Abstract
Parents of children with autism spectrum disorder (ASD) may have difficulty engaging their children through play, thus affecting the parent–child relationship and parental self-efficacy. This study intended to examine children’s sensory profile and adults’ playfulness as predictors of parental self-efficacy. A total of 136 parents of children ages 3–7 yr completed the Short Sensory Profile, the Playfulness Scale for Adults, and the Tool to Measure Parenting Self-Efficacy. For the parental couples of children with ASD, the most relevant predictor of general parental self-efficacy was the child’s sensory profile. However, adult playfulness resulted in the most relevant predictor of emotional parental self-efficacy. Findings suggest the importance of considering play as a relevant co-occupation that must be acknowledged when intervening with families of children with ASD and considering the child’s sensory modulation abilities, as well as parents’ playfulness and sense of self-efficacy, as potential outcomes when designing and evaluating treatment programs.
Play is the main occupation of childhood; therefore, it serves a critical role in a child’s development of cognitive, motor, and social–emotional skills (Bundy, 2012; Parham & Fazio, 2008). Play is also viewed as the most appropriate and powerful mechanism for the development of the parent–child relationship (Schaefer & Drewes, 2011). When a child cannot play or cannot play well, negative effects may be observed in the child’s development and in the parents’ well-being and sense of self-efficacy (Vernon, Koegel, Dauterman, & Stolen, 2012). According to Bandura (1977), self-efficacy refers to people’s belief in their capability to achieve a goal or outcome. Parental self-efficacy refers to the confidence and expectations that a parent has concerning the degree to which he or she can perform competently and effectively as a parent (Teti & Gelfand, 1991). Because of the social and communication difficulties observed in children with autism spectrum disorder (ASD), their parents may feel incompetent in their ability to establish an emotional connection with them. Evidence has shown that in comparison with parents of children with typical development, parents of children with ASD tend to report higher levels of stress, depression, and hopelessness (Benson & Karlof, 2009; Hastings & Brown, 2002; Totsika, Hastings, Emerson, Berridge, & Lancaster, 2015).
Success in parent–child play interactions can be attributed to factors associated with both the parent and the child. According to Belsky’s (1984) Determinants of Parenting model, characteristics of the child are identified among the main factors considered to be related to parenting skills. These characteristics determine how difficult it is for parents to care for a child and influence the quantity and quality of parental care that they provide. Children with ASD often exhibit challenging behaviors, attributed, in part, to differences in sensory modulation; these behaviors may hinder their ability to be cared for and engage in positive interactive experiences such as play (Miller Kuhaneck & Britner, 2013; Reynolds, Bendixen, Lawrence, & Lane, 2011). Sensory modulation challenges are well documented in children with ASD (Baranek, 2002; Brock et al., 2012; Kirby, Dickie, & Baranek, 2015; Tomchek & Dunn, 2007). These challenging behaviors have the potential to affect the quality and the quantity of parent–child play as well as the development of the child’s prosocial skills. Additionally, a child’s sensory profile (a classification of his or her sensory modulation difficulties) is worth considering when studying the self-efficacy of parents with children on the autism spectrum.
Parental factors, or parental skills (also included in Belsky’s [1984] model), may influence the parent–child relationship and, in turn, may influence parental sense of self-efficacy. Parents fulfill a major role in promoting children’s play when they engage with them in diverse play experiences. Parental engagement in play, or playfulness, may therefore be a parent-centered skill that can affect development of the parent–child bond. When referring to children, playfulness is defined as the disposition to play (Barnett, 1991); it is an aspect of play that entails its essence and the way in which the child approaches play situations (Skard & Bundy, 2008). For adults, playfulness has been defined as the “predisposition to frame (or reframe) a situation in such a way as to provide oneself (and possibly others) with amusement, humor, and/or entertainment” (Barnett, 2007, p. 955).
Literature from the field of play therapy provides insights about the role of adults in children’s play (Howard & McInnes, 2013; McInnes, Howard, Miles, & Crowley, 2011; Schaefer & Drewes, 2011). Some specific roles that adults might have while playing with children are (1) play partners (becoming an equal in play), (2) admirer (showing that you value play), (3) facilitator (easing play along), and (4) mediator (resolving conflict; Sheridan, Howard, & Alderson, 2011). Children tend to use an adult’s presence as a cue to distinguish between play and nonplay situations; this behavior illustrates the importance of the adult’s ability to present him- or herself as a play partner to the child (Howard & McInnes, 2013). This partnership creates other benefits that enhance the parent–child relationship, such as developing a warm and friendly connection and establishing a feeling of permission in the relationship that encourages the child to express him- or herself more freely. The degree to which the adult is successful in achieving playfulness determines the degree to which these benefits are enjoyed or experienced (Landreth, 2012).
