Abstract
The study findings provide data that support the influence of ideational praxis skills on the play skills and playfulness of autistic children.
Autism spectrum disorder (ASD) is a neurodevelopmental condition associated with persistent challenges with communication and reciprocal social interaction, as well as restricted, repetitive, and stereotypical patterns of behaviors or interests (American Psychiatric Association [APA], 2022). In addition, individuals with ASD demonstrate difficulties associated with acquisition of motor milestones, as well as difficulties in motor imitation, planning, and praxis (Miller-Kuhaneck & Watling, 2010; Lidstone et al., 2021; Mosconi & Sweeney, 2015; Tripi et al., 2018, Wymbs et al., 2021). Licari et al. (2020) suggested that praxis difficulties observed among autistic children should be considered a central element of the assessment process, and sensory-related praxis difficulties may be a specific aspect of the autistic population, In fact, prospective studies (Ozonoff et al., 2010; Paquet et al., 2016; West, 2019) identified the presence of motor difficulties during infancy among children later diagnosed with ASD. Therefore, it is likely that these difficulties are manifested at an early stage of development and may be a marker that facilitates early diagnosis.
Occupational therapists routinely assess praxis among autistic children (Ayres, 1965, 1989, 2011; Hirata et al., 2015; Lidstone et al., 2021 ; Wilkes & Lewis, 2018). Several authors (Dziuk et al., 2007; Ishak et al., 2014) have associated dyspraxia with the communicative, social, and behavioral challenges among autistic children. Praxis is a central construct of the Ayres Sensory Integration® (ASI) theory, with special emphasis on the relationship of sensory discrimination to praxis and acknowledgment of cortical contributions (Ayres, 1961, 1965, 1966, 1969). Praxis requires children to formulate internal action models; thus, poor sensory perception may interfere with the conceptualization, initiation, and execution of new actions. The abilities to represent an action and generate a motor plan are essential components of the ideation process (Gentsch et al., 2016). In the scientific literature, the conceptual capacity to generate new ideas based on recognition of affordances, or actions that allow the child to know what to do, enables effective interactions within the environment (Ayres, 1985).
Contemporary neurological research suggests that the first organization of motor action takes place in the primary sensory cortex and the supplementary motor area (SMA; Lima et al., 2016; Sheets et al., 2021). In addition, researchers have linked ideation to motor performance based on the relationship between visual perception, conceptualization, and motor planning. Vainio et al. (2008) proposed that the conceptualization of the use of an object for a motor action is configured in the anterior intraparietal sulcus cells, which appear to extract object-specific perceptual information relevant to a particular motor action. This is especially important because actions triggered by one’s own intentions result in greater activation of the anterior area of the SMA complex as well as of the anterior cingulate cortex, compared with actions triggered by external visual stimuli (Zapparoli et al., 2017). Similarly, Rizzolatti and Matelli (2003) suggested that cortical motor regions play a crucial role in perception, especially when sensory information is required to act on the environment. When all this information is considered collectively, it is reasonable to expect that difficulties with ideation and other aspects of praxis interfere with engagement in developmentally essential occupations that require interacting with and manipulating the environment, such as play (Bodison, 2015; Rutherford et al., 2007).
Although play is a universal behavior, its multiple dimensions and conceptualizations make identifying and evaluating observable and quantifiable aspects difficult. Neurodevelopmental abilities influence a child’s skills, behavior, and approach to play (i.e., playfulness). Therefore, having a developmental condition, such as ASD, is likely to affect a child’s play skills as well as playfulness. In addition, the presence of distinctive features, such as restricted interests, repetitive behaviors, reduced symbolic quality, and challenges with social skills (MacDonald et al., 2009), negatively affect children’s participation. These features limit children’s interactions in social and play environments, making it difficult to identify a unique and specific pattern of play difficulties. Previous researchers (Jarrold et al., 1996; Rutherford & Rogers, 2003) suggested that repetitive use of objects, limited and unvaried play, and preferences for a specific type of play may reflect difficulties in generating new ideas. Bodison (2015) suggested that deficits in imitation, planning, and ideational domains may contribute to observed difficulties in symbolic play and social skill development among individuals with ASD.
Understanding how ideational praxis skills relate to play and playfulness can facilitate understanding other aspects of praxis necessary for a child’s interactions in social and physical play environments. Therefore, the aim of this study was to identify the relationship between ideational praxis, play skills, and playfulness and to determine the influence that ideational praxis has on these variables.
Method
This study was conducted in Spain, and collection, management, storage, communication, and transfer of all data were completed in accordance with the provisions of the Declaration of Helsinki (World Medical Association, 2017), the data protection law in force in the General Data Protection Regulation (EU Regulation 2016/679 of the European Parliament and of the Council, April 27, 2016), and current regulations in Spain on the protection of personal data. The study was approved by the Clinical Research Ethics Committee of Universidad Rey Juan Carlos, Madrid, Spain.
