Journal of Occupational Therapy, Schools, & Early

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Case Study Analyses of Play Behaviors of 12-

Month-Old Infants Later Diagnosed with Autism

Shelley Mulligan PhD, OTR/L FAOTA

To cite this article: Shelley Mulligan PhD, OTR/L FAOTA (2015) Case Study Analyses of Play
Behaviors of 12-Month-Old Infants Later Diagnosed with Autism, Journal of Occupational
Therapy, Schools, & Early Intervention, 8:1, 1-16, DOI: 10.1080/19411243.2015.1024561

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Published online: 29 May 2015.

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 Journal of Occupational Therapy, Schools, & Early Intervention, 8:1–16, 2015
Copyright © Taylor & Francis Group, LLC
ISSN: 1941-1243 print / 1941-1251 online
DOI: 10.1080/19411243.2015.1024561

Case Study Analyses of Play Behaviors of

12-Month-Old Infants Later Diagnosed with Autism

SHELLEY MULLIGAN, PhD, OTR/L FAOTA

Department of Occupational Therapy, University of New Hampshire,
Durham, NH

Case study research methodology was used to describe the play behaviors of three
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infants at 12 months of age, who were later diagnosed with an autism spectrum disorder.
Data included standardized test scores, and analyses of video footage of semi-structured
play sessions from infants identified as high risk for autism, because of having a sibling
with the disorder. Literature describing the attributes of object and social play of young
children with and without autism was also reviewed, and considered in the interpreta-
tion of results. The object and social play behaviors of the three infants with autism
were found to be variable among each other, and different in some ways from the play
of typically developing children. Most striking was a lack of creativity, or limitation
in functional play with toys, with an apparent desire for sameness or repetition in the
way play objects were used. In addition, object play was preferred over social forms
of play. An increased understanding of the play behaviors of infants with autism has
clinical implications for early identification of the disorder, and offers guidance for the
development of effective play-based interventions.

Keywords autism, object play, social interaction, infancy

Introduction
With promising evidence of the value of early intervention for promoting positive
developmental outcomes in children with autism spectrum disorders (ASD; Rogers, &
Vismara, 2008; Vernon, Koegel, Dauterman, & Stolen, 2012), efforts to enhance capabili-
ties for early diagnosis, and for developing effective early intervention treatments for this
population are paramount. The prevalence of individuals diagnosed with ASD continues to
rise, with current estimates as high as 1 in 68 children in the United States, according to
a surveillance report in 2014 (Centers for Disease Control and Prevention, retrieved from
www.cdc.gov). This statistic alone supports the ongoing need for studies that expand our
knowledge and understanding of the complex nature of ASD, including the variability seen
in the early development of infants later diagnosed with the disorder.

Characteristics of Play
Much of literature regarding play and autism has focused on play as a context for evalua-
tion, and for the teaching of skills, rather than the consideration of play as a separate area of
Received 29 July 2014; accepted 19 February 2015.
Address correspondence to Shelley Mulligan, Department of Occupational Therapy, University
of New Hampshire, 4 Library Way, Hewitt Hall, Durham NH 03824. E-mail: Shelley.mulligan@
unh.edu

1
 2 S. Mulligan

concern in and of itself (Williams, 2003). Play however, is regarded as a primary occupation
of children (Parham, 2008; Mulligan, 2014), and it is what young children spend most of
their waking hours doing. The quality of a child’s play impacts the social engagement, and
enjoyment that results from the play, the extent of learning that takes place, and the opportu-
nities for skill development. Play behaviors have also been considered as potential markers
for early identification of ASD, such as the amount of movement and object manipulation
during play (Mulligan & White, 2012; Williams, 2003), the nature of functional play with
objects (Baranek, Barnett, Adams, Wolcott, Watson, & Crais, 2005), and the extent of social
smiling, social reciprocity, eye contact, and imitation during play (Barbaro & Dissanayake,
2013; Zwaigenbaum et al., 2005). Social interaction, use of objects, creativity, pretending,
and imitation when experienced through play are interdependent, and are the means by
which children learn, relate to others, and adapt to their physical and social worlds (May-
Benson, 2010). Therefore, our understanding of the development of play behaviors, and the
relationship of play skills to other areas of development, is an important consideration in
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the evaluation and intervention of children with ASD.

There is no universal definition of play, yet there is agreement on many attributes that
characterize play. Parham (2008) described play as being fun, non-obligatory or intrinsi-
cally motivating, active, and relatively free from rules. Play may be categorized as being
object-directed, or social, and can also have both of these features. Play is developmental,
in that with maturity, the qualitative nature of play progresses from being very simple, to
more complex. There are many influences on the development of children’s play, including
age, gender, motor, communication and cognitive skills, temperament, physical environ-
ment and sociocultural environment (Case-Smith & Kuhaneck, 2008; Mulligan 2014).
An understanding of the development of play is important for being able to implement
play activities optimally for skill development in intervention, to maximize enjoyment, and
for encouraging social engagement and relationships.
Numerous authors have described play behaviors and proposed specific sequences of
play development, or stages of play (Johnson, 2006; Mulligan, 2014; Parham, 2008; Piaget,
1962). From a developmental perspective, play with objects begins with very basic sensory
motor play, whereby the child derives enjoyment simply from exploring and experiencing
the sensory features of toys. Sensory motor play for example, includes shaking a rattle,
mouthing toys, banging and holding objects, visual inspecting such as looking at a shiny
button or watching a ball roll, or touching/feeling objects such as plush, fuzzy animal. Such
exploratory play with objects facilitates the child’s learning about the qualities or properties
of the objects encountered (Williams, 2003; Koterba, Leezenbaum, & Iverson, 2014).
Functional play with objects begins to emerge near the end of the first year of life, when
infants begin to understand the conventional or normative uses of objects, and they begin to
play with objects in intentional ways (Baranek et al., 2005). For example, a child might roll
a ball, use a toy hammer to pound a ball into a hole, feed a baby doll with a bottle, or push
a toy car along an imaginary road. Another type of play children might engage in is con-
structional play, which involves building, such as stacking blocks, or putting together chain
of pop beads. Symbolic or pretend play emerges following functional play, and involves
pretending, role-play, and symbolic representation of objects and events (Parham, 2008).
Children for example, might use pots and pans as a drum set, play house with the assign-
ment of roles as mother, father and children. Children engage with play objects in all of
these forms of play, and may play with others, or alone while doing so.
Social play like object play follows a developmental trajectory. By 3 months of age
children smile, coo, and sustain eye contact with caregivers. Very young infants are inter-
ested in the human face, and most enjoy simple face to face games like watching caregivers
 Object and Social Play of Infants with Autism 3

