Father–Child Playfulness: A Secondary Analysis of a Multiple-Baseline Single-Subject Study of Three Children With Autism Spectrum Disorder

Parent–Child Play and Children on the Spectrum

Parents of children on the spectrum can facilitate play to make it a meaningful, enjoyable experience and promote their child’s social–communicative development, purposeful play, attention, persistence, and playfulness (Baum, 2019; Godin et al., 2017; Nadel et al., 2008; Waldman-Levi, Bundy, & Shai, 2022). Helpful parental behaviors include positive affect, imitation, joint attention, initiation of social interaction, responsivity, and flexibility, all of which are captured by supportiveness of children’s playfulness (Field et al., 2013; Menashe-Grinberg & Atzaba-Poria, 2017; Nadel et al., 2008; Waldman-Levi, 2021). A recent systematic review of the effects of caregiver-mediated interventions on children with ASD provided moderate evidence of the ability of parents to improve certain aspects of their child’s play (Althoff et al., 2019). Caregiver-mediated intervention contributed to children’s joint attention and functional play (Kasari et al., 2010) but had mixed results in improving symbolic play (Kasari et al., 2014, 2015). A systematic review of the efficacy of strategies used in occupational therapy to improve the play of children on the spectrum found moderate to strong evidence that modeling improved children’s play skills (Kuhaneck et al., 2020). Overall, the duration of interventions and focus on play vary as well as the measurements, with no studies specifically focusing on fathers or playfulness behavior.

ASI is an intervention meant to improve sensory processing and praxis (Parham, Cohn, et al., 2007; Schaaf et al., 2012 ; Schaaf & Nightlinger, 2007). Well-established theory and emerging empirical evidence (Miller et al., 2007; Schaaf et al., 2014) suggest that ASI can improve varied aspects of function for children on the spectrum (Case-Smith et al., 2015; Schaaf et al., 2014). ASI theory hypothesizes that poor ability to understand and use sensory information from the environment and the body leads to difficulties in planning movement and determining how to interact with the environment (e.g., people, objects). When provided with fidelity, ASI uses play as a primary mechanism of delivery, and a child-directed approach is critical (Parham, Cohn, et al., 2007; Schaaf et al., 2012; Schaaf & Nightlinger, 2007). Play may also be an important outcome of ASI intervention. In several ASI effectiveness studies, the parents of children on the spectrum selected play as an intervention goal; however, in these studies there was no explicit effort to measure children’s play skills or playfulness (Parham, Cohn, et al., 2007; Schaaf et al., 2012, 2014). One recent single-subject research study explicitly studied play as an outcome (Kuhaneck et al., 2023) and noted changes in the frequency of specific types of play after ASI intervention.

Because of societal changes, fathers have taken on a role that is active and equivalent to that of mothers as a primary caregiver and an adult play partner (Cabrera et al., 2017; Jones & Mosher, 2013; Waldman-Levi, Cope, & Olson, 2022). There have been few studies of fathers in occupational therapy (Waldman-Levi, 2021; Waldman-Levi, Cope, & Olson, 2022) confirming that they do play differently than mothers and, more specifically, pointing to the fact that fathers’ supportive play is, indeed, related to how playful their child is. However, neither of the aforementioned studies focused on fathers of children on the spectrum. Therefore, this ASI single-subject A–B–BC design study with three fathers provided a unique opportunity to examine father–child play. Analyzing videotaped play sessions from an original multiple-baseline single-subject design (SSD) study, we examined play outcomes after ASI intervention with fidelity, along with specific parent training. We explored changes in father–child playfulness over the course of the original study. The purpose of this study was to explore whether ASI intervention changed child playfulness or the way fathers supported their child’s playfulness over time. Specifically, we adopted the Model of Playfulness (Skard & Bundy, 2008; Waldman-Levi & Bundy, 2016; Waldman-Levi et al., 2019, 2020) to detect changes over time in

▪ fathers’ support of their child’s playfulness before ASI implementation (baseline Phase A) and after receiving ASI training alone (Phase B) or ASI and parent training (Phase BC) and

Specifically, we hypothesized that parent training would alter the way in which the father supported his child’s play; that child playfulness would improve as a result of ASI, which is a playful and play-based approach; and that the parent training would translate to the child being more playful.

