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Play-Based Interventions for ASD

Autism spectrum disorder (ASD) is a intellectual disability of development and learning disability associated with impairments in an individual’s ability to interact and communicate effectively in their surroundings. ASD disrupts the functioning of the nervous system and as a result, also negatively impacts the overall emotional, cognitive, physical and social wellbeing of the individual (Hillman 2018). The severity and range of symptoms of ASD can demonstrate extensive variations from individual to individual. Prevalent symptoms of ASD include: difficulties in social interactions, difficulties in communication, behaviours which are repetitive and obsessive preferences. Timely and early onset recognition and management can decrease symptoms and encourage positive learning and development in the individual (Watkins et al. 2019).

Play based interventions are interventions and practices which are intended to enhance the physical, social, cognitive, language and emotional development of a young person using interactive and guided play. Practitioners commonly use play based interventions as an enjoyable and natural way to support development, growth and social skills during early childhood. With respect to interventions for ASD, a number of therapies target the relationships between social play and enhancement of language skills, social skills and communication skills since these are some of the foundational areas of challenge for children having ASD (Chang et al. 2018). However, the concept of play is vast and extensive and current literature on the effectiveness of play based interventions is highly heterogeneous and broad. This means that it can become a challenge for parents, teachers and early childhood practitioners to navigate through these heterogeneous interventions and make decisions on the most effective play based strategy which can be used for a child with a unique set of ASD symptoms (Will et al. 2018). With this respect, the aim and objective of this paper is to thus propose a study which can systematically review the effectiveness of current play based interventions and develop recommendations and future implications which can then be used for informing clinical decision making in ASD children.  

An extensive proportion of children with ASD have been found to experience anxiety within clinical settings. The randomized controlled trial by Wijnhoven et al., (2020) aimed to evaluate the impact of a video game named ‘Mindlight’ on the symptoms of anxiety in children having ASD. To address the same, the authors recruited a total of 109 children aged 8 to 16 years who have been diagnosed with subclinical anxiety symptoms and ASD. The sample was recruited into a control group (N = 56) as well as an experimental group (N = 53). Children who were in the experimental group played the video game MIndlight while those in the control group engaged in ‘Triple Town’ – a commercial level game for a period of 1 hour every week, for a total of six weeks. Based on the results, it was found that children rated anxiety symptoms demonstrated no significant differences for both groups prior to and after treatment. However, symptoms rated by parents indicated that a significant decrease in symptoms of anxiety within the experimental group. The study by Wijnhoven et al., (2020) thus proved to be useful in terms of demonstrating the extent to which, play based interventions as digital games can be useful for instilling positive emotional outcomes in the form of decreased symptoms of anxiety in children having ASD (Wijnhoven et al., 2020). Based on critical appraisal using the CASP Tool (Appendix 3), it can be thus stated that the study by Wijnhoven et al., (2020) focused on a research topic which was relevant, significant and focused and also effectively practices randomization and equal treatment of groups prior to intervention implementation. The effects of the treatment were also reported using confidence intervals. There is however no mention regarding whether participants and allocators were blinded to the interventions thus raising doubts on the risk of bias in findings. Additionally, the findings of this study are highly preliminary in nature and may not be fully generalizable since the authors did not explore the mechanisms which contributed to the decreased anxiety and the sample also did not include younger children or toddlers having ASD (Wijnhoven et al., 2020).

Study on Play-Based Digital Game Interventions

Play based interventions based on education and social stories have also been evidenced to be useful for encouraging positive language, social and emotional outcomes in children with AD. The randomized controlled trial by Hanrahan et al. (2020) aimed to examine the impact of digitally regulated, social story based play intervention on children having ASD. To address these objectives, the authors recruited 16 children with ASD of which 6 were in the control group and 9 children were randomized to the experimental group. Participants in the control group were required to read a poem digitally while the experimental group while the experimental group were asked to read a social story based on a maladaptive behavior (for example, not taking turns, or not arranging things in order) along with an Educational Psychologist to assist them in writing and reading skills. The results indicated that those in the experimental demonstrated positive behavioral outcomes in the form of positive play and social skills (Hanrahan et al. 2020). The findings by Hanrahan et al. (2020) thus proved to be useful in terms of demonstrating how play based interventions in the form of social stories can facilitate improved social and behavioral outcomes in children having ASD. According to critical appraisal using the CASP tool (Appendix 3) it can be stated that the study by Hanrahan et al. (2020) focused on a significant research question and also used appropriate randomization and blinding techniques to product results which are valid and reliable. However, in criticism, the study had a relatively low sample size and the interventions so used were more educational in nature rather than actual play (Hanrahan et al. 2020).