Because parent and child factors can influence aspects of the parent–child relationship, it was important in this study to consider child and adult factors that might highly contribute to parent’s sense of self-efficacy. Thus, adult playfulness was measured as a parental factor that could be a potential predictor of parental self-efficacy, whereas the child’s sensory profile was measured as a potentially relevant child factor. The primary purpose of this exploratory correlational study was to determine the relative importance of children’s sensory modulation abilities and parental playfulness as predictors of parental self-efficacy.
Method
Participants and Procedures
All study procedures were reviewed and approved by the institutional review board of the University of Puerto Rico, Medical Sciences Campus. Parents of children age 3–7 yr were invited to participate in this study; the target population was parental couples of children with ASD (P-ASD) and parental couples of children with typical development (P-Typ). Inclusion criteria for both groups were stated as follows: having a child between age 3 and 7 yr, willingness of both parents to participate, and ability to read and write in Spanish (to complete the study forms and questionnaires). In the case of the P-Typ group, children could not have any history of developmental delay and could not be participating in any therapeutic or special education services. Couples with more than one child complying with the inclusion criteria were asked to focus their responses on only one of the children; parents decided which child to select.
Convenience sampling was used to recruit parents in both groups. Recruitment procedures included the use of flyers, personal visits to specialty centers and classrooms for children with ASD, and use of a designated staff liaison at each center. Parents that communicated interest in the study received a participation package that included consent forms for both parents and copies of all questionnaires. When all questionnaires had been completed, researchers arranged a time to meet with the parents and collect the forms. Parents also had the option of returning the documents by depositing them in locked mailboxes located at the recruitment centers.
Of the 116 participation packages distributed, 91 were returned to the researchers, for a response rate of 78%. From the returned packages, 68 were complete and in accordance with the study inclusion criteria. The other 23 packages were not included as part of the sample for diverse reasons, such as incomplete questionnaires or unsigned consent forms.
Participant Characteristics
One hundred thirty-six parents (68 parental couples) of children ages 3 to 7 yr participated in this study: 36 P-ASD and 32 P-Typ. All parental couples were female–male dyads (mothers coupled with fathers). The mean age of participants’ children was 66 mo; the majority of the children were boys (60.3%). Table 1 includes demographic information for the total sample, P-ASD group, and P-Typ group.
Sample Demographics
Note. P-ASD = parental couples of children with autism spectrum disorder; P-Typ = parental couples of children with typical development.
Most of the mothers in the total sample (61.8%; n = 42) reported having an educational level of a bachelor’s degree or higher, whereas only 35.3% of fathers (n = 24) had achieved this level of education. Fisher’s exact test for categorical variables was used to determine whether the proportion of parents identified with the different educational degrees was independent of having a child with ASD or a child with typical development. Results indicated that being a mother of a child with ASD or typical development had no effect on the proportion of mothers with different educational degrees (Fisher’s exact test = 0.59, p = .92). In contrast, significantly more fathers in the P-ASD group reported lower educational degrees (Fisher’s exact test = 9.96, p = .02).
More than 40% of the couples (41.2%; n = 28 couples) reported an annual household income range of $15,000–$24,999, which is consistent with the median household income of $19,183 reported in the 2012–2013 Puerto Rico community survey (Noss, 2014). Fisher’s exact test indicated no difference in household income between the P-ASD and P-Typ groups (Fisher’s exact test = 3.07, p = .58).
Measures
Tool to Measure Parenting Self-Efficacy.
The Tool to measure Parenting Self-Efficacy (TOPSE; Kendall & Bloomfield, 2005) was used to measure parents’ perception of self-efficacy. It is a multidimensional instrument of 48 items within eight scales, each consisting of 6 items representing a different dimension of parenting. These scales are Emotion and Affection, Play and Enjoyment, Empathy and Understanding, Control, Discipline and Setting Boundaries, Pressures, Self-Acceptance, and Learning and Knowledge. An ordinal scale ranging from 0 (completely disagree) to 10 (completely agree) is used to answer questions. Initial studies on the reliability of the instrument indicated Cronbach’s alpha ranged from .81 to .95 (Bloomfield & Kendall, 2007). The TOPSE was translated into Spanish in collaboration with the Translation Center of the Humanities Department at the University of Puerto Rico. A copy of the resulting Spanish version of the TOPSE can be requested through the British Council Project (see http://www.topse.org.uk/site/index.php). Each parent (mother and father) completed the TOPSE independently.
