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A Preliminary Investigation of the

Relationship Between Sensory Processing


and Social Play in Autism Spectrum
Disorder
Heather Miller Kuhaneck, PhD; Preston A. Britner, PhD
key words: autism, play, sensory motor performance

ABSTRACT

There are well-documented play deficits in autism beginning with infant object and social play.
To create effective interventions, the predictors of play deficits in autism must be established.
Individuals with autism spectrum disorder (ASD) frequently report sensory processing difficul-
ties including poor praxis; however, these are potential predictors of play that have not been well
studied. Using a data set of 162 individuals with ASD, this study examined the direct and indi-
rect relationships between sensory processing and social play performance via structural equation
modeling. The best fitting model suggested that sensory system functions predict praxis and
play in combination, providing preliminary evidence that sensory functions are related to social
play in combination with praxis in children with ASD. The findings suggest future avenues for
research. [OTJR: Occupation, Participation and Health 2013;33(3):159-167.]

O ccupational therapists have long espoused


the importance of play (Reilly, 1974). Play
is one of the primary occupations of child-
hood and restrictions in play opportunities may
deprive a child of a necessary developmental context
may provide a type of environmental enrichment
that influences neurologic functioning as it alters
developmental trajectories in a positive manner.
Autism spectrum disorder (ASD) is a develop-
mental disorder with an unknown etiology. Preva-
(American Occupational Therapy Association, 2008a, lence was recently reported as 1 in every 50 children
2008b) and meaningful and important childhood in the United States (Blumberg et al., 2013). Primary
experiences. Many authors, as well as the American characteristics of ASD include difficulties with so-
Academy of Pediatrics, have publicly recognized the cial interaction and communication and restricted
importance of play for health and learning (Brown, and repetitive behaviors. Play deficits are also com-
2009; Elkind, 2007; Ginsburg, American Academy mon. A large body of literature has documented the
of Pediatrics Committee on Communications, & atypical play of children with ASD (Dominguez,
American Academy of Pediatrics Committee on Ziviani, & Rodger, 2006; Hobson, Lee, & Hobson,
Psychosocial Aspects of Child and Family Health, 2009; Holmes & Procaccino, 2009; Holmes & Wil-
2007; Pellegrini, 2009). Play is also enjoyable and loughby, 2005; Jarrold, 2003; Jordan, 2003; Williams,

Heather Miller Kuhaneck, PhD, is Assistant Professor, Department of Occupational Therapy, Sacred Heart University, Fairfield,
Connecticut. Preston A. Britner, PhD, is Professor, Department of Human Development and Family Studies, University of
Connecticut, Storrs, Connecticut.
Submitted: January 3, 2013; Accepted: May 13, 2013
The authors have no financial or proprietary interest in the materials presented herein.
Correspondence: Heather Miller Kuhaneck, PhD, Sacred Heart University, 5151 Park Avenue, Fairfield, CT 06825. E-mail:
kuhaneckh@sacredheart.edu
doi: 10.3928/15394492-20130614-04