The randomized controlled trial implemented by Parsons et al. (2019) aimed to examine how a pragmatic language, play based intervention mediated by peers was effective for children having ASD. A sample comprised of 71 children having ASD were randomly allocated into a control group (n = 34) and an intervention group (n = 28). Children in the intervention group participated in 10 play based sessions mediated by peers and parents on a weekly basis. Language outcomes were assessed prior to and after 3 months of the intervention using the Social Emotional Evaluation (SEE) as well as the Pragmatics Observational Measure (POM-2). Scores of POM-2 were significantly higher in the intervention group right after treatment (p = 0.031) and also after the 3 months follow up (p < 0.001) (Parsons et al. 2019). The findings by Parsons et al. (2019) were thus useful in terms of demonstrating how play-based interventions regulated by parents and peers in home settings can facilitate positive social and language outcomes for children having ASD. Using critical appraisal tools, it was found that the study focused on a relevant question with participants and assessors being blinded to the intervention. However, findings may not be fully generalizable because of the low sample size and the possibility that social and language skills in ASD children may have increased not because of the intervention but perhaps due to interactions with peers and family (Parsons et al. 2019; Appendix 3).

Social Story-Based Play Intervention Study

Thus, while the above review of literature provides a broad understanding on the efficacies of play based interventions, several limitations and gaps in research were observed. Some of the common limitations in literature were: a relatively low sample size, inadequate representation of all children form varying ages, gender or cultural groups and the absence of actual scientific explanations regarding how the mechanisms by which the play based interventions were useful in inducing positive outcomes in ASD children. Additionally, most of the studies demonstrated methodological limitations which affected the overall generalizability of findings: such as a low sample size and a lack of blinding across participants. Such limitations thus rationalized the need to implement methodologies such as a systematic review which can collect studies of the highest methodological and result quality and present an evidence based set of findings on the effectiveness of play based interventions which can be used for future clinical decision making (Parsons et al. 2019; Hart Barnett 2018; Gibson, Pritchard and de Lemos 2021).

Thus, with respect to the given background of literature, this paper intends to propose a study which aims to systematically review existing literature exploring the efficacies of play based interventions for children having autism spectrum disorder (ASD). To address the same, the paper aims to fulfil the following research objectives:

  1. To critically review current literature on the various types of or ways by which play based interventions can be used for encouraging social and communication skills in children having ASD.
  2. To critically review current literature exploring the efficacies of various play based interventions for children having ASD.
  3. To recommend, using findings from evidence based literature, on the various ways by which play based interventions can be implemented in practical surroundings by stakeholders working with children having ASD, such as teachers and parents.

For the proposed study, the research philosophy of pragmatism was considered to be the most appropriate. The research approach and philosophy of pragmatism is based on the understanding that the selection and choice of the philosophy and approach for research is generally defined by the problem which the research aims to answer. For this research philosophy, practical results are thus essential to be considered. Due to this principle, pragmatism does not rely on philosophical reality or system (Kaushik and Walsh 2019). This means that researchers are free to select the techniques, processes and methods of data collection and evaluation which they find as most appropriate for their research question. Since the topic proposed by the study, aimed to review current evidence based literature systematically regarding the effectiveness of play based interventions for ASD, a pragmatist research philosophy was thus the most appropriate. This philosophy prompted the researcher to rely on a systematic review as the data collection method based on the research aims and limitations in research focused upon this proposal (Hothersall 2019).

Alternative research philosophies, such as positivism and interpretivism were rejected. A positivist research philosophy is based on the premise that a research phenomenon is understood best from an objective analysis of its variables. In contrast, the research philosophy of interpretivism is reliant on the understanding that a research phenomenon is observed best from the perspectives of the actual participants and communities who have experienced the issue (Alharahsheh and Pius 2020). Since this study does not propose to objective evaluate any variables of play based interventions, nor does it propose to directly collect data from children and families with ASD – these two research philosophies were thus rejected.

In order to provide evidence based responses to the proposed research aims and objectives, a qualitative research design comprising of secondary data collection will be undertaken. A qualitative research is characterized by the in-depth collection and evaluation of either subjective data or the lived experiences of participants or the systematic interpretation of existing literature pertaining to a research issue (Kanbir, Clements and Ellerton 2018). A quantitative study on the other hand, comprises of the objective evaluation of a research issue so as to derive causal relationships between two or more variables using statistical or computational analysis (Tobi and Kampen 2018). Based on current background of literature, it was observed research to explore the efficacies of play based interventions across children having ASD has been mostly quantitative till date. As mentioned previously, the quantitative studies which have been conducted till date on this topic have demonstrated several limitations in evidence reliability, validity and quality. These limitations rationalized the need to use alternative research designs – such as a qualitative study in the form of a systematic review. Additionally, since this study proposes to assess current literature which have explored the efficacies of play based approach for children having ASD, a qualitative research design was thus considered as the most appropriate (Parsons et al. 2019; Hart Barnett 2018; Gibson, Pritchard and de Lemos 2021).

