Development of Symbolic Play Trough the Use of Virtual

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DOI: 10.1177/1362361307086657

2008 12: 143AutismDe Pablo

Gerardo Herrera, Francisco Alcantud, Rita Jordan, Amparo Blanquer, Gabriel Labajo and Cristinawith autistic spectrum disorders : Two case studies

Development of symbolic play through the use of virtual reality tools in children

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143

Development of symbolic playthrough the use of virtual

reality tools in children withautistic spectrum disordersTwo case studies

G E R A R D O H E R R E R A Universitat de Valencia Estudi General,Spain

F R A N C I S C O A L C A N T U D Universitat de Valencia EstudiGeneral, Spain

R I T A J O R D A N University of Birmingham,UK

A M P A R O B L A N Q U E R Centro Comunica de Diagnstico eIntervencin, Spain

G A B R I E L L A B A J O Autismo Burgos, Spain

C R I S T I N A D E P A B L O Autismo Burgos, Spain

A B S T R A C T Difficulties in understanding symbolism have been docu-mented as characteristic of autistic spectrum disorders (ASDs). Ingeneral, virtual reality (VR) environments offer a set of potential advan-tages for educational intervention in ASD. In particular, VR offers theadvantage, for teaching pretend play and for understanding imagin-ation, of it being possible to show these imaginary transformationsexplicitly. This article reports two case studies of children with autism(aged 8:6 and 15:7, both male), examining the effectiveness of usinga VR tool specifically designed to work on teaching understanding of

pretend play. The results, confirmed by independent observers, showeda significant advance in pretend play abilities after the interventionperiod in both participants, and a high degree of generalization of theacquired teaching in one of them.

AD D R ES S Correspondence should be addressed to: R I TA J O RDA N, School of Educa-tion, The University of Birmingham, Edgbaston B15 2TT, UK. e-mail: [email protected]

autism 2008SAGE Publicationsand The National

Autistic SocietyVol 12(2) 143157; 086657

1362-3613(200803)12:2

www.sagepublications.comDOI: 10.1177/1362361307086657

K E Y W O R D S

autism;imagination;pretend play;virtual reality

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Virtual reality

Computer programs are increasingly being used in clinical practice forpsychological and medical rehabilitation in children (Schneider, 1998) andalso in educational practice (Alcantud, 2000; Griffiths, 1997; Riva et al.,

1998). It has been claimed that virtual reality (VR), like other computerbased programs, provides a particularly facilitatory environment for peoplewith autistic spectrum disorders (ASDs) in that it offers structure, visualmediation of learning, opportunities for repetition, affective engagementand, additionally, control of the learning environment (e.g. Strickland et al.,1992). Murray (1997) argues that IT is an effective, comfortable, facilitativeand emotionally engaging context for learning in individuals with autism.It is likely, though as yet unproven, that VR will share those characteristicsof IT and have enhanced effects (especially in terms of generalization)

because of its greater capacity to engage and direct attention, offer controlof the environment and engage the participants emotionally. Thus, thereare good a priori reasons for using VR as a vehicle for teaching individualswith ASD.

The authors have developed a VR-based learning environment where ashopping activity is recreated. Within this learning environment, the toolI am going to act as if . . . (Herrera et al., 2004: see Appendix 1), aimedat facilitating understanding of imagination in people with ASD, has beendeveloped. Imagination is a core difficulty in ASD (Wing and Gould, 1979),

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Figure 1 Snapshot of the tool I am going to act as if . . .



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and it has been recommended that interventions in ASD should concentrateon such fundamental aspects of functioning (Rutter, 1996) rather than ongeneral cognitive gains.

Imagination and the autism spectrumDifficulties and delay in understanding symbolism, especially in relation tosymbolic play, have long been documented as characteristic of people withASD, and as possibly contributing to social difficulties (Jordan, 1999; 2003):social/emotional development and the cognitive development of play influ-ence each other through a transactional process. Thus there are social,communicative and cognitive consequences of failure to engage in play(Jordan and Libby, 1997; Sherratt and Peter, 2002) and addressing thisproblem is likely to have considerable and ecologically valid benefits. Powell

and Jordan (1994) have argued for the effectiveness of a cognitively basedcurriculum for children with autism, and texts for teaching play cognitivelyhave been developed (Howlin et al., 1999). VR offers a further opportunityfor a cognitive approach to the understanding and manipulation of symbols.