OTJR: Occupation, Participation and Health Vol. 33, No. 3, 2013 159
2003). These studies suggest that across all catego- Leekam, Turner, and McConachie (2007) used a parent-
ries of play, including social play, children with ASD report measure to examine the relationship between
demonstrate qualitative differences in the way that play behavior, level of play, and repetitive behaviors.
they play. Research has also supported the notion Using a 31-item scale developed specifically for their
that children with ASD have specific difficulty with study, the researchers compared 117 typically develop-
social play, with generating flexible and novel ideas ing children with 79 children with ASD. The children
for play, and with engaging in play with and with- with ASD received higher scores that indicated more
out peers, with spontaneity and pleasure (Craig & repetitive behavior and lower scores on play behavior
Baron-Cohen, 1999; Dichter, Lam, Turner-Brown, than the typically developing children. However, the
Holtzclaw, & Bodfish, 2009; Hobson et al., 2009; Jor- items used to measure repetitive behavior could also
dan, 2003; Lewis & Boucher, 1988, 1991, 1995; Ruth- be considered measures of atypical sensory processing.
erford & Rogers, 2003; Skaines, Rodger, & Bundy, The items addressed unusual interest in smell, bright,
2006). shiny objects, touching parts of the body, spinning, and
Occupational therapists might consider these def- rocking. Many scale items referenced some aspect of
icits within a framework of dyspraxia (Ayres, 1979; sensory processing. Therefore, perhaps sensory pro-
May Benson & Cermak, 2007). Dyspraxia has also cessing is the predictor of play behavior rather than
been repeatedly documented in individuals with repetitive behavior.
ASD and some researchers have suggested that mo- Sensory processing is theoretically related to play
tor planning is a primary problem (Dowell, Mahone, performance and may be a predictor of social play
& Mostofsky, 2009; Dziuk et al., 2007). Children with deficits (Ayres, 1979). However, no studies to date
ASD also consistently demonstrate a variety of ad- have examined the relationships between the types
ditional sensory processing difficulties (Ben-Sasson, of sensory functions (modulation, discrimination,
Hen, et al., 2009; Marco, Hinkley, Hill, & Nagara- perception, and praxis) and social play in this pop-
jan, 2011; Schoen, Miller, Brett-Green, & Nielsen, ulation. Therefore, the purpose of the current study
2009). These sensory-processing deficits are now was to complete a preliminary investigation of these
considered part of the diagnostic criteria for ASD, relationships in a sample of children with ASD. Struc-
within the category of restricted repetitive behaviors tural equation modeling (SEM) (Bryne, 2010; Kline,
(American Psychiatric Association, 2013). A large 2005) provides a tool to investigate the following hy-
body of work links sensory functions such as modu- potheses: Sensory system function will predict praxis;
lation, discrimination, and perception to praxis (see Praxis will predict social play; and Sensory system
Parham & Mailloux, 2010 for a review of this work) function will predict social play directly.
and Ayres sensory integration theory suggests a
relationship between praxis and play (Ayres, 1979). Methods
Social play in particular may require strong praxis Participants
skills for children with ASD because they must ne- The data set was obtained from the clinical sam-
gotiate rapid changes in play schemes and introduc- ple used to examine discriminant validity during the
tion of novel play ideas from others. development of the home forms of the Sensory Pro-
Because the earliest stages of object and social play cessing Measure (SPM) (Parham, Ecker, Miller-Ku-
are both sensorimotor and imitative in nature and be- haneck, Henry, & Glennon, 2006) and the SPM-Pre-
gin early in infancy as body awareness is developed, it school (SPM-P) (Miller-Kuhaneck, Ecker, Parham,
is likely that impaired sensory processing could lead to Henry, & Glennon, 2010). One hundred eight chil-
impaired play; however, this has not been well stud- dren from the SPM sample and 55 children from the
ied. Lower scores were found on a measure of play in SPM-P sample were diagnosed as having ASD, for
children with sensory processing dysfunction than in a total sample of 162 children. Children in the clini-
children without the disorder, although play prefer- cal sample were provided by school personnel. As a
ences were similar between the two groups and many secondary data analysis, this project was deemed ex-
of the children with sensory processing disorder com- empt from review by the institutional review board.
pensated well, despite poorer motor control (Bundy,
1989; Clifford & Bundy, 1989). One study found that Measures
children with sensory processing dysfunction have The SPM is intended for use with children in
poorer scores on playfulness than typically develop- kindergarten through grade 6 and the SPM-P is for
ing controls (Bundy, Shia, Qi, & Miller, 2007). Although children 2 through 5 years of age who have not yet
still relatively playful, those with the disorder tend to entered kindergarten. Both tools examine sensory
engage in sedentary rather than active play. Honey, processing, praxis, and social participation. Items