Pragmatic Language Play-Based Intervention Study

For the purpose of fulfilling the research aims and objectives, the proposed study aims to implement a systematic review. Qualitative research in the form of a systematic review is a systematic and structured process by which, the researcher collects evidence based articles specific to the research question and critically appraises the quality of their methods and findings using relevant and valid tools (Munn et al. 2018). As mentioned previously, research regarding the efficacies of play based interventions for children having ASD have till date demonstrated limitations such as lack of generalizations, under-presentations of several groups and poor quality of articles used for narrative synthesis. To overcome such limitations and also add to the repertoire of existing evidence pertaining to this research question, a systematic review was thus found to be the most appropriate (Munn et al. 2018). Additionally, current literature on play based interventions are too heterogeneous and broad to inform clinical decision making for ASD. A systematic literature review can thus be considered as an appropriate way by which the research can present the most relevant, generalizable and valid scientific data on play based intervention effectiveness which can then be used to assist clinical decision making for practitioners, families and teachers in the future respectively.

Since this study proposes to rely on secondary data collection, the recruitment and sampling of human participants are not applicable. However, in order to provide findings which are evidence based, reliable and valid, systematic reviews must include articles which are highly relevant and coherent to the research question (Wohlin et al. 2020). To ensure the same, the proposed study will use a detailed exclusion and inclusion criteria for selecting articles based on the PICO framework (Table 1):

Table 1: Inclusion and Exclusion Criteria for Systematic Review (Source: Created by the Author)

PICO Components

Inclusion Criteria

Exclusion Criteria

Population

Children in the age group of 2 to 12 years having Autism Spectrum Disorder

Adolescents, Adults or Older Adults having Autism Spectrum Disorder

Individuals having any other learning, development of intellectual disability apart from ASD.

Intervention

Play based interventions

Interventions which are not associated with play based activities

Control/Comparison

Not Applicable

Not Applicable

Outcomes

Improvements in Social, Communication, Language, Emotional or Cognitive skills

Any outcomes not related to Social, Communication, Language, Emotional or Cognitive skills such as Learning outcomes in Educational Settings

 Additionally, care will be taken to ensure that articles older than the last 7 years are excluded so as to enable the selection of the most recent and updated evidence regarding play based interventions for ASD. Additionally, articles which are not peer reviewed or relying on research designs with low strength of evidence will be excluded – such as opinion editorials or grey literature (Glasofer and Townsend 2019). This will ensure the selection of articles with a reasonably good quality methodological quality as per the evidence pyramid (Figure 1).

Pyramid or Hierarchy of Evidence (Source: Glasofer and Townsend 2019) 

Figure 1: Pyramid or Hierarchy of Evidence (Source: Glasofer and Townsend 2019)

One of the major yet preventable limitations of systematic reviews are the risk of publication bias. Publication bias is when researchers tend to include those articles which seem favourable to them without considering their coherence to the research question or the credibility of their findings (Williams, Boyland and Nunan 2020). In order to ensure that the most valid and reliable articles are selected in the systematic review, critical appraisal will be conducted with the help of using the checklists provided by the Critical Appraisal Skills Programme (CASP). This is because CASP checklists provide a repertoire of tools by which researchers can assess the quality and rigor of studies following various research designs such as observational studies, reviews, qualitative studies and randomized controlled trials (Long, French and Brooks 2020). An example of a CASP Checklist has been outlined in Appendix 1.

For the purpose of collecting evidence based data for the proposed systematic review, an electronic search strategy will be implemented. This will comprise of using keywords which are relevant to the research question and applying them in databases which contain articles relevant to the same. This means that keywords such as ‘interventions’, ‘play based’ , ‘effectiveness’, ‘children’ and ‘autism spectrum disorder’ will be applied to databases such as PubMed, Medline, CINAHL and BioMed Central (Li et al. 2019). This is because such databases are known to contain a repertoire of articles relevant to the subjects focused upon by the research question, such as psychology, behavioural sign, medicine, early childhood and healthcare. To further expand the same, Boolean operators such as ‘AND’ or ‘OR’ will be used along with the keywords. This is because Boolean operators like ‘AND’ enable the selection of articles containing multiple keywords whereas operators like ‘OR” enable the selection of articles which contain either of the two or more keywords applicable to the research question (Ali and Usman 2018).