Imagination involves conscious dissociation from reality and the mentalmanipulation of the environment, and imaginative behaviour involves spon-taneity, intention rather than response, and creativity. Play involves the firsttwo of these characteristics and symbolic play all three; thus, symbolic playis often characterized as imaginative play. Leslie (1987) has defined pretend

play as covering both functional play (using objects, including miniaturesor toys, as if they were the object they represent) and symbolic play (usingobjects as if they were something else, had imaginary properties, or weredifferent from the way they are). Leslie suggests that the autistic difficultylies in understanding and using symbolic play with its associated need formental state understanding, whereas functional play should be unaffected.Experimental and clinical evidence for this is confused and contradictory,in part because of the failure of many studies to distinguish the symbolicfrom the functional aspects of pretend play (Jarrold et al., 1993).

Attempts to teach pretend play to children with ASDs have usuallyfound that such play can be copied or even cued, but that it does not havethe qualities of spontaneity, intention and creativity that distinguish imag-inative play (Jarrold et al., 1996; Libby et al., 1998). This has led to thesuggestion that play deficits in ASD may result not from fundamental diffi-culties in symbolism, but from generativity problems arising from execu-tive functioning faults. Sherratt (2002) was able to teach all five childrenin his study to copy and extend taught symbolic play narratives, and someto generalize to other forms of symbolic play. Sherratt attributes the successof his programme to the use of a clear structure, the repetition of familiar

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routines, and the degree of affective engagement. He suggests this enabledthe children with ASD to overcome their generativity problems and revealtheir capacity to play.

VR may provide a similarly facilitatory structure for imaginative under-

standing through its use of structure, its opportunities for repetition, itsability to encourage intention through control of the learning environ-ment, and its inherent capacity to evoke affective engagement in childrenwith ASD. This study seeks to examine these claims for the advantages ofVR, with two individuals with ASD.

Description of the tool I am going to act as if . . .The contents and strategies in the manual for the tool I am going to act asif . . . include an introduction that reviews the relevant features of play inautism compared to typical development, a proposal for the teaching process,

and methods and tests for assessing all the abilities worked on (Herrera etal., 2005). The contents of the manual can be seen in Appendix 1.

The research we present here involves one version of the interventionusing a touch screen, since the immersive version of Virtual Reality is atpresent not generally available. The version used is technically moreadvanced than those used in other studies (Strickland et al., 1992) to date,but necessarily represents only the state of the art at the time.

The virtual supermarket provided with the tool has a set of progres-sive exercises that advance from the mere physical manipulation of the

objects when shopping to practice with play first functional and thensymbolic with those objects. The structure for teaching what the toolprovides involves following the steps shown in Figure 2, each of which, inturn, requires a set of intervention sessions.

Intervention starts with a stage of supermarket exploration, in whichthe individual with ASD has to manage in the virtual environment, buyingthings by following the list (see Figure 2) that is provided visually, andpaying at the till. In the next stage, functional use, a video is shown forevery object, indicating how this object is used in a purely functional way

(in the first section of the video) and in a social way (in the last section).In the subsequent functional play stage, another video shows a child playingwith a miniature version of the current object. An example is dressing adoll with a pair of toy trousers, equivalent to the real trousers situated onthe supermarket hangers.

The stage of imaginary play is divided into three. The first stage,imag-inary play with junk and representational materials, includes a set of videoswhere the play of the protagonist is no longer functional but symbolic,performing imaginary object substitutions. An example is acting as if a pieceof clothing (blue and neutral) were a pair of trousers. In the second stage, an

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imaginary transformation is shown explicitly, taking advantage of VR. Forexample, the pair of trousers is transformed into a road (Figure 1). As they

represent an imaginary transformation, images are presented framed intoa think bubble. In the third stage, related to magic, the same set of trans-formations is shown but this time without the think bubble, trying to illus-trate that this kind of situation can occur magically in reality (or at leastin fantasy stories, films, and so on). This was inserted on the pragmaticassumption that some children would be familiar with media transform-ations of objects and thus needed to distinguish between this making realof imagination and imagination itself. This carefully stepped approach toteaching, ensuring understanding at each stage, avoids the confusion whichcould result from the premature use of a VR tool.


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Figure 2 Teaching steps and session detail

Supermarket Exploration Session 1 Session 2 Session 3 . . . . . . . Session n

Functional Use Session 1 Session 2 Session 3 . . . . . . . Session n

Functional Play Session 1 Session 2 Session 3 . . . . . . . Session n

ImaginaryPlay

Session 1 Session 2 Session 3 . . . . . . . Session n

Creative Use Session 1 Session 2 Session 3 . . . . . . . Session n



with objects

transformations

magic

Session 2: (detail)

Session 1 video reviewing

List 3: item 1, tem 2, List 4: item 1, tem 2,

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For research purposes, in order to compare the VR program to conven-tional play teaching, we did not use any additional teaching material suchas toys or miniatures. However, for the regular use of this VR tool, it shouldbe used in combination with natural play materials, to provide an even more

enriching experience.In summary, this tool aims to enable individuals with ASD to improvetheir knowledge and autonomous management of real objects equivalentto those worked on in the virtual environment, and to improve their pretendplay and their understanding of imagination.