make silly faces or noises, or tickling games (Dilavore, Lord, & Rutter, 1995; Sullivan et al.,
2007). By 6 to 8 months of age, infants are interested in simple, adult initiated turn-taking
games like Peek-a-boo, or Pat-a-Cake. Infants are usually very interested in watching other
children, and play comfortably next to other children. By 10 to 12 months of age, infants
may begin to initiate interactions with caregivers by making faces, sharing a social smile,
are able to imitate simple movements like clapping or blowing a kiss, and they may enjoy
teasing others, or showing off (Zwaigenbaum et al., 2005). Social play that involves mutu-
ally agreed upon roles, working towards a common goal, back and forth social interactions
or social reciprocity, sharing, and turn-taking with materials typically does not emerge until
around 24 months of age, and increases substantially as children develop language, and
become less egocentric. This type of play requires children to be able to determine and
follow the rules of the group, appreciate that perspectives of others might be different from
their own, be flexible in accepting changes in rules as the play unfolds, and be agreeable to
following the lead and ideas of others.
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Skard and Bundy (2008) proposed that professionals working with children should
concentrate less on what a child plays, and the toys they prefer, and more on how a child
plays, or playfulness. They conceptualized playfulness as being defined by three dimen-
sions, each of placed on a continuum. The first dimension, motivation, is exhibited on a
dimension from external to intrinsic, with intrinsic motivation being most highly associated
with playfulness. The second dimension is level of control, whereby internally controlled
play behaviors are more playful than externally controlled behavior. Finally, the third
dimension is the extent to which the play is free from the constraints of objective real-
ity, with pretend play and imaginative play without the boundaries of reality being most
reflective of playfulness (Skard & Bundy, 2008).

Object and Social Play of Children with Autism

Differences in both object and social play of children with autism have been cited by
many authors (Baranek et al., 2005; Barbaro & Dissanayake, 2013; May-Benson, 2010;
Williams, 2003; Wong & Kasari, 2012; Zwaigenbaum et al., 2005). With respect to object
play, children with autism have been described as exhibiting stereotypic play that is often
overly focused on certain sensorimotor properties (e.g. spinning wheels, twirling objects,
watching wheels turn). They tend to prefer concrete play themes or certain objects such
as trains (Desha, Ziviani, & Rogers, 2003). Pierce and Courchesne (2001) found children
with autism spend less time in active exploration of toys, and tend to play with a limited
repertoire of toys.
When compared with typical children, and children with Down’s syndrome, children
with ASD performed simple, single acts on play objects more often, and their play behav-
iors with objects were less variable than those seen by children in the comparison groups
(Williams, Reddy, & Costall, 2001). These researchers also noted that the children with
ASD spent less time in functional play, and produced fewer play sequences. In examining
sensory, exploratory object play in 6- and 9-month-old children at high risk for developing
the disorder (infant siblings of child with autism), Koterba et al.(2014) discovered that the
high risk infants demonstrated more visual inspection or looking of objects than typical
counterparts, less mouthing of objects at 6 months, and subtle differences in object manip-
ulation. They concluded overall that there were subtle delays in object exploration in the
high-risk infants.
Williams (2003) reported that unusual behaviors are sometimes seen in the solitary,
object exploration children with ASD, such as preoccupation with certain parts of objects,
 4 S. Mulligan

or looking in unusual ways such as holding the object very close to the eye. She also
noted that lower functioning children with ASD tend to persist in simple manipulative play
like mouthing, and banging objects, even when their developmental levels would suggest
abilities for more advanced forms of functional or symbolic play. Baranek et al., (2005)
found that the exploratory, object play of infants 9-12 months of age with and without
autism was similar, although the infants with ASD in their study did not engage in higher
levels of functional play as did some of the typically developing infants. Ozonoff, Macari,
Young, Goldring, Thompson, and Rogers in their 2008 study of object play of 12-month-old
infant siblings of children with ASD found that the ASD group performed more spinning,
rotational movements, unusual visual exploration than comparison groups (typically devel-
oping, and other developmental delays). Basic exploratory play behaviors such as banging,
shaking and mouthing were seen similarly among the different groups of children.
In comparison with typically developing young children, the functional play of chil-
dren with autism has also been found to be less organized, more repetitious, and less diverse
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(Blanc, Adrien, Roux, & Barthelemy, 2005; Williams, Reddy & Costall, 2001). Children
with ASD have been found to spend less time in functional play even when matched with
controls at similar levels of communication and cognitive function (Jarrold, Boucher, &
Smith, 1996; Williams, 2003). Charman, Swettenham, Baron-Cohen, Cox, Baird and Drew
(1997) also found that children with ASD had less functional play than typical controls, in
addition to demonstrating some impairment with the demonstration of empathy, imitation,
and shared attention during play. May-Benson (2010) suggested that deficits with praxis or
motor planning may be related to the preoccupation with objects, lack of flexibility, and
stereotypic play with objects often seen in children with ASD. Subsequently, she hypothe-
sized that these challenges may further impede the ability of children with ASD to engage
not only in solitary, object functional play, but with social forms of play.
A core deficit of individuals with ASD is social communication, and atypical language
development, therefore engagement in effective and satisfying forms of social play are
especially challenging for children with ASD. Wai Wan et al. (2013) explored the quality
of interaction between children at risk for ASD at 12-15 months of age, and their caregivers
during play. They found that the at-risk children demonstrated less intensity of engagement,
less attentiveness to their parents, and flatter, less positive, affect. Barbaro and Dissanayake
(2013) in their study of early markers of autism spectrum disorders noted aspects of social
play as being different between high risk and low risk infants. Among the best predictors
of later diagnosis of ASD was a lack of pretend play at 24 months, decreased eye con-
tact, and less joint attention behaviors including pointing, and showing during play. Strid,
Heimann, and Tjus (2013) also found that children with ASD demonstrated less pretend or
symbolic play than typical children, and less deferred imitation defined as occurring when
children use a previously seen action on a play item. Deferred imitation, according to Strid,
Heimann, and Tjus (2013), is related to use of memory, motor imitation, and acquisition
of communication skills. Engagement and initiation of social games such as Peek-a-Boo,
sharing and turn-taking were also shown to be of concern in children at risk for or with
ASD (DiLavore, Lord, & Rutter,1995; Vernon et al., 2012; Williams, 2003).
In summary, the literature provides some evidence that children with ASD exhibit dif-
ferences in object, and social play, which has been noted as early as 12 months of age.
However, questions remain regarding the nature of the differences of the play behaviors,
as the majority of literature has focused on the social, communication, and motor behav-
iors observed during play, rather than on the characteristics of the object and social play
in and of itself. Therefore, this study focused on providing a detailed analysis of the qual-
ity of the object and social play behaviors observed in three children at 12 months, who
 Object and Social Play of Infants with Autism 5