The keywords for the study will be identified and structured following a PICO framework. A PICO framework is a process by which, researchers can structure an appropriate and evidence based research question for article selection and evaluation. In this case, ‘P’ stands for the population targeted by the research question, ‘I’ standards for the interventions whose outcomes will be evaluated, ‘C’ stands for the control mechanism which will be compared with the intervention and ‘O’ standards for ‘Outcomes’ of the intervention (Eriksen and Frandsen 2018). With this respect, the keywords for the proposed systematic review are as follows (Table 2):

Table 2: Proposed Keywords as per PICO Framework (Source: Created by the Author)

Population

Intervention

Control/Comparison

Outcome

Children in the age group of 2 to 12 years having Autism Spectrum Disorder

Play based Interventions

Non-played based interventions or Standard interventions

Improved Social, Communication and Language Skills.

Using the PICO framework, the keywords and the Boolean operators for the proposed research question, will be used as a search strategy in article selection in the following manner (Table 3):

Table 3: Proposed Search Strategy (Source: Created by the Author)

Population

Boolean Operator

Intervention

Boolean Operator

Control/Comparison

Outcomes

Autism Spectrum Children

OR

Children with ASD

OR

Children with Autism

OR

Children having Autism Spectrum Disorder

AND

Play-based Interventions

OR

Play based

OR

Play Interventions

OR

Play activities

OR Play

AND

-----

Social Skills

OR

Language Skills

OR

Communication Skills

OR

Emotional Skills

OR

Cognitive Skills

Additionally, in order to refine the search strategy, limiters such as restricting the language to English and restricting the publication date to last 7 years (that is, from 2015 to 2022) will be established. This will ensure that the most recent literature will be collected for the systematic review (Wang et al. 2019). With this respect, the search strategy for each database will be used for the proposed study can be tabulated as follows (Table 4):

Table 4: Proposed Search Strategy as per Databases (Source: Created by the Author)

Databases

Limiters

Keywords

PubMed

Publication years from 2015 to 2022 and English Language

As per PICO Framework, for example: (Children with ASD) AND (play based interventions) AND ((Social) OR (Communication Skills)

BioMed Central

CINAHL

Medline

In order to understand and anticipate the possible findings which can be retrieved using the proposed search strategy, a search string, comprising of the following keywords: ((((children) AND (autism)) AND (play based intervention)) AND (social skills)) AND (communication skills) were implemented in PubMed – an open access database for medical and behavioural science. The research string revealed a total of 66 articles thus rationalizing that using a PICO based framework combined with Boolean operators can be effective for obtaining systematic review articles. The findings of the search strategy have been outlined in Appendix 2.

Upon application of the proposed inclusion and exclusion criteria (Table 1), a total of 4 articles were observed to be the most appropriate based on the research question. These were: a single case research design by Glugatch and Machalicek (2021), a mixed methods study by Parsons et al. (2019) and a randomized controlled trial by Ioannou et al. (2020). This thus demonstrates that the proposed exclusion and inclusion criteria have the potential to effectively identify the most relevant articles for a systematic review. The data of each of these studies have been extracted in the following table (Table 5):

Table 5: Data Extraction of Anticipated Findings (Source: Created by the Author)

Authors

Research Aim

Research Design

Methodology

Results

Glugatch and Machalicek (2021)

To examine the feasibility and benefits of a play based sibling intervention across children having ASD

Single Case Research

Five neuro-typical siblings were trained on play and behavioural skills

Increased reciprocal play among children with ASD and their siblings.

Parsons et al. (2019)

To examine the appropriateness and feasibility of a play based, peer to peer intervention for enhancing pragmatic language skills in children having ASD.

Mixed Methods

10 children having ASD as well their peers and families participated in a play based intervention for two months. Language and social skills were assessed and parental interviews were taken before and after the interventions.

The children demonstrated improvements in higher level language (p = 0.035) and pragmatic language (p = 0.011).

Ioannou et al. (2020)

To assess how theatre techniques and peer actors enhance social play and control anxiety in children having ASD

Randomized Controlled trial

77 children with ASD were randomized into an experimental and control group. The experimental group were provided with a theatre based program to enhance social play and social skills in young people with ASD.

After 40 hour sessions, the experimental group demonstrated in greater group play (p = 0.007) and decreased trait anxiety (p = 0.001) as per the control group.