Method

The Sacred Heart University (SHU) Institutional Review Board (IRB) approved the original ASI, multiple-baseline SSD study, and both the SHU and Long Island University IRB committees approved the present study. As noted, study design is A–B–BC, with three father–child dyads. We randomly selected six videos representing three phases: Phase A, the baseline, consisting of one video; Phase B, ASI, consisting of two videos; and Phase BC, ASI and parent asynchronous education, consisting of three videos.

Results

All three dyads had cancellations or required rescheduling of sessions across the study period, leading to the intervention taking longer than the planned 12 wk. However, all three dyads eventually completed all 24 sessions. Jim and Kelly had four sessions rescheduled because of snow, illness, or a family vacation. One visit was not filmed or counted because Kelly’s mother came rather than her father. Matthew and Chris had three sessions rescheduled because of illness and one session was rescheduled because of a family vacation. Jake and Kevin had eight sessions rescheduled for various reasons.

Jim and Kelly

At baseline, Jim provided a moderate level of support in quality, flow, and creativity (see Figure 1A), with an average score ranging between 1.72 and 2.37 on a 4-point scale ranging from 0 (low) to 3 (high). From the baseline phase to the 10th session, there was a noticeable increase in the level of support for Kelly’s playfulness, followed by a decrease from Session 15 to Session 23 in all PC–SCP scores (Figure 1A). Kelly is a relatively playful child. Her ToP scores ranged from 2 to 3 from the baseline phase through the last session (see Figure 1B). In a comparison of Jim’s and Kelly’s scorings, it appeared that, after Jim received the educational training (between Sessions 5 and 10), his PC–SCP scores increased, whereas Kelly’s playfulness score decreased.

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Figure 1.

Jim’s level of support (A) and Kelly’s level of playfulness (B).

Matthew and Chris

Matthew’s level of support was consistently low in quality and creativity except for his Flow scale score, which slightly fluctuated, with an average score ranging between 0.89 and 1.24 on a 4-point scale. Matthew received the educational training before the Session 10, with the Flow scale score increasing after that (see Figure 2A). Chris’s playfulness scores were at a lower range, with his baseline score being the highest (see Figure 2B). Matthew’s and Chris’s scores both decreased after the baseline. After Matthew received the educational training, Chris’s scores decreased, whereas Matthew’s scores on the Flow and Creativity scales remained constant.

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Figure 2.

Matthew’s level of support (A) and Chris’s level of playfulness (B).

Kevin and Jake

Kevin’s level of support was low across all phases of the intervention, except after the sixth session, when his Quality and Flow scale scores increased to a moderate level (see Figure 3A), which was after he received the education training (the average score ranged between 1.08 and 1.28 on a 4-point scale). Jake was mildly playful, with scores fluctuating between 1.5 and <2 on the ToP and peaking at the sixth session after his father was exposed to the PowerPoint parent training (see Figure 3B). Kevin’s and Jake’s scores mirror each other. As Kevin’s quality, flow, and creativity decreased, Jake’s level of playfulness decreased as well.

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Figure 3.

Kevin’s level of support (A) and Jake’s level of playfulness (B).

Discussion

Although ASI has been found to improve children’s praxis and sensory processing (i.e., Schaaf et al., 2012) and alter the frequency of specific types of play skills (Kuhaneck et al., 2023), there has been no explicit effort to date to measure improvements in children’s or fathers’ playfulness after ASI intervention. This study measured changes in fathers’ support of their children’s playfulness as well as in the children’s playfulness before and during implementation of ASI as well as after receiving parent training.