were all diagnosed with ASD by 24 months of age. This information has the potential to
be clinically helpful for understanding how play behaviors can be used for early identifica-
tion of ASD. In addition, enhanced knowledge regarding play provides some guidance for
interventions aiming to develop the play skills of children with ASD, and for appropriately
applying play-based strategies for developing other functional, motor, and social commu-
nication skills. The specific research question posed was: What is the nature of the object
and social play of infants at 12 months, who are later diagnosed with ASD?

Methods

Research Design, Sample, and Measures

Descriptive, case study methodology was used to examine and describe the play behaviors
of three 12-month-old infants who were ultimately diagnosed with ASD. The three subjects
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were selected from a larger pool of data from infant siblings of children with autism who
had been enrolled in study to examine potential early markers of ASD (see Mulligan and
White, 2013). The subjects were selected because their records contained complete data
including quality video footage of object and social play, and because their ASD diagno-
sis was confirmed by at least two professional sources, including a positive result on the
Autism Diagnostic Observation Schedule (ADOS, Lord, Rutter, DiLavore & Risi, 2002)
considered a gold standard in the diagnostic assessment of ASD. Data collected and ana-
lyzed for the purposes of this study were examined from each case using the measures and
sources described below.

1. Standardized test scores from the Vineland Adaptive Behavior Scales, Interview
Edition (VABS; Sparrow, Cicchetti, & Balla, 1984), the Mullen Scales of Early
Learning (Mullen,1995), and the Communication and Symbolic Behavior Scales
(Communication Symbolic Behavior Scales, Wetherby & Prizant, 2002) were used to
describe each child’s developmental level. The VABS is a caregiver interview that
assesses the adaptive functioning of individuals from birth to adulthood, across four
domains: Communication, Daily Living Skills, Socialization, and Motor Skills as well as
providing an Adaptive Behavior Composite. It was standardized on a very large national
sample of individuals matched to U.S. census data, has high internal consistency and
test-retest reliability data, and adequate validity data. The Mullen Scales of Early
Learning (MSEL; Mullen, 1995) is a standardized, norm-referenced, developmental
measure administered to children from birth to 68 months of age. The MSEL generates
standard scores for the following five subscales: Gross Motor, Visual Reception, Fine
Motor, Receptive Language, and Expressive Language as well as an Early Learning
Composite score. The test was normed on 1849 children based on U.S. census data and
has strong validity and reliability. The Communication and Symbolic Behavior Scales
Developmental Profile, Behavior Sample (CSBS-DP; Wetherby & Prizant, 2002) is a
semi-structured, play-based interaction between the child, clinician, and parent. The
tool examines communication in the context of play, yielding standard scores related
to social communication, speech, and symbolic behavior for 6 to 24-month-olds, based
on a normative data sample of 337 culturally diverse children. Criterion levels for con-
cern are set at 1.25 SD below the mean (10th percentile) for developmental norms on
the CSBS-DP.
2. Performance on many items from the Autism Observation Scale for Infants (AOSI;
Zwaigenbaum et al., 2005) relating to social and object play were examined. The
 6 S. Mulligan

AOSI is a measure developed to assess behaviors specific to ASD in infants (Bryson

et al., 2008; Zwaigenbaum et al., 2005), with seven or more positive markers indicat-
ing high risk for developing the disorder. The examiner administers several play-based
activities to elicit possible behavioral markers for ASD, such as poor eye contact, lack
of orienting to name, and lack of social smiling. The AOSI has been shown to have
strong inter-rater reliability, fair test-retest reliability, and strong predictive validity when
administered at 12 months (Bryson et al., 2008). Items associated with play that were
examined for this study included anticipatory responses, social babbling, social interest
and shared affect, social smiling, visual tracking, disengagement of attention, imitation
of actions, engagement of attention, insistence with play with particular objects, and
social referencing.
3. Ratings and performance observations from individual test items directly associ-
ated with play were examined from the Vineland Interpersonal Relationships and
Play/leisure Domains, (Sparrow et al., 1984) and from the Object Use, and Symbolic
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Behavior items of the CSBS DP, Behavior Sample (Wetherby & Prizant, 2002).
4. Video footage of a 10 minute, semi-structured play session between the mother and
infant with a standard set of enticing toys was coded for 16 sensorimotor and play
behaviors. In addition, object and social play behaviors were qualitatively described.
The toys used included large soft blocks, mirror, play phone, two rattles, squishy ball
and medium-sized ball, doll with a spoon, bottle and blanket, and a play set with toy
hammer, balls, and mazelike structure that when the balls are hammered into holes on
top of the structure, they move through the maze, and out a hole at the bottom of the
structure. The procedure for coding behaviors was developed by the author for the larger
study described earlier, and involved the development of operationally defined behav-
iors, and establishment of inter-rater reliability for 12 sensorimotor behaviors as follows:
Motor stereotypy, object stereotypy, mouthing objects, object manipulation, movement
transitions, motor imitation, orients towards a visual, tactile, and auditory stimulus, has
aversive response to a visual, tactile, and auditory stimulus, and four play behaviors:
sensorimotor, exploratory play, functional play, construction play, and social play. Data
were recorded every 30 seconds, indicating whether targeted behaviors were present
or absent, yielding a maximum frequency score of 20 for each behavior. Data on the
inter-rater reliability indicated 72% to 100% agreement for the variables, based on data
from 3 raters, using 10 sessions (30 pairs). For comparison purposes, average number
of occurrences for each of these behaviors was obtained from a small normative sample
of 11- to 13-month-old children, who were observed and videotaped under the same
conditions as part of the earlier study (see Mulligan & White, 2012).
5. Qualitative features of the object and social play behaviors were examined during the
10-minute semi-structured videotaped play session on the floor between the mother and
infant, and described. To minimize researcher bias in the interpretations made, the pri-
mary researcher (author) and a second researcher viewed the DVDs, and both made
individual notes describing the play. Notes were then compared, and the play behavior
discussed collaboratively so that agreement was reached on the most accurate ways to
describe the social and object play for each case.