Short Sensory Profile.
The Spanish version of the Short Sensory Profile (SSP; McIntosh, Miller, Shyu, & Dunn, 1999) was used to measure children’s sensory modulation. The SSP, an abbreviated version of the Sensory Profile (Dunn, 1999), is a 38-item, parent-report questionnaire that is used to measure children’s behavioral responses to sensations during daily life events (McIntosh et al., 1999).
The SSP enables caregivers to indicate the frequency with which a particular behavior is observed on a five-level frequency scale: always (100% of the time), frequently (75% of the time), occasionally (50% of the time), seldom (25% of the time), or never (0% of the time). The questionnaire provides a total score and a score for each of its seven subdomains: Tactile Sensitivity, Taste/Smell Sensitivity, Movement Sensitivity, Under-Responsive/Seeks Sensation, Auditory Filtering, Low Energy/Weak, and Visual/Auditory Sensitivity. Reports of reliability coefficients estimated for the SSP total score and for subdomain scores ranged from .70 to .90 (McIntosh et al., 1999). Only one copy of the SSP was filled out per parental couple.
Playfulness Scale for Adults.
The Playfulness Scale for Adults (PSA; Schaefer & Greenberg, 1997) consists of 28 items. It measures how much the participant considers him- or herself to be a playful person through questions about personal preferences and behaviors exhibited during life. The items are answered on a 7-point ordinal scale ranging from 1 (strongly disagree) to 7 (strongly agree). The original German version was administered to 104 college students and demonstrated high internal consistency (Cronbach’s α = .90). Other versions have indicated a Cronbach’s alpha of .86 and item-total correlations of .43, with a range from .11 to .67 (Schaefer & Greenberg, 1997). For this study, the PSA was translated into Spanish in collaboration with the Translation Center of the Humanities Department at the University of Puerto Rico. Each parent (mother and father) completed the PSA independently.
Statistical Analysis
Descriptive statistics (mean [M] and standard deviation [SD]) were computed to examine sample scores on each of the measures. We used t tests to compare P-ASD and P-Typ groups on the basis of TOPSE, SSP, and PSA scores. We completed preliminary analyses to assess relationships among the three constructs (self-efficacy, adult playfulness, and child’s sensory profile) using Pearson’s correlation coefficients. These variables were then included in a series of linear regression models. For purposes of regression analyses, data collected were split into two separate databases: one for the P-ASD group and one for P-Typ group. Because of the exploratory nature of the analyses, we applied multiple linear regression models, using the standard method for variable entrance, to evaluate the relative importance of the child’s sensory profile and the adult’s playfulness as predictors of parental self-efficacy. We conducted all analyses using IBM SPSS Statistics (Version 21; IBM Corp., Armonk, NY).
Results
Scores on the Short Sensory Profile
McIntosh et al. (1999) suggested that the total score on the SSP is the most reliable score that can be used to identify children with sensory modulation issues. Therefore, for the purposes of this study, only the total score of the SSP was used. As expected, the P-ASD group reported lower scores on the SSP (M = 120.50, SD = 22.04) compared with the P-Typ group (M = 154.69, SD = 14.05), indicating that children with ASD had more sensory modulation difficulties than typically developing children. A t test indicated a significant difference between groups (P-ASD and P-Typ) on the SSP, t(122.02) = 10.91, p = .00.
Scores on the Playfulness Scale for Adults
On average, the P-Typ group reported slightly higher scores than the P-ASD group on the measure of adult playfulness (P-Typ: M = 129.97, SD = 27.58; P-ASD: M = 126.46, SD = 23.36). However, differences between the groups on the PSA were not statistically significant, t(134) = 0.80, p = .42.
Scores on Parental Self-Efficacy
Two scores of the TOPSE were included as part of the statistical analyses. The first one was the total score, which provides an indicator of general parental self-efficacy. On average, the P-Typ group reported higher scores on this measure (M = 417.56, SD = 36.64) compared with the P-ASD group (M = 406.69, SD = 45.04); however, differences between the groups did not reach statistically significant levels, t(134) = 1.53, p = .13.