It is proposed that in order to successfully complete this research and achieve dissemination, the following timeline and milestones need to be followed (Table 6):

Table 6: Timeline of Proposed Research (Source: Created by the Author)

Milestones

1st to 2nd month

3rd to 4th month

5th to 6th month

7th to 8th month

9th to 10th month

11th to 12th month

Approval of Research Proposal

ü 

Development of Research Protocol

ü 

ü 

Collection of Articles for Literature Review

ü 

ü 

ü 

Collection of Articles for Systematic Review

ü 

ü 

ü 

Evaluation and Analysis of Findings

ü 

ü 

ü 

Draft Dissertation Formation

ü 

ü 

ü 

Completed Work

ü 

ü 

Publication in National or International Journals

ü 

Dissemination of Findings in University, National or International Seminars and Webinars

ü 

In order to complete the proposed research successfully, it is likely that the following expenditures will be incurred (Table 7):

Table 7: Budget of Proposed Research (Source: Created by the Author)

Research Milestones/Activities

Estimated Costs

Collection of Grey Literature and Articles for Systematic Review

Not applicable if using online databases from the university laboratory

Collection of CASP Checklists

Not applicable since they are open access

Recruitment of Participants

Not applicable due to secondary data collection

Peer reviewing for assessing article validity

£10 approximately

Printing hard copies of the dissertation for publication

£60 approximately

Travelling to the Library to access Resources

£10 approximately

Total

£80

When working with human participants, researchers must ensure that certain ethical considerations are followed so as to prevent any harm to the health, safety, privacy and confidentiality of participants. Since this study proposes to rely on secondary data collection and not work directly with human participants, ethical considerations are not applicable. However, it will be ensured that only those articles, which have recruited human participants and have obtained ethical approval regarding the same, are included in the systematic review (Cascio, Weiss and Racine 2021). Additionally, since systematic reviews are mainly focused on the collection of secondary data, it is expected that issues in feasibility will not be faced. This is because the researcher will be able to access evidence based databases, journals and articles easily using then online library instead of incurring the costs and time of primary data seen in quantitative studies (Munn et al. 2018).   

References

Alharahsheh, H.H. and Pius, A., 2020. A review of key paradigms: Positivism VS interpretivism. Global Academic Journal of Humanities and Social Sciences, 2(3), pp.39-43.

Ali, N.B. and Usman, M., 2018. Reliability of search in systematic reviews: Towards a quality assessment framework for the automated-search strategy. Information and Software Technology, 99, pp.133-147.

Cascio, M.A., Weiss, J.A. and Racine, E., 2021. Making autism research inclusive by attending to intersectionality: A review of the research ethics literature. Review Journal of Autism and Developmental Disorders, 8(1), pp.22-36.

Chang, Y.C., Shih, W., Landa, R., Kaiser, A. and Kasari, C., 2018. Symbolic play in school-aged minimally verbal children with autism spectrum disorder. Journal of autism and developmental disorders, 48(5), pp.1436-1445.

Eriksen, M.B. and Frandsen, T.F., 2018. The impact of patient, intervention, comparison, outcome (PICO) as a search strategy tool on literature search quality: a systematic review. Journal of the Medical Library Association: JMLA, 106(4), p.420.

Glasofer, A. and Townsend, A.B., 2019. Determining the level of evidence: experimental research appraisal. Nursing2020 Critical Care, 14(6), pp.22-25.

Glugatch, L.B. and Machalicek, W., 2021. Examination of the effectiveness and acceptability of a play-based sibling intervention for children with autism: A single-case research design. Education and Treatment of Children, 44(4), pp.249-267.

Hanrahan, R., Smith, E., Johnson, H., Constantin, A., & Brosnan, M. (2020). A pilot randomised control trial of digitally-mediated social stories for children on the autism spectrum. Journal of autism and developmental disorders, 50(12), 4243-4257.

Hillman, H., 2018. Child-centered play therapy as an intervention for children with autism: A literature review. International Journal of Play Therapy, 27(4), p.198.

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Hothersall, S.J., 2019. Epistemology and social work: Enhancing the integration of theory, practice and research through philosophical pragmatism. European Journal of Social Work, 22(5), pp.860-870.

Ioannou, S., Key, A.P., Muscatello, R.A., Klemencic, M. and Corbett, B.A., 2020. Peer actors and theater techniques play pivotal roles in improving social play and anxiety for children with autism. Frontiers in Psychology, 11, p.908.

Kanbir, S., Clements, M.A. and Ellerton, N.F., 2018. Research Design and Methodology. In Using Design Research and History to Tackle a Fundamental Problem with School Algebra (pp. 115-140). Springer, Cham.

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