Results
The results are presented for each individual case (pseudo-names have been used) begin-
ning with background information and developmental status. This is followed by a
description of each child’s object play and social play, using relevant data from the mul-
tiple sources described above. Following the presentation of the three cases, similar and
 Object and Social Play of Infants with Autism 7

dissimilar findings regarding characteristics of object and social play across cases are dis-
cussed and interpreted in consideration of current literature on object and social play of
children with and without ASD.

Case 1: John
Background and Developmental Status. John lived in a two-parent home with his 3-year-
old brother, who was diagnosed at age 2 with ASD. John was born a healthy, term infant
with no complications, and at 12 months of age, there were no reported medical or health
concerns. Mom however, reported some concerns regarding his development, stating that
he was not yet saying his first words, not yet crawling nor walking. With his play, she
was somewhat worried that he spent most of his time rolling objects, and watching them
roll, and she viewed this as an atypical play behavior. John was a good-natured, happy
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baby, who was usually interested in play materials, and people, and very aware of his sur-
roundings. With respect to his overall development, according to the MSEL, his Composite
score was 76, below average, falling more than 2 standard deviations below the mean for
his age group. Domain scores revealed Visual Reception and Fine Motor scores within
the average range, at the 34th and 27th percentile, respectively. Gross Motor skills were
below average at the 1st percentile, and the Receptive and Expressive Language Domains
were below average, at the 1st and 10th percentiles, respectively. Consistent with these
results, John’s Adaptive Behavior Composite on the VABS was below average with a
Standard Score of 84. Daily Living and Socialization Scales were scored within the aver-
age ranges, with Communication and Motor Scales scores, below average, both falling
at the 13th percentile. Results from the Communication and Symbolic Behavior Scales
Developmental Profile (CSBS DP) are reported in Table 1 and indicate deficits in the Social
and Symbolic Behavior areas. His total score on AOSI was 8, with 6 positive markers for

Table 1
Results from the Communication and Symbolic Behavior Scales (CSBS)

CSBS Standard Score (Mean = 10, SD = 3); Percentile

CSBS Domains John Sam Ruby
Social
Emotion & Eye Gaze 5, 5th 8, 25th 5, 5th
Communication 6, 9th 9, 37th 5.5th
Gestures 7, 16th 10, 50th 7, 16th
Composite 6, 9th 9, 37th 5, 5th
Communication
Sounds 10, 50th 14, 91st 7, 16th
Words 10, 50th 12, 75th 10, 50th
Composite 10, 50th 13, 84th 8, 25th
Symbolic Behavior
Understanding 8, 25th 14, 91st 13, 84th
Object Use 6, 9th 10, 50th 6, 9th
Composite 5, 5th 12, 75th 10, 50th
 8 S. Mulligan

ASD. This placed him borderline for high risk for ASD (a score ≥7 indicates significant
risk, Zwaigenbaum et al., 2005).

Object Play. Play/Leisure items on the Socialization Domain of the Vineland indicated
that John sometimes showed an interest in novel objects or new people, and was often
interested in playing with toys. He was not yet using common household objects for play,
nor engaging in pretend play. During the administration of the AOSI, John easily visually
tracked objects, and coordinated his eye gaze when reaching for, and grasping objects. He
was able to disengage his attention from a play object to look towards a competing auditory
stimulus. He was not observed to imitate simple motor actions during play with objects
such as hopping the bunny. He engaged primarily in sensory motor play, and seemed most
interested in the visual properties of objects. He tried to roll almost all of the play objects.
During the administration of the Object Use items of the CSBS DP Behavior Sample, when
the child and caregiver were provided with toy objects such as a doll (cookie monster),
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bottle, cup, spoon, plates, and bowl, and were asked to play with them. John demonstrated
three different action schemes on objects, directed only to himself. For example he brought
the cup to his mouth as if to drink. During the block item, John mouthed and banged the
blocks, rather than stacking them, and he engaged in very little functional play with the doll
or the kitchen items.
During the 10-minute play session on the floor with his mother, no atypical motor
stereotypies were noted during play. John occasionally mouthed objects, enjoyed visually
inspecting, and making noises with toys (Table 2). He engaged in sensorimotor play and
functional play with objects, equally, about 50% of the time. However, his functional play

Table 2
Behavioral Coding of 10 minutes of Semi-Structured Play
Number of Average
Occurrences Occurrences∗
Behavior John Sam Ruby
Motor Stereotypy 0 0 0 0.2
Repetitive Object Stereotypy 0 0 0 1.4
Mouths Object 5 4 3 4.1
Goes Toward Visual Stimulus 20 20 20 17.4
Goes Toward Auditory Stimulus 16 18 10 14.4
Goes Toward Tactile Stimulus 7 17 20 6.5
Aversive Response Visual Stimulus 0 0 0 0
Aversive Response Auditory Stimulus 0 0 1 3
Aversive Response Tactile Stimulus 2 0 0 0.2
Movement Transition-Position Change 20 6 10 12.7
Object Manipulation 6 11 8 13.4
Motor Imitation 2 6 0 2.7
Sensorimotor Play 20 9 4 11.4
Functional Play with Objects 10 19 13 11.2
Construction Play 0 0 0 0.4
Social Play 6 20 6 10.4
∗
Based on sample of typically developing infants (N = 12), 11 to 13 months of age.
 Object and Social Play of Infants with Autism 9

was limited in scope, and repetitious. He enjoyed rolling the ball, and motor imitation was
seen only on two occasions, and involved tossing the ball. John physically moved around
a great deal throughout the session using a notably atypical manner, by pivoting in sitting
and scooting forward in sitting with one leg tucked under his bottom. He played briefly
with the toy phone by attempting to push the buttons, and responded by picking it up after
his mother made it ring. However, he did not put the phone to his ear, or babble as if to
pretend talking. He played briefly with baby bottle, mostly by rolling it and then retrieving
it; however, on two occasions he did bring it to his mouth, as if to drink. John liked to
explore the toys on his own, and rarely responded to his mothers’ requests to play with her,
or with other toys. He spent most of the time with the ball, rolling it, watching it intently,
and then he would quickly move to retrieve it. He was very determined to get to the ball
quickly, and on more than one occasion, he flung a toy across the room that happened to be
in his path. Hand manipulation abilities were limited to reach, grasp, and toss, although was
able to change the position of the phone, ball and bottle in his hands on a few occasions,
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and transfer a toy from one hand to the other. He was very stable in a sitting position, and
easily freed his hands for play. He was not yet able to crawl or walk, but with his mother for
support, he pulled himself to a standing position and maintained supported standing for up
to10 seconds at a time. In summary, his object play was largely sensory motor, and solitary
in nature, with an unusual desire to roll and intensely watch rolling objects. Functional play
was observed, although it was repetitious, and limited in scope. He was quite an active
player, moved around a lot, and seemed to enjoy the play. Aside from the ball, he tended to
move very quickly from toy to toy, without staying with any one object for more than about
15 seconds.

