Peers. American Journal of Play, 1(5), pp.55-80.

 

Author information

Sheila Cross is a Certified Researcher and has almost twenty years in the field of research of which eight years has been spent in autism.  Sheila is employed as Research Projects Manager at Middletown Centre for Autism and is currently completing her Masters degree in Autism at the University of Strathclyde. Her research interests include inclusive education and the diagnosis and experience of girls with autism in education.