The first hypothesis, that parent training would alter the way in which the fathers supported their child’s play, was partially supported. All three fathers demonstrated an increase in the way they supported their child’s playfulness after parent training; however, their support then either declined or fluctuated. As has been found in other studies (Althoff et al., 2019; Kasari et al., 2010, 2015), parents can learn to alter their interactions with their children with ASD to the benefit of their child’s performance. However, one additional difference between these studies of parent-mediated intervention and our study was in the length and intensity of the parent training. Our study provided a brief parent training using video and PowerPoint presentations as opposed to the repeated and modeled parent training provided in the aforementioned studies of parent-mediated interventions. This suggests that one reason for the lack of sustained change is the length and intensity of parent training provided. It is possible that the changes were not maintained merely because both child and father needed more time to integrate the changes and create new play behaviors and habits with each other. It is well substantiated that forming new habits and changing behavior is difficult (Gardner & Rebar, 2019). Therefore, without continued encouragement, assistance, and support from the therapist, it is likely that the dyads could occasionally slip into prior patterns of behavior. This is a variable that should be specifically addressed in future studies.

The second hypothesis—that child playfulness would change in response to ASI and parent training—was partially supported. Playfulness fluctuated for each of the three children, reaching a peak after the fathers received training, but none of the children maintained that change. Why would this be? First, it is possible that the change in the children’s behaviors was in response to how their fathers played with them; thus, the children’s changes fluctuated as the fathers’ support fluctuated. Children with ASD need continued and explicit modeling from any play partner, and fathers need to continue with intensive modeling, which they did not sustain over time. Second, it is possible that changes in the children’s playfulness were due to their own internal manifestation of symptoms, including praxis. Third, it is possible that the children’s playfulness fluctuated as they responded to the additional play time at the end of the ASI session, or they responded to the transition of playing with their father instead of the occupational therapist. Fourth, the need for consistent and sustained intervention over time may mean that the repeated cancellations and extension of the intervention period influenced the findings. Last, the total amount of interventions required to achieve lasting change may suggest that 24 sessions is not long enough to achieve lasting change in playfulness in the ASI intervention for children with ASD. The weekly intervention dosage was set for two sessions; however, all three dyads had multiple cancellations, which may have affected their performance.

ASI specifically addresses praxis, and deficits in praxis significantly influence children’s ability to imitate their playmate’s behavior (Roley et al., 2015). Therefore, over time, as praxis improved from ASI, it would be expected that play could improve. It could also be expected that child playfulness would improve with a parent who was trained to be more playful. Research has documented that parent training can have an impact on parent behaviors and thereby child behaviors, for example, in studies of parent-mediated interventions (Althoff et al., 2019; Kasari et al., 2010, 2015). These studies differ substantially from ours in that their intervention was provided by the parent after training, whereas our intervention (ASI) was provided by a therapist, with parent training as an adjunct to that therapy rather than as the primary intervention. Thus, comparisons are limited. The systematic review by Althoff and colleagues (2019) of parent- mediated interventions for children with ASD measured child outcomes such as communication and language, adaptive behavior, and the type of play children engaged in, along with initiation and response to parent. Kasari et al. (2010, 2015) measured the effectiveness of parent-mediated intervention in improving parent–child interaction in a play procedure similar to ours. However, their coding scheme captured the child’s awareness of the parent’s participation and the child’s functional and symbolic play (Kasari et al., 2015) or the percentage of child’s engagement in play with the parent (Kasari et al., 2010).

Of interest as well is how each of the individual changes for child and parent may have, in turn, fostered further changes in the other. It is likely that, as the children fluctuated in performance and manifested their ASD symptoms, their fathers’ playfulness would have fluctuated as well. Like Godin et al. (2017) pointed out, children with ASD differ in their playfulness, and ASD affects how they play and interact with others. Baker and colleagues (2015) found that parent–child physiological synchrony and mutuality during play interaction depended on ASD symptoms. Nadel et al. (2008) found that high-approach children (i.e., those who display social and communication behaviors) had parents who demonstrated positive affect and imitative behaviors and who were more playful. Field et al. (2013), expanding on Nadel et al.’s (2008) study, found that adult playfulness occurred more frequently when imitation was present and elicited children’s social behavior. The back-and-forth “dance” of their play would likely change in response to both of their behaviors, perhaps leading to a roller-coaster type of up-and-down, inconsistent performance that would gradually grow more consistent and rise over time.