Social Play. Play/Leisure items on the Socialization domain of the Vineland related to
social play revealed that John showed an interest in watching other children, but rarely
played simple interaction games with others. He was not yet sharing toys with others or
engaging in make believe play. He imitated simple movements like clapping hands, but
not more complex motor actions. Performance related to Communication on the CSBS DP
Behavior Sample indicated that John engaged in social interaction with his mother only
on one occasion, when looking at a book together, and he did not initiate joint attention.
Communication during play occurred for requesting and protesting, through the use of
simple gestures such as reaching or pulling away. During the administration of the AOSI,
John initiated little social interaction with his mother, and aside from during play with the
ball, three-point gaze (person–object–person or object–person–object) was rarely seen. He
did not engage in any spontaneous giving, showing or pointing behavior, and his mother
was unable to elicit a social smile during play, except with physical contact such as tickling.
During a social game of Peek-a-boo, John demonstrated clear anticipatory responses to the
examiner, and eye contact.
During the 10-minute play session, John engaged briefly with his mother during ball
play, by rolling the ball back and forth with her. On numerous occasions his mother
attempted to get him to engage with her, take turns, or respond to her to create some back
and forth interaction, but most of those attempts were ignored. John appeared much more
interested in solitary, object and functional play (with the ball) than with social forms of
play.

Case 2: Sam
Background and Developmental Status. Sam lived in a two-parent home with his 4-year-
old sister, who had been diagnosed the year prior with ASD. Sam was born a healthy, term
 10 S. Mulligan

infant with no complications, and at 12 months of age, there were no reported medical
or health concerns. Mom however was worried about his language development, since he
was not using many communicative gestures nor babbling very much, and he not yet said
his first word. With his play, she stated that he had a definite preference for playing with
trucks, but he would also play with other toys. She described him has a relatively easy
baby to manage who was affectionate and good-natured. In terms of his overall devel-
opment, according to the MSEL, his Composite score was 100, exactly average for a
child his age. His Visual Reception score was well above average at the 95th percentile,
Fine Motor, Gross Motor, and Expressive Language scores were within the average range,
and Receptive Language was below average at the 7th percentile. Consistent with these
results, Sam’s Adaptive Behavior Composite on the Vineland was 109, within the average
range, with Communication, Daily Living Skills, Socialization and Motor Skill Domains
all scoring within the average range with percentile scores ranging from 39 (Socialization)
to 84 (Daily Living Skills). Results from the Communication and Symbolic Behavior
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Scales Developmental Profile (CSBS DP) indicated typical development in the Social,
Communication and Symbolic Behavior areas (see Table 1). On the Autism Observation
Scale for Infants the number of ASD markers scores as positive was 1, placing him at low
risk for the disorder.

Object Play. Play/Leisure items on the Socialization Domain of the Vineland indicated
that Sam showed an interest in novel objects and new people, and was usually interested in
playing with toys either alone or with others. He routinely used common household objects
for play, but was not yet engaging in elaborate pretend play. During the administration of
the AOSI, Sam did not consistently use eye gaze to visually track objects, but he used
well-coordinated eye gaze when reaching for, and grasping objects. He was able to imitate
simple motor actions during play with objects, such as hopping the frog, and tapping a
stick. During the administration of the Object Use items of the CSBS DP Behavior Sample,
Sam engaged in some functional play with objects such as using the spoon to stir, although
action schemes with objects were done only towards himself (not with his mother, or the
doll). During the block item, Sam attempted to stack the blocks and managed to stack one
block on another. When afforded opportunities for both sensory motor and functional play,
he spent about equal amounts of time in both types of object play.
During the 10-minute play session on the floor with his mother, no atypical motor
stereotypies were noted during play, he occasionally mouthed objects, and he was interested
in the visual, tactile, and auditory properties of toys (see Table 2). He engaged in functional
play with objects about twice as often as sensory motor play, and many different examples
were demonstrated, such as feeding the baby doll with the bottle, and with the spoon, using
the hammer to pound to the balls into the holes, tossing the ball, and putting the phone to
his ear and babbling. Sam spent most of the time playing with the hammer and balls, the
squeaky ball, the doll, the phone, and the soft blocks. Object play was often observed in the
context of social play. Sam responded to his mother quite consistently by looking at her,
and taking turns with the play objects. Motor imitation was observed on six occasions, such
as rolling the ball, pounding the balls with the hammer, and covering the baby doll with the
blanket. Hand manipulation during play included changing the position of the phone, balls,
blocks, and bottle in his hands, and transferring toys from one hand to the other. Sam played
in a variety of positions on the floor, including sitting, side lying, kneeling and standing, and
moved occasionally by crawling. In summary, object play was seen mostly in the context
of functional and social forms of play, with some sensory motor, exploratory play. A good
variety of play objects were used, and many examples of functional play with objects
 Object and Social Play of Infants with Autism 11

was observed, although he spent a large portion of the session playing with the hammer
and ball set.