Methodology

Technological development is a continuous process, so the interventioninvolves using prototypes in such a way that reflection on the results

improves both the prototype and the intervention plan simultaneously.

ParticipantsThe two individuals with a diagnosis of ASD matched the criteria for autismin DSM-IV (American Psychiatric Association, 2000). Both participants werereceiving some form of service from the Society of Autism of Valencia(APNAV). Both were also strongly attracted to computers and, for both,conventional approaches to encouraging participation and teaching playhad failed. Participant data are included in Table 1.

Participant 1. This boy had good expressive language with imperatives, a fewdeclaratives and long sentences, but no conversation or discourse skills. Hewas easily able to learn the mechanical components of the learning environ-ment (virtual supermarket), which was a precondition for using the I amgoing to act as if . . . tool. As his scores in the ToPP (Lewis and Boucher,1997) showed before starting the intervention, however, he had seriousdifficulties in pretend play. Interviews with parents and professionalsrevealed that he had a strong fear of any film situation that involved magic.

He also showed difficulties in his understanding of mental states, as assessedthrough sections of the Inventory of the Autism Spectrum (IDEA) test(Rivire, 1997: see Appendix 2) and through the SallyAnn Test withoutwindow (Wimmer and Perner, 1983), and with window (Nuez, 1993).

Participant 2. This young man had some appropriate speech but none of itwas spontaneous. He used some imperatives but no declaratives, spoke inshort sentences, had some echolalia, and displayed no conversation ordiscourse skills. However, he did have a good ability to communicate inwriting when asked. He was also easily able to learn the mechanical actions

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needed for managing the virtual learning environment. He showed verylimited pretend play, as ToPP scores show. His scores in the IDEA test(Table 2), together with severe problems in solving theory of mind tasks(SallyAnn, with and without windows), showed he had difficulties ingeneral mental state understanding. Difficulties in the understanding of

pretence were also recorded.

Assessment instrumentsThere were specific questionnaires for collecting any potentially pertinentdata (such as the play techniques used before the study, the attitude towardscomputers), and a clinical history was obtained through interviews withparents and professionals, to obtain background data on the participants.The scores obtained by both participants before and after intervention arerecorded in Table 2.

The most relevant test for the objectives of this research (ToPP) has twoparts: structured and free. In the structured part, play materials are givenfirst in an elicited way (without any specific instructions about how to usethem) and then in an instructed or modelled way. The participants scoreis doubled if s/he plays in response to elicitation rather than needing model-ling or instruction. As this test does not have different sets of items fordifferent assessment points, the same models of play are used both beforeand after intervention, which inevitably leads to a memory effect in thefinal scores. Results from the ToPP test were assessed by four observers(Table 3), two of whom were independent of the research team. To minimize


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Table 1 Participants data

Participant 1 Participant 2

Age at the moment of starting intervention 8:6 15:7

Leiter IQ (Roid and Miller, 1996) 89 89

Spontaneous acts of initiating communication, as Frequent Absent

recorded in both assessment and intervention sessions

Structured Test of Pretend Play (ToPP) (months) 29.8 40.3

Non-structured ToPP (months) 37.3 18

IDEA [social,language and communication, anticipation/ [13,12, 15, 11] [11,13, 11, 10]

flexibility, symbolization];maximum score in each

category is 24 (see Appendix 2)

SallyAnn test, False Belief Task Not resolved Not resolved

Mentalistic understanding of pretence (specific tests for 41 38

this research)



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disagreements on the functional or symbolic character of the observed play,

observers were trained to use the same criteria in their scoring before andafter intervention. The samples of behaviour used for ToPP were pretendplay events that the individual showed at different observational moments,together with measures of their quantity and category (Leslie, 1987: objectsubstitution, false properties attribution, and disappearing/reappearing),according to the general procedures of the ToPP test.

