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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.]
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
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
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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
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
processing dysfunction and their specific outcomes symptoms in individuals with autism spectrum disorders.
in terms of play performance. Theoretically, a child Journal of Autism and Developmental Disorders, 39, 1-11.
with sensory defensiveness would avoid activities Blumberg, S. J., Bramlett, M. D., Kogan, M. D., Schieve, L. A.,
in play that provide sensory stimuli that are uncom- Jones, J. R., & Lu, M.C. (2013). Changes in prevalence of
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carefully in a naturalistic study conducted in the
Bryne, B. M. (2010). Structural equation modeling with AMOS: Basic
home or classroom.
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Clinical Implications Bundy, A. C. (1989). A comparison of the play skills of normal
The findings of this study suggest that perhaps sen- boys and boys with sensory integrative dysfunction. The
sory processing is an area to assess in relation to social Occupational Therapy Journal of Research, 9, 84-100.
play deficits in children with ASD. The relationship Bundy, A. C., Shia, S., Qi, L., & Miller, L. J. (2007). How does
found between sensory functions and the combined sensory processing dysfunction affect play? American Journal
praxis and play factor within this data set was strong. of Occupational Therapy, 61, 201-208.
The praxis scale of the SPM and SPM-P includes items Clifford, J. M., & Bundy, A. C. (1989). Play preference and play
that measure generativity and imitation, suggesting performance in normal boys and boys with sensory integra-
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that sensory functions may also be related to these con- 9, 202-217.
structs. If these relationships can be further supported,
Craig, J., & Baron-Cohen, S. (1999). Creativity and imagination
these results might suggest that greater attention to the in autism and Aspergers syndrome. Journal of Autism and
sensory elements of play could be beneficial in future Developmental Disorders, 29, 319-326.
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N., & Bodfish, J. W. (2009). Generativity abilities predict com-
Conclusion munication deficits but not repetitive behaviors in Autism
Spectrum Disorders. Journal of Autism and Developmental
Disorders, 39, 1298-1304.
This study provides preliminary evidence of a
Dominguez, A., Ziviani, J., & Rodger, S. (2006). Play behaviours
relationship between sensory functions and social
and play object preferences of young children with autistic
play in combination with praxis. Despite the neces- disorder in a clinical play environment. Autism, 10, 53-69.
sary caution in interpretation and the limitations in Dowell, L. R., Mahone, E. M., & Mostofsky, S. H. (2009).
measurement, the study has two primary strengths. Associations between postural knowledge and basic motor
First, a common problem in ASD play research is the skill with dyspraxia in autism: Implication for abnormalities in
use of small samples, and this research was complet- distributed connectivity and motor learning. Neuropsychology,
ed with a large sample of children with ASD. Sec- 23, 563-570.
ond, although there is a large body of work suggest- Dziuk, M. A., Gidley Larson, J. C., Apostu, A., Mahone, E. M.,
Denckla, M. B., & Mostofsky, S. H. (2007). Dyspraxia in
ing sensory-processing deficits including dyspraxia
autism: association with motor, social, and communicative
and poor play performance in children with ASD, deficits. Developmental Medicine and Child Neurology, 49, 734-
this is the first study to examine these constructs 739.
together to consider the potential impact of sensory Elkind, D. (2007). The power of play. Cambridge, MA: De Capo
processing on social play. The findings suggest fu- Press.
ture avenues for research. Gallese, V., Rochat, M., Cossu, G., & Sinigaglia, C. (2009). Motor
cognition and its role in the phylogeny and ontogeny of
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