160 Copyright American Occupational Therapy Foundation


within the social-participation scale examine social the difference between the covariance matrices. A sig-
play performance (Plays with friends cooperatively; nificant chi-square value suggests a difference between
Shares things when asked; Joins into play with oth- the covariance matrices. Therefore, a good model fit
ers without disrupting the ongoing activity). Each to the data provides an insignificant chi-square result
item is scored with a 4-point Likert-type response (Hooper et al., 2008). Chi-square is the most commonly
scale ranging from never to always. A higher raw used measure of fit; however, it is affected by sample
score on the SPM is suggestive of greater dysfunc- size (Gao et al., 2008; Hooper et al., 2008).
tion. The SPM and SPM-P both demonstrate ad- Many authors suggest also using the CFI when
equate psychometrics (Miller-Kuhaneck et al., 2010; determining model fit (Gao et al., 2008; Hooper et
Parham et al., 2007). al., 2008). The CFI performs well even with a smaller
To develop the measurement model, the two sample size. The measure assumes the latent vari-
home forms of the SPM and the SPM-P were com- ables are uncorrelated and compares the sample co-
pared to select the identical items between the two variance matrix with the null model. Values closer
within the chosen scales. No items were moved from to 1 indicate good fit. For this study, the CFI was ex-
their original categories, as determined by prior ex- amined and the cutoff value was greater than 0.95 as
pert and clinician review during development of is currently recommended within related literature
the assessment tools. However, items were dropped (Hooper et al., 2008).
from the original scales if they were not included RMSEA is a measure of how well the model
in both versions. This resulted in scales compris- would fit the population covariance matrix if it had
ing fewer items than were reflected in the published optimal parameter estimates. This measure is often
tools. Summed scale scores were used in the model selected because it is sensitive to the number of pa-
analysis. A final list of items is presented in Table 1. rameter estimates, and it favors both the best fit and
the most parsimonious model (Hooper et al., 2008).
Data Analysis A range of values have been proposed for cutoffs of
Data analysis was completed with SPSS 16.0 and the RMSEA. For purposes of this study, values of the
AMOS 16.0 software (SPSS, Inc., Chicago, IL) follow- RMSEA were examined and the cutoff used was 0.06.
ing procedures outlined by Bryne (2010) and Kline RMR is the square root of the difference between the
(2005). The analyses included descriptive statistics, residuals of the covariances matrices (Hooper et al.,
examination of the normalcy of the distribution, 2008). Values range from zero to 1 and good-fitting
and the correlations between the selected scales and models should have values less than 0.05, with zero
SEM. A Cronbachs alpha was calculated to examine suggesting a perfect fit.
the reliability of the scale scores for the children with
ASD. Relationships between the variables and scales Results
were examined via Pearson product-moment corre-
lations. Univariate skew and kurtosis and multivari- The participants in this study had ages ranging
ate normalcy were tested. from 2 years and 2 months to 13 years and 6 months,
With any set of data, more than one model can with an average age of 7 years and 2 months. As was
fit. Therefore, after examining the fit of the hypoth- expected with a sample of individuals with ASD,
esized model, the next step was to compare alterna- 82.7% were male. Other sample demographics are
tive models that might better fit the data. The alter- provided in Table 3. For the 162 participants in the
native models were based on Ayres prior research current study, there were no missing data in any of
(see Parham & Mailloux, 2010 for a review of this the items provided in the data set.
body of work) and discussion with current experts Scale scores, used as indicators in the model test-
in Ayres Sensory Integration. The models are de- ing, were summed item scores. Cronbachs alpha for
scribed in Table 2. the scales used in this study ranged from .66 for the
During each step of the process, the model fit was vision scale to .83 for the praxis scale, with the rest of
examined using measures of goodness of fit. Model the scales in the .73 to .78 range. There were no items
fit was examined using chi-square, the comparative that, if deleted, would have substantially altered the
fit index (CFI), root mean square of error approxima- alpha levels for any scale.
tion (RMSEA), and the root mean square residual Skew and kurtosis data indicated that the majority
(RMR). Multiple authors have suggested viewing and of the scales were positively skewed, with the excep-
reporting multiple measures when examining model tion of play, which was negatively skewed. The Kol-
fit (Bryne, 2010; Hooper, Coughlan, & Muellen, 2008; mogorovSmirnov tests were significant for each of
Kline, 2005). Chi-square measures the magnitude of the scales, indicating data that are different than nor-