Intervention programmeBoth intervention and assessment sessions were conducted in a controlledenvironment and were video recorded to allow for inter-observer analysis

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Table 2 Assessment instruments and scores at test and retest

Test description and score range Participant 1 Participant 2

Test Retest Test Retest

Functional use: assessed with different items in which 30 33 30 32

the person has to choose the right alternative for

using any of the 33 objects involved, thus scoring

from 0 to 33 pointsa

Functional play: SPT from Lowe and Costello (1976), 20 24 23 22

scoring from 4 points (12 months) to 24 points

(36 months or more)

Symbolic play, s tructured test: ToPP from Lewis and 10.25 16.75 15.5 20.25

Boucher (1997), scoring from 1 point (11.3 months)

up to 34 points (77.3 months)b

Symbolic play, non-structured (free) test: ToPP from 10.5 15.5 1.5 7

Lewis and Boucher (1997), scoring from 1 point

(16.9 months) up to 34 points (87.9 months)b

Number of free play samples in the free play ToPP test 5 18 1 9

Imagination understanding:mentalistic understanding 41 59 38 49

of imagination, through the use of a specific test in

which the user has to choose whether the

representation of imaginary contents is associated

or not with a comic think bubble through a total

of 60 itemsa

Magic understanding, indicating which situations are 47 59 39 52

magic and which others are real, also through a

total of 60 items (see Figure 3 for example)a

a Complementary test designed for this research, non-standardized.Given both verbally and non-verbally.b Standardized over English population,but used here only with relative value to testingretesting.



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when necessary. The participants attended the Society for Autism in Valencia,receiving the initial test in the first half of March and a retest in the first 2weeks of June 2003. During the 212 months of intervention, each individ-ual received a total of 28 intervention sessions, lasting 2030 minutes each(approximately three sessions per week).


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Table 3 Scores at ToPP by four observers

Participant 1 Participant 2

Structured Free Structured Free

Pre Post Pre Post Pre Post Pre Post

First observer our team 10 21 8 12 15 18 0 6

Second observer our team 7 16 8 12 18 24 2 8

First independent observer 13 17 14 22 14 19 2 8

Second independent observer 11 13 12 16 15 20 2 6

Figure 3 Snapshot of the magic understanding test



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Results and analysis

Reliability measuresAll the correlations of the assessments made by observers were highly

significant: the correlation was 0.877 (p = 0.004) between observers fromthe team and 0.923 (p = 0.001) between external observers. Finally, corre-lation between external and internal observers was 0.838 (p = 0.009).

Functional understanding and useThe participants understanding of the functional use of each object in thesupermarket was checked as a prerequisite for the following levels ofteaching. Participant 1 increased his spontaneous functional use of objectsafter the intervention, and was able to generalize from the virtual to thereal environment. For example, his mother reported that, after starting to

use the VR tool, the child started to say I am going to use the toothbrushcorrectly, repeating exactly the use of this object he had learnt through thevideos of functional use. The same thing occurred with other items suchas the trousers, the sausages, the sandwich, and so on. Both participantsshowed a good level of functional play, obtaining scores near the maximumbefore (and after) intervention.

Symbolic understandingThe first participant, as shown in Table 2 and Figure 4, showed consider-

able progress in structured pretend play, obtaining an improvement of 6.5points in ToPP (from a 29.8 months level of typical play development to42.8 months). He gained 5 points in the more relevant free play test,advancing from 37.3 months (free play age) to 48.1 months. The goodexpressive language of this participant appeared to be important in hisunderstanding and use of the symbolic content. Generalization to otherenvironments, people and situations was reported by both parents andprofessionals.

The advances shown by the second participant were also in both types

of play (structured and free: see Table 2). In the structured play test hegained 4.75 points (from 40.3 to 49.8 months) and in the free play testhe gained 5.5 points (from 18 months to 29.8 months). Parents andteachers did not report any generalization of this play to other situations,however.

Imagination understandingIn relation to understanding imagination as a mental state, which was repre-sented through the use of comic think bubbles, the first participant showeda very significant increase in his ability to determine which of the given

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situations corresponded with reality and which with imagination, recorded

through the teachers impressions and through specific tests (see last rowsof Table 2). In these tests, an increase of 18 points from a total of 60 wererecorded, correctly resolving almost all the items (59), with all of theminvolving contents different to those worked on through the intervention.Equally positive results were found in the magic understanding test (Figure3). Results from the second participant in both tests were also very positivebut not as notable; he obtained increases near to 20 percent, but did notmanage to successfully complete all of the items.

Discussion

Positive results were found in all the tests used (see Table 2). In the ToPPtest, memory effects occurred with the first participant in just one of theitems, resulting in 1 false point in his final score. Allowing for such possibleeffects on the scores, results still suggest increased scores in both parti-cipants after the intervention period.

