Question 3.

Summarize at least 3 articles which explore play patterns, perseveration, and self-injurious behaviors. 

Play Patterns

Miller & Kuhaneck carried out a study in 2008 entitled Children’s Perceptions of Play Experiences and Play Preferences: A Qualitative Study. The study investigated the perceptions of play and rational for play preferences for ten typically developing children aged 7 to 11 years. The importance of play as being a child’s primary means to develop socially, emotionally, cognitively and physically is emphasized. How children play is often more important than what they play with. However what children select and prefer to play with is also looked at in this study.

Play choice can be influenced by many factors. In typically developing children research has shown that gender impacts play choices significantly, with girls preferring dyadic play and social interaction and boys tending to be drawn to more physical outdoor play. Another major factor impacting play is age. Typically developing children as they develop new motor and cognitive skills move towards more complex play. They use play to explore the world around them; relational play is followed by symbolic or pretend and social play.

In the study children were asked what were their favorite toys and why. They were asked how they felt when they played and how they chose what to play with. Questions also included where they played and what their favorite places to play were.

The results of the Miller & Kuhaneck study indicated that play choices for the typically developing children were primarily influenced by the ‘fun’ factor.

Fun was described by most of the children as the opposite to being bored. They talked about play being something you can do with your friends and how play made them feel happy.

The children in the study selected play activities that were perceived as ‘fun’  The primary activities chosen were  activities that incorporated a challenge,  that were seen as not too hard or too easy. They chose activities that involved  teamwork, playing with peers and bonding play with others.

The study concluded “When viewed in this manner, it becomes clear that therapists need to pay particular attention to creating the just-right challenge, being fun and playful in approach, and using peers and others in therapy.”

(Miller, E., & Kuhaneck, H. (2008). Children’s perceptions of play experiences and the development of play preferences: A qualitative study. American Journal of Occupational Therapy, 62, 407–415.)

When looking at the play patterns and choices of children with an ASD we see a very different picture.

Children with an ASD do not follow typical developmental patterns of play. Due to poor executive functioning they have difficulty initiating and carrying out play ideas. The skills inherent in executive function require that the child build a fund of knowledge about their environment and the objects in it. This fund of knowledge is built and developed through play exploration and interaction with their environment. Without these cognitive functions the child lacks the ability to generate an idea, think imaginatively, and make a plan to play.

Typically developing children appear to be intrinsically motivated to play and explore by their perception of fun. By contrast children with an ASD often appear to be motivated more by sensory needs which can result in play that is restrictive and repetitious.

The lack of constructive play patterns in children with an ASD reduces learning opportunities. The difficulties in engaging in peer or team play impacts socialization and social skills.  And restrictive repetitive play patterns means that the child misses out on exploration, as well as social and learning opportunities and the ability to have fun.

Perseveration

Perseveration refers to a set of repetitive behaviors frequently seen in individuals with an ASD. They include verbal, physical or gestural behaviors. A child who perseverates repeats a meaningless action over and over again, even though the initial stimulus is no longer present. For example, a child may perseverate by repeating a word or a question over and over again, or repeat a gesture or action repeatedly without any apparent meaning. Perseveration is one of the key diagnostic criteria in autism.  

A study was carried out by the UC Center for Research on Special Education, Disabilities and Developmental Risk to look at the various types of perseverative behaviors and document the frequency of the different types of behaviors that the children with autism displayed.

Perseveration is not specific to children with an ASD. It is also present in children with other disorders such as trisomy 21 and fragile X syndrome. 

Perseverative behaviors impact individuals in three areas: 

• socialization
• communication 
• restrictive play or interests

The study included 37 children between the ages of 29 to 73 months. All children had an autism diagnosis. The Timed Stereotypies Rating Scale, revised (Luce, 2003) was used. This rating scale was developed to ascertain the frequency of perseverative behaviors in individuals with an ASD. It looks at a diverse range of behaviors including:

• teeth grinding
• tiptoe walking
• spinning objects
• hand flapping
• biting
• covering ears or eyes
• body rocking

The results showed that the most prevalent perseverative behavior was verbal perseverative and the most infrequent behavior recorded was perseverative actions.

In summary the article stated that perseveration persists in individuals with an ASD into adulthood and these behaviors take up a large portion of the individual’s time. It suggested that further research into perseverative behaviors is imperative to improve our understanding of this phenomenon in children with autism. It is hoped this would assist in the development of appropriate interventions to address these behaviors. (Arora, 2008)



Self-Injurious Behaviors

Perhaps one of the most frightening and difficult aspects of ASD, self-injurious behaviors, result from a number of causes and may consist of the following:

• hitting or punching
• head banging or forceful shaking
• gouging the eyes 
• biting hands or fingers 
• picking at, scratching, or pinching skin
• pulling hair

Because so many people with an ASD are nonverbal it is difficult to determine exactly what triggers these behaviors. Some possible causes include:

• Physiological Causes, Self-injurious behavior may be caused by pain that isn't being addressed, illness or infections, tic disorders (Clements and Zarkowska, 2000), sub-clinical seizure activity, endorphin release,  high serotonin levels, and perhaps dopamine imbalances. 

• Social Causes Self-injurious behavior brings a great deal of attention very quickly. This behavior may be an effective way to avoid demands placed on a person with an ASD. Also, behaviors like head slapping may be a way to convey frustration or other emotions when more effective forms of communication are not possible.

• Environmental Causes It is possible that arousal levels and sensory issues may lead to self-injurious behavior. Activities such as biting hands may be a way to let off steam in an environment that is too loud or complex. For those with low levels of arousal, inducing pain may be a way to provide stimulation. 

• Perseverative Behavior Self-injurious behavior may be a part of ritualistic, repetitive behavior that is so common in ASDs.

Because such a wide array of issues may lead to these types of behaviors, it is important to rule out medical issues as well as to observe the social and environmental milieu as self-injurious behaviors are happening. Finding the cause of this behavior can be challenging and time-consuming. Caregivers have found some creative and effective ways to protect their charges from self-harm:

Treating self-injurious behavior may be as simple as reducing or increasing the stimulation levels in the environment. For some groups an environment that includes toys, a lack of demands, and reinforcement for non self-injurious behaviors and redirection seems to work the best. (Iwata et al, 1994) Future blog entries will explore the uses of drug therapies and sensory integration strategies. 

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References:

Aurora, T. (2008). Perseveration in Autism. UC Center for Research on Special Education, Disabilities, and Developmental Risk. Santa Barbara.


Clements, John, & Zarkowska, Ewa. (2000) Behavioural Concerns and Autistic Spectrum Disorders: Explanations and Strategies for Change. Philadelphia: Jessica Kingsley Publishers.


Iwata, Brian A.; Dorsey, Michael F.; Slifer, Keith J.; Bauman, Kenneth E.; Richman, Gina S. (1994) Toward a Functional Analysis of Sef-Injury. Journal of Applied Behavior and Analysis, 27, 197-209.


Miller, E., & Kuhaneck, H. (2008). Children’s perceptions of play experiences and the development of play preferences: A qualitative study. American Journal of Occupational Therapy, 62, 407–415.