Social Play. Play/Leisure items on the Socialization domain of the Vineland related to
social play revealed that Sam usually showed an interest in watching other children, played
simple interaction games with others. He showed a desire to please his caregiver, would
share toys when prompted to do so, and routinely imitated simple movements like clap-
ping hands, but not more complex motor actions. Social smiles were easily elicited by his
mother. Performance related to Communication on CSBS-DP Behavior Sample indicated
that Sam communicated regularly during play with his mother, for requesting, for social
interaction, and initiation of joint attention. He used gestures such as giving, pointing and
waving, and frequently babbled. He demonstrated six different action schemes on objects,
and one action sequence. During the AOSI, Sam consistently responded to his name by
looking at his mother when his name was called, and a social smile was easily elicited
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during play. During Peek-a-boo, Sam demonstrated clear anticipatory responses with the
examiner, and good eye contact.
During the 10-minute play session, Sam engaged consistently with his mother while
playing with a variety of toys, with good eye contact, sharing of materials, and joint atten-
tion. Results of the behavioral coding indicated that he engaged in social play at least once
during each of the 20 coded 30-second periods. He enjoyed playing with the hammer and
ball toy, and he took turns pounding the ball in the holes with his mother. When initiated
by his mother, he also enjoyed some ball play, play with the doll, and the phone. He imi-
tated his mother’s action on six occasions, including feeding the doll, pounding the balls,
and pressing the buttons on the phone. In summary, Sam’s social play was frequent, and
characterized by frequent back and forth interactions, turn-taking, consistent eye contact,
the ability to following simple directions, social smiles and laughter, and motor imitation
with play objects.

Case 3: Ruby
Background and Developmental Status. Ruby lived in a two-parent home with her 4-year-
old sister, who had been diagnosed the year prior with ASD. Ruby was born a healthy,
term infant with no complications, and at 12 months of age, there were no reported med-
ical or health concerns. Mom however, reported that Ruby was a difficult baby, who was
emotionally sensitive, and over-active to many sensations such as noises, and food textures.
She experienced some challenges with sleeping and with the transition to solid foods, cried
excessively, and was difficult to soothe. She described Ruby’s play as sensory motor, and
exploratory in nature, and mostly solitary. In terms of her overall development, accord-
ing to the MSEL, her Composite score was average, with a standard score of 96. Her
profile showed strength in the fine motor area (85th percentile), and a relative weakness
with expressive language (20th percentile). Ruby’s Adaptive Behavior Composite on the
Vineland was 94, within the average range, with Communication, Daily Living Skills,
Socialization and Motor Skill Domains all scoring within the average range. Results from
the Communication and Symbolic Behavior Scales Developmental Profile (CSBS DP) are
reported in Table 1 and indicated typical development in the Communication and Symbolic
Behavior areas, and concerns in the Socialization area. On the Autism Observation Scale
for Infants, the number of ASD markers scored as positive was 9, placing her at high risk
for the disorder.
 12 S. Mulligan

Object Play. Play/Leisure items on the Socialization Domain of the Vineland indicated
that sometimes Ruby showed an interest in novel objects and new people, and was usually
interested in playing with toys alone rather than with others. She sometimes used common
household objects for play, and was not yet engaging in elaborate pretend play. During
the administration of the AOSI, Ruby did not consistently respond when her name was
called, and it was difficulty to elicit a social smile without physical touching. Ruby used
well-coordinated eye gaze when reaching for, and grasping objects. She was unable to
imitate simple motor actions during play with objects, and was more drawn to playing with
objects than people. For example, during the Peek-A-Boo game, she was more interested
in grabbing and playing with the blanket, than engaging with the examiner, or her mother.
During the administration of the Object Use items of the CSBS DP Behavior Sample, Ruby
engaged in some functional play with objects such as using the spoon to stir, and the cup to
drink, although action schemes with objects were done only towards herself.
During the 10-minute play session on the floor with her mother, no atypical motor
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stereotypies were noted during play. Ruby occasionally mouthed objects, and she was inter-
ested in the visual, and tactile properties of toys. She engaged in functional play with objects
about twice as often as sensory motor play, and many different examples were demon-
strated, such as feeding the baby doll with the bottle, and with the spoon, using the hammer
to pound to the balls into the holes, tossing the ball, and putting the phone to her ear and
babbling as if to talk. Ruby spent most of the time playing with the hammer and balls,
and seemed to over-focus on that activity such that she was often unresponsive or annoyed
with her mother who tried to get her to play with other toys. Object play was however
also observed at times in the context of some social play. Ruby responded to her mother’s
requests to interact with her or certain toys inconsistently. No instances of motor imitation
were observed although her mother made many attempts. Hand manipulation of objects
during play were well executed such as changing the position of the hammer and balls in
her hands, and easily transferring toys from one hand to the other. Ruby rarely moved dur-
ing play, and seemed somewhat overly focused on pounding the balls into the holes, and
then watching the balls move through the maze. In summary, object play was seen mostly
in the context of functional play and was limited in scope or variety. She also engaged in
some sensory motor, exploratory play and her play was primarily solitary in nature. There
was a high level of intensity about the way in which she played with the objects, with
frequent protesting when her mother made attempts to expand upon her play, or interact
with her.

Social Play. Play/Leisure items on the Socialization domain of the Vineland related to
social play revealed that Ruby usually showed an interest in watching other children, and
she played at least one simple interaction game with others. She sometimes showed a desire
to please her caregiver, but would rarely share toys when prompted to do so. Her mother
reported that she routinely imitated simple movements like clapping hands, but not more
complex motor actions. Performance related to Communication on CSBS-DP Behavior
Sample indicated that Ruby directed communication regularly during play with her mother,
for requesting, and protesting, and rarely for social interaction, or initiation of joint atten-
tion. During the AOSI, Ruby was inconsistent in responding when her name was called,
and eye contact with the examiner was fleeting, and rare with the examiner. She would not
engage in a social game of Peek-a-boo, and was unable to imitate simple motor movements
with objects.
During the 10-minute play session, Ruby socially engaged occasionally with her
mother and was coded as demonstrating social play in 6 out of the 20, 30-second time
 Object and Social Play of Infants with Autism 13

intervals. She enjoyed playing with the hammer and ball toy, and occasionally took turns
pounding the ball in the holes with her mother. She looked towards her mother primarily
when she wanted help, or when she wanted something from her. Her mother’s attempts to
engage her in simple play with the doll, or imitation with play materials such putting the
phone up to her ear, stacking the blocks, or placing the blanket were largely ignored. She
did play with her mother with phone briefly, by placing the receiver towards her mother’s
ear, and with some joint attention based on 3 point eye gaze (look towards the phone, fol-
lowed by eye contact with her mother, and then looking back to the phone). Ruby appeared
much more interested in playing with the toys on her own than with her mother, although
there were instances of occasional back and forth interactions, and social smiling.