Study Design
Data from this descriptive, cross-sectional study were part of a larger research project to determine the influence of ideational praxis on play skills, playfulness, and adaptive social and leisure behavior skills of children with an ASD diagnosis. Families of children in the study completed the informed consent process and agreed to the video recording necessary for the individualized analysis of play.
Participants
The study sample (N = 90) consisted of two groups of children ages 4 yr 6 mo to 6 yr 11 mo (M = 5.4 yr, SD = 0.9). The final sample (64.4% boys and 35.6% girls) included typically developed (TD) children (TD group; n = 45) and autistic children (ASD group; n = 45; see Table 1).
Characteristic Information of Children (N = 90) in TD and ASD Group by Sex and Age
Note. TD = typical development; ASD = autism spectrum disorder.
Children in the TD group met the inclusion criteria if they were within the age range, did not have siblings with autism, had appropriate development for their age with no concerns, and did not require educational supports. Children in the ASD group were included in the study if they were within the age range and had a confirmed diagnosis of ASD identified by a physician, psychologist, neurologist, or psychiatrist (APA, 2022). We contacted several public education schools in Madrid for the recruitment of children with typical development. We obtained approval for the children’s participation from the educational center and informed consent from the parents or primary caregivers. We recruited children with a diagnosis of ASD from seven early care clinics (public and private) from Galicia, Comunidad Valenciana, Castilla y León, and Comunidad de Madrid, as well as special education schools with ASD students in Madrid. See Table 1 for demographic details of the sample.
Procedure
Data collection was completed between December 2019 and December 2020. Participants in both groups were administered the Test of Ideational Praxis (TIP; May-Benson & Cermak, 2007), the Revised Knox Preschool Play Scale (RKPPS; Knox, 2008), and the Test of Playfulness (ToP; Skard & Bundy, 2008). Restrictions on mobility and access to outdoor spaces such as parks and playgrounds in Spain during the COVID-19 pandemic led to a need for modifications to the evaluation context with play observations videotaped in an indoor space. For both samples, the space in which the play observations were conducted included different toys but with similar characteristics, such as manipulative and assembly toys, construction toys, toys with sound, action figures, dolls, and various toys that facilitated functional play. To select toys for play observations for both groups of children, the principal investigator (Sergio Serrada-Tejeda) met in person with clinicians or the educational staff of the school and via telephone with parents of the autistic children who were assessed at their home. Materials and toys familiar to participants of both groups were available in all evaluation spaces. Serrada-Tejeda made video recordings necessary to evaluate play observation with the RKPPS and ToP and assessed ideational praxis in the school setting, the clinical setting, or at the participant’s home depending on the needs of each participant’s family.
Variables and Data Measurements
TIP
The TIP is an assessment that evaluates the ideational component of praxis, including the ability to generate ideas and perform multiple actions with an object (Lane et al., 2014 ; May-Benson & Cermak, 2007). The final version includes the use of a string (i.e., a 1-m round shoelace). The actions the child performs (affordances) show what the child can do with the string (e.g., pull it against a part of the body, shake it, bite it, tie it). Observations of children’s actions are a means of determining their ability to recognize object affordances and to assess their ideational abilities. To accurately score the different actions and ideas demonstrated, we videorecorded each child during administration. The number of total actions and ideas is the score with the highest discriminant validity. The psychometric properties of the Spanish-adapted version of the TIP demonstrated acceptable global interrater reliability (intraclass correlation coefficient [ICC] = 0.85) and adequate internal consistency (Cronbach’s α = .74; Serrada-Tejeda, 2022).
RKPPS
The RKPPS is an observational assessment that provides a description of the typical development of play skills and behaviors from birth to 6 yr (Knox, 2008). Play skills are described in 6-mo intervals for the first 3 yr of development and in 1-yr increments from 4 to 6 yr. To develop a play profile, we scored children according to demonstrated skills. The RKPPS includes 12 categories of play behaviors grouped into four dimensions: space management (gross motor and interest), material management (manipulation, construction, purpose, and attention), pretense–symbolism (imitation and dramatization), and participation (type, cooperation, humor, and language). We scored each child on behaviors reflecting the four dimensions and 12 categories; those scores were then averaged to obtain an overall age of the child’s play in months. The assessment required observing the child playing with age-appropriate toys in two environments (outdoors and indoors) for a minimum of 30 min. However, the COVID-19 lockdowns during the research period led to assessment of only indoor play. Adequate interrater reliability had been observed and evaluated in observation periods of as little as 15 min (Jankovich et al., 2008). Psychometric properties of the Spanish-adapted version of the RKPPS (Serrada-Tejeda, 2022) demonstrated acceptable global interrater reliability for each dimension: space management ICC = .996, 95% confidence interval [CI] [.988, .998], p < .001; material management ICC = .998, 95% CI [.996, .999], p < .001; pretense–symbolism ICC = .987, 95% CI [.966, .995], p < .001; participation ICC = .998, 95% CI [.996, .999], p < .001; overall play age ICC = .997, 95% CI [.991, .999], p < .001; and adequate internal consistency (Cronbach’s α = .97).