Because of the particular interest of this study on the emotional aspect of parental self-efficacy, the other score included in the analyses was the Emotion and Affection scale score of the TOPSE. On average, parental groups recorded similar scores on this TOPSE scale (P-Typ group: M = 54.97, SD = 9.04; P-ASD group: M = 53.49, SD = 6.68), with no significant differences found between the two groups, t(134) = 1.11, p = .27.
Correlations and Regression Models
Pearson correlation coefficients were examined for both groups in the sample (P-ASD and P-Typ; see Table 2). For both groups, a moderate and significant correlation was found between the total score of the TOPSE and the score on the Emotion and Affection scale (P-ASD: r = .69; P-Typ: r = .53). This correlation was expected because the Emotion and Affection scale is part of the TOPSE. In the P-Typ group, the only other significant correlation identified was between the SSP total score and the PSA (r = −.31), indicating that children of parents with higher levels of playfulness tended to score lower on the SSP. This inverse relationship does not necessary imply the presence of sensory modulation difficulties among these children. Note that the magnitude of the correlation was low; additionally, the mean total score of typically developing children in the SSP (M = 155) was within the typical performance range. For the P-ASD group, significant and low to moderate correlations were found among other variables (r = .41 between Emotion and Affection scale and PSA; r = .28 between Emotion and Affection scale and SSP; and r = .37 between total scores of the TOPSE and SSP).
Regression Models Analyzed
Note. Ad-Play = adult’s playfulness; Child-Sens = child’s sensory profile; CI = confidence interval; P-ASD = parental couples of children with autism spectrum disorder; PSE-E/A = parental self-efficacy related to emotion and affection; PSE-G = general parental self-efficacy; P-Typ = parental couples of children with typical development.
p < .05.
Four linear regression models were analyzed (see Table 2): two of them with the P-ASD database and two with the P-Typ database. PSA and SSP scores were included as predictors in all four models. Variables used as criterions were general self-efficacy (indicated by the total scores of the TOPSE) and emotional parental self-efficacy (indicated by the Emotion and Affection scale of the TOPSE).
For the P-Typ group, none of the regression models analyzed were statistically significant. In contrast, both models were significant for the P-ASD group. The model predicting general parental self-efficacy explained 17.8% of the variance (F = 8.68, p = .000). In this model, the child’s sensory profile became the most relevant predictor (β = .39 vs. β = .26 for adult playfulness). In the model with emotional parental self-efficacy as the criterion, 24.8% of the variance was explained (F = 12.70, p = .000). In this model, it was the adult’s playfulness (β = .44), rather than the child’s sensory profile (β = .32), that was the predictor showing higher relative importance.
Discussion
In this study, we examined the relative importance of children’s sensory modulation abilities and adult playfulness as predictors of parental self-efficacy. Children with ASD in this sample had a significantly higher prevalence of sensory modulation issues compared with typically developing peers. This finding was not surprising because it has been well established in the literature that children on the autism spectrum have differences in sensory processing that affect their ability to participate in functional daily routines. It is interesting to note that parents of children with ASD reported similar levels of self-efficacy compared with parents of typically developing children. This finding is in contrast to previous research suggesting parents of children with ASD may have lower self-efficacy and higher levels of parental-related stress than parents of typically developing children (Estes et al., 2013; Weiss et al., 2013). Our findings suggest that having a child with ASD is not the sole determinant of parental self-efficacy, indicating the need to examine more specific characteristics of the parent and the child.
As highlighted by this study, the sensory modulation characteristics of children with ASD may influence parental factors such as self-efficacy. By definition, parental self-efficacy refers to the confidence and expectations that a parent has concerning the degree to which he or she can perform competently and effectively as a parent (Teti & Gelfand, 1991). Parental self-efficacy has been linked to positive parental behaviors, such as frequency of positive interactions with their children (Mash & Johnston, 1983), use of encouragement, and joint engagement in activities (Elder, Eccles, Ardelt, & Lord, 1995). On the basis of the findings of this study, it is possible that parents of children with ASD interpret their child’s atypical sensory behaviors as negative feedback on their performance as a parent. Thus, the potential association between sensory modulation issues and parental self-efficacy evidenced in the P-ASD sample of this study should encourage clinicians’ reflection regarding the importance of a family-centered practice. The achievement of role competence, one of the desired intervention outcomes in the Occupational Therapy Practice Framework: Domain and Process (Framework ; 3rd ed.; American Occupational Therapy Association [AOTA], 2014), seems particularly relevant.
Aside from sensory modulation, another important challenge for children with ASD is their performance during social–emotional interactions. For this reason, emotional parental self-efficacy was examined as a criterion in the regression analyses. The result showing adult playfulness as the predictor with greater relative importance (instead of the child’s sensory modulation ability), when emotional parental self-efficacy was used as the criterion in the model, merits consideration.