Discussion
The object and social play behaviors of the three children examined were more dissimilar
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from one another, than they were similar. Therefore, we drew first the conclusion that there
is significant variability in the ways that young children with ASD play. John’s play behav-
ior for example, was most consistent with the characterization of play of children with,
or at risk for ASD in the literature. He seemed overly focused on the visual properties of
toys as was seen in the study by Ozonoff et al. (2008). In particular, he enjoyed watching
objects move. He also had a limited repertoire of play actions with objects, as described
by Koterba et al. (2014), and Pierce and Courchesne (2001). Williams (2003) reported
that unusual behaviors are sometimes seen in the, solitary object exploration children with
ASD, as was seen with John’s preoccupation with rolling objects, and watching them roll.
The other two children did not display any unusual play behavior. Sam demonstrated many
typical play behaviors and was quite social in his play with his mother, although he was
not yet using words to communicate. He appeared calm, happy, and engaged in play, while
both Ruby and John had a higher level of intensity with the way in which they engaged
with objects, and people. One explanation that may account for some of the variability in
their play, were differences among the developmental profiles of the children. Foundational
skills for play in the motor, cognitive and communication areas differed among the children,
with John’s developmental profile showing delays in most areas, while Ruby and Sam had
scores reflective of mostly average skill development.
One of the few similarities in their play, was that all three children did not engage in
high levels of sophisticated functional play with objects either with others, or alone, as was
also described by Baranek et al., (2005). The children appeared to get comfortable with
one play scheme (hammer and ball set for Ruby and Sam; the ball for John), and engage in
similar actions repeatedly. Similarly, the functional play of children with ASD was reported
to be more repetitious, and less diverse by Blanc, Adrien, Roux, and Barthelemy (2005),
and by Williams, Reddy and Costall (2001). Although the children did not spend less time
in functional play than typical children (according to the video, behavior coding) as was
reported by previous researchers (Charman et al, 1997; Williams, 2003), the functional play
that was observed was very basic. One explanation for this might be that children with ASD
may have motor planning deficits or dyspraxia hindering their creativity to come up with
play ideas, and/or their ability to plan, sequence, and execute a variety of actions on play
objects. This explanation of play differences was also suggested by May-Benson (2010),
and often occurs despite typical fine and gross motor skills, and cognitive functioning.
In terms of social play, Sam was clearly the most social of the three children, and he
appeared to enjoy interacting with his mother during structured play in the context of stan-
dardized testing, and during the more unstructured, play session. Ruby and John although
 14 S. Mulligan

capable at times, were both much more difficult to engage socially. These two children
played with objects intently, and there was an emotional intensity with the way in which in
they played. A good example of this was when John flung a toy out of his way to get to a
rolling bottle, or when Ruby screamed when her mother interrupted her play in an attempt
to expand upon her play with a different toy. Wai Wan et al. (2013) found in their study,
that children at risk for ASD, were less attentiveness to their parents, and had less positive
affect, and less eye contact, which reflects the social play behavior of John and Ruby. Joint
attention behaviors including pointing at and showing objects, and turn-taking were rarely
displayed by John and Ruby, although often observed from Sam.
Some limitations inherent in case study research design need to be considered in the
interpretation of the results of this study. First, the inclusion of only a small sample, three
children, all at 12 months of age limits the generalizability of the findings to the larger
population of young ASD children. All children were Caucasian, and from middle class
families. However, both genders were represented, and there was some variability in the
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developmental profiles of the children. The behavioral coding from the videotaped play
sessions were also limited as the time sampling coding process only allowed for behaviors
to be coded as either being present or absent every 30 seconds. Therefore, if a behavior was
demonstrated multiple times (such as moving towards to a visual stimulus, imitation, or
engaging in social play) within a 30 second interval, that behavior would only be captured
as occurring at least once during the interval. Given the repetitious nature of some the play
behaviors observed, a different time sampling method (such as using 10-second, rather
than 30-second intervals) would have provided more detailed information. Finally, because
qualitative descriptions of the play behaviors observed were made by a researcher who was
aware of the literature on play behavior of young children with ASD, and aware that the
children being studied all had been diagnosed with ASD, there is the risk of researcher
bias in the interpretations made. To minimize this risk, multiple data sources including
standardized scores, and observations from standardized testing were considered along with
the qualitative descriptive data. In addition, having second researcher provide a descriptive
analysis of the play sessions increased trustworthiness of interpretations of behavior made.
In order to deal with these limitations, future research should use larger, more diverse
samples of children, and examine the development of play behaviors over time. Second,
videotape analysis of semi-structured play sessions presented as a promising methodology
for studying play behaviors, and can be expanded to include the examination of unstruc-
tured play in the natural contexts of home, community, and/or child care centers, with more
precise coding procedures. Future research should also explore the relationship between
early play behaviors and the development of language, cognition, motor, and social com-
munication in children with and without ASD, to guide the development of intervention
programs involving play.

Clinical Implications and Conclusions

Findings from this study provide some clinical implications for translating research on
object and social play, to services for children with ASD. Qualitative differences in play
seen among children at 12 months of age may aide in early diagnosis. Although variable
among children, potential differences in object play might include unusual repetitive play,
such as intense visual inspection of objects or rolling objects, and a lack of variety in the
ways toys are used. Functional use of objects may be seen as frequently as it is seen in typ-
ically developing children, but there tends to be less variety, sophistication, or complexity
such as fewer numbers of action schemes used on objects. Differences in social play might
 Object and Social Play of Infants with Autism 15

include a lack of desire or interest for social play, with stronger desire to play with objects
over people. It may be difficult to engage young children with ASD in social forms of
play, with little initiation of joint attention beyond the purposes of requesting or protesting.
In addition to considering these differences as potential markers for early identification
of ASD, they also represent important areas to target in early intervention. Results from
this study suggest that early intervention services for young children at risk for, or with
ASD should be deliberate about expanding the complexity and variety of functional play
with objects, addressing social interaction and joint attention during play, and promoting
emerging skills with imaginative play.

References
Baranek, G.T., Barnett, C.R., Adams, E.M., Wolcott, N.A., Watson, L.R., & Crais, E. (2005). Object
play in infants with autism: Methodological issues in retrospective video analysis. American
Downloaded by [University of Lethbridge] at 01:00 12 June 2016

Journal of Occupational Therapy, 59, 20–30.