ToP
The ToP is an observational tool that evaluates the child’s disposition to play, from 6 mo to 18 yr, through the operationalization of four elements of play: intrinsic motivation, internal control, suspension of reality, and framing (e.g., ability to understand and provide clues during play interactions). For this study, we used Version 4.4 (Bundy, 2017), which included a total of 28 items, scored from 0 to 3, for extent (3 = almost always, 2 = much of the time, 1 = some of the time, 0 = rarely or never), intensity (3 = highly, 2 = moderately, 1 = mildly, 0 = not), or skillfulness (3 = highly skilled, 2 = moderately skilled, 1 = slightly skilled, 0 = unskilled) demonstrated by the child during play. The ToP has good clinical utility (Brentnall et al., 2008; Harkness & Bundy, 2001), and its Spanish version has shown adequate psychometric reliability (Cronbach’s α = .945, interrater reliability = .64 ≥ κ ≤ 1.00, p < .01; Serrada-Tejeda, Santos-Del-Riego, May-Benson, et al., 2021).
Data Analysis
We used basic descriptive methods to describe the sample: the number of cases present in each category and the corresponding percentage for categorical variables; means and standard deviations for quantitative variables. For quantitative variables, we used Student’s t test to compare means between two groups once the assumptions of normality with the Shapiro–Wilkes test and homogeneity of variances with the Levene test had been checked. To examine the relationship between variables, we used Pearson’s linear correlation coefficient. For categorical variables, we performed comparisons between groups using χ2 tests. We used multiple linear regression to determine the possible effect of TIP on RKPPS and ToP scores. Statistical analysis was performed with IBM SPSS Statistics 25.0 for Windows. To minimize the possibility of a Type I error, we applied Bonferroni correction to adjust for multiple comparisons at a level of significance of p < .008 (0.05/6).
Results
Table 2 shows test scores by group as well as the results of Student’s t tests comparing scores of the two groups. Scores for the children in the TD group were significantly higher (i.e., indicating better performance) on all tests than children in the ASD group.
Comparative Analysis Between Children in the TD and ASD Group
Note. TD = typical development; ASD = autism spectrum disorder; RKPPS = Revised Knox Preschool Play Scale; ToP = Test of Playfulness; TIP = Test of Ideational Praxis.
Table 3 shows the Pearson correlation coefficients between the tests. The TIP showed a statistically significant positive relationship with all RKPPS dimensions and with the ToP score.
Correlations Between TIP, RKPPS, and ToP
Note. TIP = Test of Ideational Praxis; RKPPS = Revised Knox Preschool Play Scale; ToP = Test of Playfulness.
p < .001.
We conducted multiple linear regressions separately with data from the TD and ASD group to examine the effect of the TIP on each of the dimensions of the RKPPS as well as on the ToP total score. Results for the TD group showed that age was the variable that most influenced play skills and playfulness; ideational praxis was not a factor in the development of play skills in that group. In contrast, for the ASD group, ideational praxis significantly influenced all play skills and playfulness, whereas age had a significant effect on social participation skills (see Table 4).
Multiple Regression Analysis of TIP and Demographic Variables on RKPPS and ToP for Children in the TD Group and ASD Group
Note. TIP = Test of Ideational Praxis; RKPPS = Revised Knox Preschool Play Scale; ToP = Test of Playfulness; TD = typical development; ASD = autism spectrum disorder.
Discussion
Assessment of the core components of praxis is essential to understanding and identifying areas of difficulty that affect children’s play skill development and interactions with the environment. However, even though affordances are acquired in socially interactive and observational contexts such as play (Deák, 2014), the influence that ideational praxis has on autistic children’s play skills and playfulness has been examined only minimally (May-Benson et al., 2017).
In this study, when data from both groups were combined, ideational skills reflecting conceptualization and idea generation (TIP scores) were associated with play skills (RKPPS) and playfulness (ToP). Initially, material management and use of pretense and symbolism reflected the complexity with which the child interacted with the environment, objects, and peers during play. As play evolved, the use of toys revealed the child’s ability to recognize the affordances of objects, the quality of their actions, and the relations that can be established among objects in the physical environment (Dauch et al., 2018). Furthermore, use of simple or repetitive affordances and difficulties interacting in the environment may influence the way in which the child perceived and discovered the properties of objects.