OTJR: Occupation, Participation and Health Vol. 33, No. 3, 2013 161
Table 1
Selected Items From the Sensory Processing Measure and Sensory Processing MeasurePreschool
Used to Develop the Structural Equation Model
Scale Category Item
Play performance Plays with friends cooperatively
Shares things when asked
Joins into play with others without disrupting the ongoing activity
Vision Seems bothered by light, especially bright light (blinks, squints, cries, closes eyes, etc.)
Has difficulty recognizing how objects are similar or different based on their colors, shapes, or sizes
Has trouble finding an object when it is part of a group of other things
Enjoys watching objects spin or move more than most kids his/her age
Walks into objects or people as if they were not there
Likes to flip light switches on and off repeatedly
Enjoys looking at moving objects out of the corner of his/her eye
Touch Pulls away from being touched lightly
Prefers to touch rather than to be touched
Becomes distressed by having his/her finger- or toenails cut
Seems bothered when someone touches his/her face
Avoids touching or playing with finger paint, paste, sand, clay, mud, glue, or other messy things
Has an unusually high tolerance for pain
Dislikes teeth brushing, more than most kids his/her age
Seems to enjoy sensations that should be painful, such as crashing onto the floor or hitting his/her own body
Proprioception Grasps objects (such as a pencil or spoon) so loosely that it is difficult to use the object
Seems driven to seek activities such as pushing, pulling, dragging, lifting, and jumping
Seems unsure of how far to raise or lower the body during movement such as sitting down or stepping
over an object
Seems to exert too much pressure for the task, such as walking heavily, slamming doors, or pressing too
hard when using pencils or crayons
Jumps a lot
Tends to pet animals with too much force
Bumps or push other children
Chews on toys, clothes, or other objects more than other children
Vestibular Seems excessively fearful of movement, such as going up and down stairs or riding swings, teeter-
totters, slides, or other playground equipment
Avoids balance activities, such as walking on curbs or on uneven ground
Falls out of a chair when shifting his/her body
Fails to catch him/herself when falling
Seems not to get dizzy when others usually do
Spins and whirls his/her body more than other children
Shows distress when his/her head is tilted away from the upright, vertical position
Shows poor coordination and appears to be clumsy
Leans on other people or furniture when sitting or when trying to stand up
Praxis Has trouble figuring out how to carry multiple objects at the same time
Seems confused about how to put away materials and belongings in their correct places
Fails to complete tasks with multiple steps
Has difficulty imitating demonstrated actions, such as movement games or songs with motions
Has trouble coming up with ideas for new games and activities
Tends to play the same activities over and over, rather than shift to new activities when given the chance

162 Copyright American Occupational Therapy Foundation


Table 2
Proposed and Alternative Models
Model Description
Proposed The scales of vision (7 items), touch (7 items), vestibular (9 items), and proprioception (9 items) load on one
factor called sensory functions, which is directly related to praxis (6 items) and play (3 items). Praxis is
directly related to play and also serves as a mediator between sensory functions and play.
Model 2 All indicators could load on one factor of general ability because the data are from a sample of children
with autism spectrum disorder and, perhaps, their scores were simply reflective of a common measure of
the lower ability with autism spectrum disorder.
Model 3 The sensory scales of vision, touch, vestibular, and proprioception could load on one factor of sensory func-
tions, whereas play and praxis load on another of higher general ability.
Model 4 The three near-body senses of touch, vestibular, and proprioception could load on one factor, with vision
and praxis loading on another and play alone.
Model 5 The scales of vision, touch, vestibular, proprioception, and praxis could load on one factor (i.e., sensory inte-
gration) and play could remain alone as an indicator of higher function.
Final Model The scales of vision, touch, vestibular, proprioception load on one factor and play and praxis combine in
another factor. This is model 3 with correlated error. See Figure 1.