A further possible contaminating influence on the results was theincrease in the level of attention shown by the participants on the retest

compared to the initial test, perhaps because of the increased familiaritywith the structured teaching situation during the 2 months of the inter-vention. In sections III (representational toy alone) and IV (self alone)of the structured test of ToPP, very few (or no) play samples were observedin the first test session, because of the difficulties shown by the child inattending to the teachers instructions, despite her being his usual teacher.

We know that people with ASD tend to show greater difficulties in non-structured situations in which it is necessary spontaneously to generateoriginal models of play, apart from any difficulties they may have with theunderstanding of imagination itself. For these reasons, the results of the


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Figure 4 Progress in the scores of the structured ToPP

1

10

20

30

0

5

1015

20

25

30

35

11.3 29.3 49.3 69.3

months

Typical

Development

Participant 1

Participant 2B

E

B

E



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free play test are more relevant, since there were no elicitations, modellingor instructions and all the play samples were original and adequate.

In addition, we also asked observers to collect data on the number offree play episodes shown by the participants in a defined period of obser-

vation (as this measure is not included in the ToPP procedures). The resultsindicated a very important increase in both participants (see fifth row ofTable 2).

In order to assess the ecological validity of our results, interviews withparents and educational professionals were undertaken. With the firstparticipant there was a clear reflection of the results of the intervention inhis daily life, both in relation to the autonomous use of objects and in theperformance of imaginary actions and appropriate play in his usualcontexts of interaction. For example, the child began to express his ideasto obtain his mothers attention. He performed symbolic play scenarios

such as Look Mummy, I am going to act as if the sock were a beard, andother appropriate and spontaneous samples of play that were different tothose trained on the VR. Fear of films with magic content was replaced byan increasing interest and curiosity towards all imaginary situations.

The failure of the second participant to demonstrate any generalizedsocial use of imagination (despite improvements in his scores on the ToPPtest) may result in part from the paucity of social contact in his environ-ment. If this is the case, this suggests that to obtain a better outcome, notonly in cognitive play but also in the wider and more important social play,

it would be necessary to follow a complementary programme orientedtowards the initiation and maintenance of social contact. However, thedegree of language development may also be an important factor in inter-preting the different results of the two participants.

Future workThe results obtained suggest that VR is a useful tool in educational inter-vention in children with ASD, at least in the two participants who weretested. However, it is necessary to compare the efficacy of this tool with

the use of conventional tools. In order to make this comparison possible,we have created a toy-based equivalent version of the VR tool, and thatanalysis is ongoing. This, and the results from other research on educationalinterventions in ASD, will help determine the design and content of futuretools.

Our team intends to replicate this study using a larger number of parti-cipants, with the aim of testing and extending the validity of our results.It is also intended to determine more precisely the profile of the individualswith ASD for whom this kind of tool would be of the greatest benefit.

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Appendix 1: contents of manual for the tool I am going to actas if . . .

1 For whom it is created

2 IntroductionImportance of play in child developmentPlay in children and adults with autismTeaching play in autismThe tool I am going to act as if . . .

3 A teaching processModalities and levels of playThe abilities that support playWhat is the role of these abilities in autism?

Structured teachingThe steps in the teaching process: shopping and management in thesupermarketTeaching functional useTeaching functional playTeaching imaginary playCreativity teaching

4 AssessingNecessary space and materials

Test structure, administration and scoringRecord sheets and video recordingSummary of the whole process

5 Technical specifications

Appendix 2: dimensions of the IDEA test (Rivire, 1997)Each dimension score depends on the degree of impairment (minimum 0to maximum 8). The maximum score for the global test is 96 points.

1 Social1.1 Relating socially1.2 Joint attention1.3 Intersubjectivity and mentalistic ability

2 Communication and language

2.1 Communicative functions2.2 Expressive language2.3 Receptive language


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3 Anticipation and flexibility

3.1 Ability to anticipate3.2 Mental and behavioural flexibility3.3 Conscious of the sense of his/her activity

4 Symbolization4.1 Ability to pretend4.2 Ability to imitate4.3 Creating and mentally working with pending things

AcknowledgementsThis work has been carried out thanks to funding from the SpanishMinistry of Science and Technology (PROFIT), the Spanish Ministry ofSocial Affairs (IDI) and the Regional Government of Valencia, through the

projects INMER-II and APRIL.

NoteA version of this article in Spanish only appeared in a book Dificultades del Desarrollo:Evaluacin e Intervencin (2007), Pirmide, Madrid.

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Development of Symbolic Play Trough the Use of Virtual

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