One last point of discussion in relation to our findings has to do with the dosage of ASI sessions. Children on the spectrum demonstrate difficulty forming relationships and responding to changes and transitions. Interventions are reported to work best when they are frequent, repeated, and intensive; thus, dosage may have been an issue. The necessary dosage of ASI sessions is still under debate (Schaaf et al., 2014), with prior studies providing three weekly sessions (Schaaf et al., 2014; Watling & Dietz, 2007). Furthermore, participation is another avenue to ensure sustainability of gains.

Limitations and Future Research

This study completed a secondary analysis of a multiple-baseline study, applying an A–B–BC SSD to examine fathers’ support of child playfulness as well as the playfulness of children with ASD after ASI and parent training. Using an A–B–BC design provided control over the independent variable along with reliable and valid measurement of the dependent variables. Unfortunately, one of this study’s shortcomings was the small pool of data points (video recordings). It is recommended that each phase of an SSD study consist of a minimum of three data points. Although the original multiple-baseline design met this criterion, for this secondary analysis we chose not to review each of the baseline videos to have three data points for that phase but rather to review more intervention sessions across the entire phase of intervention. However, the choice to limit the analysis to these six videos may have potentially affected the father–child play, for example, a bad day at work or school or an unexpectedly difficult transition. In addition, because this secondary analysis study methodology did not meet the criteria established by the Single-Case Reporting Guideline in BEhavioural Interventions (Tate et al., 2016) of a minimum of three data points for the baseline condition, it is missing a critical feature of validity. Nevertheless, these pilot data can be used to inform future studies.

Although parent training is a typical and regular component of ASI intervention (Parham, Cohn, et al., 2007), for the purposes of the original study—and, therefore, for this one as well—it was standardized and provided in a certain timing that might not have met each dyad’s play needs. In addition, the variation in the total amount of times that the fathers observed intervention sessions, once they were allowed to observe, may have affected the results. It is important for future studies to structure parent training components that are tailored to parental needs and specific child-related play difficulties more specifically.

All father–child play sessions occurred immediately after either the baseline or the ASI intervention sessions. Children could have had a hard time transitioning between the two environments, and this could have differentially affected their behavior on various days. It is also reasonable to assume that, after the children played with the therapist for 45 min, they were less likely to want to continue to be playful in the room with their father. It may also be that the fathers were not perceived to be as playful as the therapist was.

This secondary analysis has provided important information for occupational therapists who want to continue examining the impact of ASI and parent training in playfulness. Although many of the original study methods could be repeated, and the current measures were able to document change, future study requires more specific targeting of parent training with greater intensity and support across the entire intervention phase, with repeated measures of playfulness for a greater number of data points in each phase. In addition, specific play behaviors could be coded using behavioral observation. Of potential use to occupational therapists, future studies could also add a qualitative component such as a parent interview before, during, and at the end of the study to capture the parent’s approach to playing with their child and their perceptions of their own change and their child’s after parent training. Last, future studies could specifically add a telehealth component of parent training for playfulness while observing parent–child play in the home.

Implications for Occupational Therapy Practice

The study has the following implication for occupational therapy practice:

▪ The playfulness of children with ASD can change in response to intervention; however, occupational therapists should discuss with parents the impact of the child’s praxis and communication deficits on their play and playfulness.

Conclusion

Promoting play between children with ASD and their fathers lies at the heart of occupational therapy family-centered practice. Both theory and recent research suggest that there is a relationship among sensory processing, praxis, and play (Kuhaneck et al., 2020, 2023). However, little is known about the efficacy of ASI in promoting playfulness. This study’s unique contribution is in its attempt to measure changes in the playfulness of children with ASD and fathers’ support of their child’s playfulness over the course of ASI intervention with parent training. We conclude that dyadic changes in playfulness occurred but were not maintained. It appears that additional support by the therapist may be necessary for parents to learn new strategies and use them to promote consistent change in behavior and function. Occupational and family-centered frameworks may be useful in guiding occupational therapy practice with families of children with ASD. The Playfulness Model can be added to existing interventions to facilitate play and support families in forming joyful moments.