Although correlations between all measures were significant for the total sample, regression analyses computed separately for the TD and ASD groups revealed that TIP scores predicted play skills and playfulness only for children in the ASD group. The results highlight the importance of ideational praxis skills and their influence on the perception of multiple affordances in the environment that promote play, especially among autistic children. In fact, research by Schaaf et al. (2022) suggests that sensory-related praxis difficulties may be a specific aspect of the autistic population, and that difficulties in sensory perception may limit praxis skills, affecting the ability to guide motor actions such as imitation of gestures, novel actions, and social participation.
Several of the findings from the regression models require discussion. Gabbard et al. (2008) pointed out that environmental affordances influence infants’ development of motor skills. In our study, the video recordings from the ASD group associated with RKPPS space management scores revealed that, despite assessment in an indoor environment, children in the ASD group engaged primarily in running or moving around, compared with children in the TD group who engaged in goal-specific motor play.
Similarly, results from regression analyses of the material management and pretense–symbolism dimensions were also of interest. In our study, fewer ideas with a functional or symbolic meaning were observed, and most were related to sensorimotor use of the string, which facilitated the occurrence of repetitive actions in which the same idea was displayed in succession. Studies (Kaur et al., 2018) have identified that children with suspected ASD show unusual exploratory activity with objects. This finding is interesting because, to understand the function of an object, one must select affordances that are relevant to its use. However, for autistic people, exploration of objects is often unusual and focuses on aspects of the object that are not relevant and may trigger ritualized or stereotyped behaviors. This type of exploration may create a barrier to the development of symbolic play, because the perception and recognition of affordances depend on the information the person receives during interaction with the environment or object (Gibson & Pick, 2000).
Similar to our findings, previous research assessing playfulness found that autistic children were less motivated to participate in and initiate play activity (Chiu et al., 2017) and less able to understand gestures and verbal cues in social contexts (Centelles et al., 2013; Parron et al., 2008; Tillmann et al., 2015). In our study, playfulness was significantly associated with play skills, which is consistent with results observed in previous research (Chen et al., 2019; Lee et al., 2016; Serrada-Tejeda, Santos-Del-Riego, May-Benson, et al., 2021). It is interesting that, for ToP items associated with internal control (e.g., negotiates, enters, participates in social play, initiates, or shares) and framing (e.g., gives or responds to cues), children in the ASD group attained lower scores than those in the TD group, highlighting the difficulties in engagement in play and understanding and promotion of social interactions among autistic children. Previous studies that assessed playfulness among autistic children identified that internal control significantly predicted general play skills (Chen et al., 2019) and seemed to be related to the children’s pretend play (Chiu et al., 2017). We suggest that self-initiation and idea generation facilitate and promote sequencing of actions as well as use and representation of objects during play. These results coincide with our findings that ideational skills predict playfulness in autistic children.
Limitations
This study had several limitations that should be considered to improve the quality and interpretability of future research on the TD and ASD population. Our study was conducted during the COVID-19 pandemic when it was impossible to access outdoor environments; therefore, all results should be considered in an indoor play context.
Given that ours was a convenience sample, the possibility of equalizing the gender distribution of the participants was limited. However, although differences in participants’ gender distribution were identified, the ratio of girls in this study was similar to that estimated in the ASD population (4.1:1; Fombonne et al., 2022).
Finally, it should be noted that we focused the assessment on the ideational aspects of praxis and did not assess the sensory–perceptual aspects. Given the current need to provide objective data on the assessment of sensory integration functions, formal assessment of multiple aspects of praxis with tools such as the Evaluation in Ayres Sensory Integration® (EASI) will be necessary (Mailloux et al., 2018). The EASI is an open-access test that is being standardized and normalized internationally, including a version culturally adapted to Spanish (Gándara-Gafo et al., 2021). The EASI allows for a comprehensive and reliable assessment of sensory functions (sensory perception and sensory reactivity) and praxis of children between 3 and 12 yr of age. In addition, we recommend that occupational therapists begin to use the EASI praxis test because it has shown adequate psychometric properties (Lamash et al., 2022), which can contribute substantially to understanding the role of praxis with play and playfulness in future studies.
Implications for Occupational Therapy Practice
This study shows the influence of ideational praxis on play and playfulness among autistic children and has the following implications for occupational therapy practice: ▪ Ideational praxis is an important factor that may affect a child’s ability to participate in play; thus, assessment of play functions is important for occupational therapists. Accurate assessment is an important foundation for intervention. ▪ There is a need to consider and address ways in which affordances present in objects and the environment influence the play and social interactions of autistic children.
Conclusion
The positive associations between ideational praxis, play skills, and playfulness in unstructured play support consideration of how different qualities of objects and the environment influence play and social interactions. New interventions focused on purposeful and meaningful exploration may help improve children’s abilities to understand and act on possibilities offered by the objects and the environment.