The emotional piece of parental self-efficacy has not been a common focus in parental self-efficacy studies. Findings of this study support the importance of play as a primary tool in the development of emotional relationships between children with ASD and their parents. It is possible that playfulness, as an adult trait, increases the parents’ likelihood to engage with their children in positive play activities. Conversely, these parents may have enhanced or developed their own playfulness through more intentional efforts to engage their children in play situations.
Theorists and researchers have referred to play as a powerful mechanism for building adult–child relationships (Schaefer & Drewes, 2011). From an occupational therapy perspective, acknowledgment of play as the primary occupation of the child makes it a valuable means by which to build and enhance the emotional bonding between the parent and child. Indeed, some intervention models use play as a primary tool to help children with ASD. For example, the Developmental, Individual Difference, Relationship-Based model uses floortime as its distinctive technique, in which the adult turns into a play partner to work with the child on the mastery of his or her developmental capabilities (Greenspan & Wieder, 2011). However, despite the intense family involvement required in this particular program, the reported outcomes of this intervention are almost entirely focused on the child’s capabilities, ignoring potentially important outcomes such as parental role competence or self-efficacy. On the basis of the current study’s findings, variables associated with parent characteristics deserve more attention. This finding is also in line with the Framework, which suggests that the term client encompasses the person with a disability and his or her caregivers (AOTA, 2014).
The results of this study, although exploratory, support the need to conceptualize play as a co-occupation, especially in the context of families with children on the autism spectrum. Grounded in the interdisciplinary play literature, co-occupations are considered the most highly interactive types of occupation and are the purposeful and meaningful occupations that two or more people share or are reciprocally engaged in (Morozini, 2015). Simply stated, co-occupation can be viewed as the act of doing something meaningful with someone else. Occupational therapy practitioners use occupation with clients as both a means and an end (AOTA, 2014). Accordingly, considering play as a co-occupation for children with ASD and, at the same time, as a means and an end may be the desired approach, attuned with the establishment of more family-centered intervention planning.
Limitations and Future Research
In this study, we used a relatively small sample recruited through convenience sampling, which limits generalization of results. Although parents were asked to focus their answers to the questionnaires on one specific child, procedures did not allow control of the influences that their experiences and interactions with their other children could have on their answers. Additionally, this study has the following limitations regarding measurement tools: (1) The PSA measures adult’s playfulness as a trait, evidenced during the person’s daily life, but not necessarily in the context of playing with his or her child, and (2) although the measurement tools were translated into Spanish, they have not been culturally adapted for the Puerto Rican population.
In future studies, researchers should focus on gaining a deeper understanding of the play experiences between parents and children with ASD as well as parental self-efficacy during those play experiences. Development of measures of parental self-efficacy during play, and measures of adult playfulness in the context of play and interactions with their children, must also be considered. Moreover, in future research, occupational therapy practitioners should focus on the development and evaluation of intervention programs that encourage relationship building with a deeper emphasis on the sensory modulation characteristics of the child. Practitioners can provide essential guidance to assist parents in matching their playfulness level and their intensity of engagement to the specific sensory needs of their child. This guidance could increase the number of successful interactions that parents have with their children and their overall levels of parental self-efficacy.
Implications for Occupational Therapy Practice
The results of this study have the following implications for occupational therapy practice:
The relationship among the explored triad of variables (child’s sensory modulation, adult’s playfulness, and parental self-efficacy) provides evidence to be considered when designing support programs directed to parents of children with ASD. Particularly important is the adult’s playfulness, which is not typically considered when designing intervention services.
Occupational therapy practitioners’ comprehensive understanding of different occupations across the human lifespan qualifies them as the appropriate professionals to educate parents of children with ASD about play as a co-occupation.
Helping parents to better relate with their children with ASD can have a positive impact on general parental self-efficacy and emotional parental self-efficacy, thus helping them to increase their role competence.
Footnotes
Acknowledgments
We thank the following institutions and occupational therapists for their important collaboration in the recruitment of participants: Julmarie Vargas (Centro Ponceño de Autismo, Ponce, Puerto Rico); Yelitza Ávila; Centro de Autismo, San Juan, Puerto Rico; Trillis for Kids, Vega Alta, Puerto Rico; SER de PR, San Juan; and Centro de Desarrollo Integral Luna, Guaynabo, Puerto Rico.