Barbaro, J., & Dissanayake, C. (2013). Early markers of autism spectrum disorders in infants and
toddler prospectively identified in the Social Attention and Communication Study, Autism, 17,
64–86.
Blanc, R., Adrien, J.L., Roux, M.S., & Barthelemy, C. (2005). Dysregulation of pretend play and
communication development in children with autism. Autism, 9, 229–245.
Bryson, S.E.L, McDermott, C., Rombough, V., Brian, J., & Zwaigenbaum, L. (2008). The Autism
Observation Scale for Infants (AOSI): Scale development and reliability data. Journal of Autism
and Developmental Disorders, 38, 731–738.
Case-Smith, J., & Kuhaneck, H.M. (2008). Play preferences of typically developing children and
children with developmental delays between the ages of 3 and 7 years. OTJR: Occupational
Participation and Health, 28, 19–29.
Charman, T., Swettenham, J., Baron-Cohen, S., Cos, A., Baird, G., & Drew, A. (1997). Infants with
autism: An investigation of empathy, pretend play, joint attention, and imitation. Developmental
Psychology, 33(5), 781–789.
Desha, L., Ziviani, J., & Rogers, S. (2003). Play preferences and behavior of preschool children
with autism spectrum disorder in the clinical environment. Physical and Occupational Therapy in
Pediatrics, 23, 21–42.
Dilavore, P.C., Lord, C., & Rutter, M. (1995). Pre-linguistic autism diagnostic schedule. Journal of
Autism and Developmental Disorders, 25, 355–379.
Jarrold, C., Boucher, J., & Smith, P,K. (1996). Generativity deficits in pretend play in autism. British
Journal of Developmental Psychology, 14, 275–300.
Johnson, J. E. (2006). Play development from ages four to eight, In D.P. Fromberg & D. Bergen (eds).
Play from birth to twelve: Contexts, perspectives and meanings (2nd edition, pp.13–20), New York:
Routledge.
Koterba, E., Leezenbaum, N.B., & Iverson, J.M. (2014). Object exploration at 6 and 9 months in
infants with and without risk for autism. Autism, 18(2), 97–105.
Libby, S., Powell, S., Messer, D. & Jordan, R. (1998). Spontaneous play in children with autism: A
reappraisal. Journal of Autism and Developmental Disorders, 28, 48–7497.
Lord, C., Rutter, M., DiLavore, P.C., & Risi, S. (2002). Autism diagnostic observation schedule (WPS
edition). Los Angeles: Western Psychological Services.
Mullen, E. M. (1995). Mullen: Scales of early learning (AGS Edition.). Circle Pines, MN: American
Guideline Service, Inc.
May-Benson, T.A. (2010). Play and praxis in children with an autism spectrum disorder. In H. Miller
Kuhaneck, & R. Watling (eds), Autism, a comprehensive occupational therapy approach (3rd
edition, pp.383–425), Bethesda MD: AOTA Press.
Mulligan S. (2014). Occupational therapy evaluation for children, 2nd edition. Philadelphia:
Lippincott Williams & Wilkins.
 16 S. Mulligan

Mulligan, S., & White, B.P. (2012). Sensory and motor behaviors of infant siblings of children with
and without autism. American Journal of Occupational Therapy 66(5), 556–566.
Ozonoff, S., Macari, S., Young, G.S., Goldring, S., Thompson, M. & Rogers, S.J. (2008). Atypical
object exploration at 12 months of age is associated with autism in a prospective sample. Autism,
12, 457–472.
Parham, L.D. (2008). Play and occupational therapy. In L.D. Parham & L .S. Fazio (Eds), Play in
occupational therapy for children (2nd edition, pp. 3–39). St. Louis, MO: Mosby Elsevier Inc.
Piaget, J. (1962). Play, dreams and imitation in childhood. New York: W.W Norton.
Pierce, K., & Courchesne, E. (2001). Restricted interests and stereotyped behaviors in autism. The
role of the cerebellum. Biological Psychiatry, 49, 655–664.
Rogers, S.J. & Vismara, L.A. (2008). Evidence-based comprehensive treatments for early autism.
Journal of Clinical Child and Adolescent Psychology, 37(1), 8–38.
Skard, E., & Bundy, A. (2008). Test of Playfulness. In L.D. Parham & L S. Fazio (Eds), Play in
occupational therapy for children (2nd edition, pp. 71–94). St. Louis, MO: Mosby Elsevier Inc.
Sparrow, S., Cicchetti, D., & Balla, D., (1984). Vineland adaptive behavior scales (Interview edition).
Downloaded by [University of Lethbridge] at 01:00 12 June 2016

Circle Pines, MN: American Guidance Service.

Strid, K., Heimann, M. & Tjus, T. (2013). Pretend play, deferred imitation, and parent-child interac-
tion in speaking and non-speaking children with autism. Scandinavian Journal of Psychology, 54,
26–32.
Sullivan, M., Finelli, J., Marvin, A., Garrett-Mayer, E., Bauman, M., Landa, R., Response to joint
attention in toddlers at risk for autism spectrum disorder: A prospective study. Journal of Autism
Development Disorders, 37, 37–48.
Vernon, T.W., Koegel, R.L., Dauterman, H., & Stolen, K. (2012). An early social engagement inter-
vention for young children with autism and their parents. Journal of Autism and Developmental
Disorders, 42, 2702–2717.
Wai Wan, M., Green, J., Eisabbagh, M., Johnson, M., Charman, T., Plummer, F., & the BASIS Team
(2013). Quality of interaction between at-risk infants and caregiver and 12-15 months is associated
with 3-year autism outcome. Journal of Child Psychology and Psychiatry, 54(7), 763–771.
Wetherby, A.M., & Prizant, B. (2002). Communication and symbolic behavior scales, normed
edition. Baltimore, MD: Paul H. Brookes Publishing.
Williams, E. (2003). A comparative review of early forms of object-directed play and parent-infant
play in typical infants and young children with autism. Autism, 7, 361–377.
Williams, E., Reddy, V., & Costall, A. (2001). Another look at functional play in children with autism.
Journal of Autism and Developmental Disorders, 31, 67–77.
Wong, C., Kasari, C. (2012). Play and joint attention of children with autism in the preschool special
education classroom. Journal of Autism and Developmental Disorders, 42, 2152–2161.
Zwaigenbaum, L., Bryson, S., Rogers, T., Rogers, W., Brian, J., Szatmari, P. (2005). Behavioral
manifestations of autism in the first year of life (AOSI). International Journal of Developmental
Neuroscience, 23, 143–152.