mally distributed data. This was addressed in SEM Table 3


with the bootstrapping procedure. Two age groups Sample Demographics
were combined in this data set (SPM and SPM-P), but Demographic % of Sample
Levines test of the homogeneity of variance for each
Ethnicity
of the scale scores examining the two groups based
on age was not significant, suggesting that the homo- American Indian/Native Alaskan 1
geneity of variance assumption was met between the Native Hawaiian/Pacific Islander 3
younger and older participants. The AMOS assess- Black 5
ment of data normality and Mahalanobis d-squared Hispanic 7
results suggested no cases to be deleted. Each of Asian 3
the scales was moderately correlated with the other.
White 80
Table 4 provides these correlations. The proposed
model was estimated and subsequently compared Other 1
to the four alternative models described, because the Education level of parent
proposed model did not fit the data. The Bollen-Stine Did not complete high school 4
bootstrap value and measures of model fit for each of High school degree 20
the models are provided in Table 5.
Some college 22
An AMOS diagram of the final model with the esti-
Bachelor degree or higher 54
mates is provided in Figure 1. The optimal model was
the model of sensory functions predicting a combined Region of the country
play and praxis factor of higher ability. However, this Northeast 11
model did not obtain adequate fit to the data with- South 10
out correlating error. The practice of correlating error Midwest 50
terms is controversial in SEM (Hooper et al., 2008;
West 29
Kline, 2005). Correlated error is the variance across
measures that is not explained by the constructs and
is from some common cause. The unknown, shared with ASD, vision, proprioception, and tactile and ves-
something can be a common method of measure- tibular functioning are strongly related to praxis and
ment, measurement of a construct unrepresented by social play ability in combination.
the model, or similar wording between items. There-
fore, theory and prior research, along with an exami- Discussion
nation of item wording and prior item categorization,
were considered in the process of correlating errors in This study provides preliminary evidence that
this study. The final model proposes that, in children sensory functions are related to social play/praxis

OTJR: Occupation, Participation and Health Vol. 33, No. 3, 2013 163
Table 4
Scale Correlationsa
Scale Play Vision Touch Proprioception Vestibular Praxis
Play 1.000
Vision 0.322 1.000
Touch 0.441 0.639 1.000
Proprioception 0.404 0.574 0.538 1.000
Vestibular 0.226 0.527 0.477 0.481 1.000
Praxis 0.519 0.496 0.439 0.345 0.446 1.000
a
All p < .01, two tailed.

Table 5
Model Fit Indices
Bollen-Stine
Model Bootstrap Chi-square CFI RMSEA Decision
Proposed p = .015 23.1 (8), p = .003 0.957 0.108 Not a good fit to data
Model 2 p = .000 40.4 (9), p = .000 0.910 0.147 Not a good fit to data
Model 3 p = .026 23.1 (8), p = .003 0.957 0.108 Not a good fit to data; suggested correlated
error that made sense based on scale items
Model 4 p = .000 40.3 (7), p = .000 0.904 0.172 Not a good fit to data
Model 5 p = .000 40.4 (9), p = .000 0.910 0.147 Not a good fit to data
Final Model p = .803 9.14 (6), p = .166 0.991 0.057 Acceptable fit to data and theory
CFI = Comparative Fit Index; RMSEA = Root Mean Square of Error Approximation

with ideas for new games and activities and the


other states tends to play the same activities over
and over, rather than shift to new activities when
given the chance.
It was decided early in the development of this
study to avoid moving items from the scales within
which they were originally placed during develop-
ment of the SPM tools; these two items therefore re-
mained within the praxis scale. However, given the
clear relationship with play in these two ideational
praxis items, doing so may have created the need
to combine the scales to obtain adequate model fit.
The correlation between these two scales was mod-
Figure 1. The final two-factor structural model with erate (r = 0.519). Three of the six items within the
correlated error. Standardized estimates are indicated. praxis scale are related to either imitation or genera-
prop = proprioception; vestib = vestibular tivity, both of which have been addressed in studies
of play in children with ASD (Hobson et al., 2009;
in children with ASD as measured by the SPM and Lewis & Boucher, 1991, 1995). Therefore, the combi-
SPM-P. The final model, with a collapsed social nation of praxis and play into one factor is under-
play/praxis factor, is likely a better fit to the data standable. The combined factor could also imply
because of the items that make up the scales. Items that rather than being a separate construct from play
in the praxis scale include two that are worded to skill or other higher level skills, praxis may be an
measure ideation but also overlap considerably with integral part of higher level functioning, as has been
items that would be in a scale of play performance. suggested by researchers studying motor cognition
One of these items states has trouble coming up (Gallese, Rochat, Cossu, & Sinigaglia, 2009).

164 Copyright American Occupational Therapy Foundation


A relationship between sensory functions and also limitations. First, children to be included as hav-
praxis is well supported with Ayres research, as well ing ASD were gathered by school professionals and
as a more recent reexamination of data that related there was no way to confirm diagnosis. Therefore, it
sensory functions and praxis in ASD (see Parham is possible that some of the children included in the
& Mailloux, 2010 for a review of Ayres work; Mail- sample were misdiagnosed. Second, because there
loux et al., 2011). Theoretically, children must have was no measure of symptom severity in the original
adequate processing of sensation to determine how data set, it is impossible to know whether some of the
to move their bodies appropriately. However, body relationships found between the scales are due merely
awareness and the ability to process sensory infor- to the confounding relationship with overall symptom
mation may also be related to both imitation and severity. The one finding that argues against this inter-
generativity, because these abilities were measured pretation is the poor model fit when all indicators were
within the praxis scale. These relationships have been placed as loading on one factor of general ability.
suggested by other researchers in imitation and dys- A second important limitation is the small number
praxia in ASD (Roeyers, Van Oost, & Bothyne, 1998; of items available to create the play scale. The origi-
Williams et al., 2006). Perhaps basic body awareness nal social participation scale was much more broadly
is necessary to perform creative motions of the body defined and included items in addition to play. There-
in relation to objects for play and to learn through the fore, only certain items could be pulled from the social
senses that objects can be used in novel ways. participation scale to form the play scale. To achieve
The link between sensory processing and play the larger sample of this study by combining data
found in this study is not yet well supported within from the SPM and SPM-P, certain items could not be
related literature. Research has found that children included that were not available on both measures.
with sensory-processing difficulties perform some- Although there is evidence that scales can be reduced
what more poorly during play (Bundy, 1989; Bundy to two to three items and maintain their reliability
et al., 2007; Clifford & Bundy, 1989). However, none (Moran, Guyatt, & Norman, 2001), construct and con-
of these studies focused on children with ASD and tent validity is diminished with scales of fewer items.
all used different measures than implemented in the One could not argue that the social play scale of three
current study. One such study of play in children items could adequately comprise a complete assess-
with ASD examined items that could be considered ment of play. The three items that made up the play
measures of sensory processing. Children exhibit- scale are important aspects of social play with peers.
ing more repetitive behaviorsmany of which were However, deficits in social interaction in this popula-
measures of sensory seekinghad lower scores on tion are complex and the items of social play likely
play behavior (Honey et al., 2007), suggesting a rela- also reflect many other aspects of performance in chil-
tionship between repetitive sensory-seeking behav- dren with ASD. The relationships between sensory
ior and poor play. Past research that has examined processing and other forms of play might be different
children with ASD in natural settings found that the in this population. For example, one could argue that
children tend to prefer sensorimotor activities, often the relationships between sensory processing abilities
engaging in sensory-seeking play, which suggests and sensory-motor play might be stronger. These is-
an influence of sensory-seeking preferences on play sues will need to be explored in future research with a
choices (Holmes & Procaccino, 2009). Although the different and more comprehensive play measure.
items used in the current study were more balanced Finally, reduction of items within the scales also
between sensory-seeking and sensory-defensive reduced score reliability somewhat. Although most
items, the participating children with ASD generally of the scales maintained adequate internal consis-
had more atypical scores on the sensory-seeking, tency, Cronbachs alpha measures of the vision and
praxis, and play items. These two results together vestibular scales were low for current accepted use
suggest that perhaps the relationship between sen- in test development. Therefore, for all of these rea-
sory-processing issues and poor social play perfor- sons, the results of this study must be considered
mance is due to sensory seeking that interferes with preliminary in nature.
more developed modes of play. However, varied as-
pects of sensory processing could, theoretically, have Future Research
different effects on play behavior. Future study of the relationship between sensory
processing and play must use a well-established
Limitations play assessment with more comprehensive coverage
Although there were benefits to using the large of the construct of play and a measure of ASD symp-
preexisting data set available to this study, there were tom severity and cognitive ability. Future research

OTJR: Occupation, Participation and Health Vol. 33, No. 3, 2013 165
could more specifically examine types of sensory- Ben-Sasson, A., Hen, L., Fluss, R., Cermak, S. A., Engel-Yeger,
B., & Gal, E. (2009). A meta-analysis of sensory modulation
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